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Buccal midazolam as an alternative to rectal diazepam for prolonged seizures in childhood and adolescence
  1. Richard Body, Senior House Officer,
  2. Mawra Ijaz, Staff Grade


    A short cut review was carried out to establish whether buccal midazolam is better than rectal diazepam for treating prolonged seizures in childhood and adolescence. Eight papers were found using the reported search, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.

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    Report by Richard Body, Senior House OfficerChecked by Mawra Ijaz, Staff Grade

    Clinical scenario

    An 11 year old girl, known to be epileptic, is brought to the Emergency Department with a prolonged seizure. You have no intravenous access at this point. A colleague recently mentioned that buccal midazolam is an available alternative to rectal diazepam. You are aware that this would be easier and more socially acceptable in the situation, but wonder if it would be as efficacious.

    Three part question

    In [children with prolonged seizures] does [buccal midazolam or rectal diazepam] lead to [quicker resolution of seizures]?

    Search strategy

    Medline 1966-01/2005 using the OVID interface and the Cochrane Library, Issue 4, 2004. Medline: [exp status epilepticus OR status OR exp seizures/ OR exp seizures, febrile/ or OR fit$.mp] AND [exp midazolam/ OR OR exp Benzodiazepines] AND [exp Mouth Mucosa/ OR OR exp administration, buccal/] AND [exp diazepam OR] AND [ OR exp Rectum/ OR per OR exp Administration, Rectal] LIMIT to human AND English language. Cochrane: status epilepticus OR buccal.

    Search outcome

    Medline: Eight papers were identified, two of which were relevant to the three part question (table 1). Cochrane: Nine hits, none of which was relevant.

    Table 1


    Buccal midazolam is gaining in popularity as a treatment for prolonged seizures in children. It overcomes many of the disadvantages associated with rectal diazepam, including difficulty of administration in wheelchair users and in tonic seizures, potentially unpredictable absorption with constipation and bowel movements and social unacceptability, particularly in older children. Nasal midazolam has also been used,3 although the greater surface area of the buccal mucosa could potentially confer advantages with regard to absorption.

    One small trial suggests that buccal midazolam is at least as effective as rectal diazepam and one suboptimally designed telephone survey suggested a degree of parental satisfaction with the drug. However, the patient group in the randomised controlled trial is very different from that presenting to emergency departments. There remains a paucity of evidence regarding this topic.


    Buccal midazolam may be equal or superior to rectal diazepam for treatment of prolonged seizures in children but more evidence is needed for emergency patients.

    Report by Richard Body, Senior House OfficerChecked by Mawra Ijaz, Staff Grade