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Editor,—The fitting child is a common problem presenting to the emergency department. Prolonged fitting is potentially harmful and early treatment of seizures may reduce actual mortality and morbidity.
The gold standard against which new treatments have to be compared has been rectal diazepam or intravenous lorazepam.
Obtaining intravenous access in a fitting child can be difficult. The rectal route has become popular both in hospital and before hospital admission. There are however difficulties with this route: absorption may be variable1 and non-medical staff may be reluctant to administer rectal drugs.
Recently interest has been shown in the use of midazolam administered via the buccal route to treat fits in the prehospital environment. It was shown to be efficacious and safe though no significant reduction in time to seizure cessation was found in comparison with rectal diazepam.2 A further trial set in an emergency department compared intranasal midazolam (0.2 mg/kg) with intravenous diazepam.3 Time to seizure control from admission was found to be less in the midazolam group.
Midazolam via the intranasal route has been successfully used for pre-procedural sedation of children and has confirmed anti-epileptic properties. Indeed EEG evidence of anti-epileptic action within two to five minutes of intranasal administration of midazolam has been demonstrated.4
We have successfully used intranasal midazolam on two fitting paediatric patients who proved difficult to obtain intravenous access. The dose chosen was 0.5 mg/kg; one that has been used successfully for procedural sedation with no respiratory compromise.5
A 15 month old male epileptic had been fitting for two hours before admission despite administration of rectal diazepam (2 × 5 mg). He was given 0.5 mg/kg intranasal midazolam. Fitting stopped within five minutes of treatment.
A 3 year boy had been fitting for 15 minutes. Fitting was seen to stop within 2.5 minutes of administration of 0.5 mg/kg of intranasal midazolam.
No patient suffered any respiratory depression, or any other adverse effects.
We feel that the intranasal administration of midazolam warrants further evaluation as a treatment of the fitting child.