Midazolam is now considered a first-line therapy for the acute management of seizures in children, replacing rectal diazepam in a number of guidelines. Midazolam is a short-acting hydrophilic benzodiazepine that forms a lipophilic free base at physiological pH. This facilitates its rapid absorption and onset of action while also allowing greater flexibility in the route of administration.

Seizures that last longer than five minutes become increasingly challenging to control. In addition, neurological sequelae of convulsive status epilepticus, which may include motor and cognitive deficits, develop in 6% of patients over three years of age and 29% of patients below 12 months of age. Therefore, timely administration of effective antiepileptic therapy is crucial. This may include supplying emergency treatment options to the carers of patients who experience prolonged convulsive seizures or who have limited access to emergency services.

Studies demonstrate that midazolam administered by the buccal, intranasal, or intramuscular route is at least as effective as rectal diazepam. Buccal and intranasal midazolam is also expected to be more socially acceptable in the pre-hospital setting. The 5mg/ml ampoule is currently recommended for this purpose due to the absence of a proprietary product in Australia. The Royal Children’s Hospital Melbourne provides carer information for its administration by the buccal and intranasal routes.


  1. Howard K, Crittenden L, Smith R, O’Meara M, Ratoni T, Cardamone M, et al. Infants and children: acute management of seizures. Sydney: NSW Government Ministry of Health, 2016.
  2. Ramachandrannair R, Sotero de Menezes M, Simon E, Corden TE. Pediatric status epilepticus. New York: Medscape; 2014.
  3. Smith R, Brown J. Midazolam for status epilepticus. Aust Prescr. 2017; 40: 23-5.

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