McIntyre J et al. (2005) Safety and efficacy of buccal midazolam versus rectal diazepam for emergency treatment of seizures in children: a randomised controlled trial. Lancet 366: 205–210

A study recently reported in The Lancet compared the safety and efficacy of buccal midazolam with that of rectal diazepam in children with acute seizures.

Between October 2000 and February 2004, four UK hospitals recruited children aged ≥6 months who presented with an acute seizure. Patients were randomized to treatment with age-determined doses of either buccal midazolam or rectal diazepam. The primary endpoint was therapeutic success, defined as seizure cessation within 10 min, lasting for at least 1 h, without respiratory depression requiring mask inflation or intubation. Lorazepam was given intravenously if seizures lasted >10 min; in these cases, treatment was considered to have failed.

Overall, 177 patients were treated for 219 separate seizure episodes. Buccal midazolam was more effective than rectal diazepam, even when numerous variables were adjusted for (e.g. hospital, age, prior treatments, epilepsy diagnosis and presence of fever; odds ratio 4.1, CI 2.2–7.6; P <0.001), and when only the initial episode for each patient was included (odds ratio 3.5, CI 1.8–7.0; P = 0.008). Compared with those receiving rectal diazepam, fewer children receiving buccal midazolam experienced treatment failure. Buccal midazolam also ended seizures more rapidly than rectal diazepam (P = 0.01). The incidence of respiratory depression was not significantly different between treatment groups.

The authors conclude that buccal midazolam is more effective than rectal diazepam for the emergency treatment of children presenting with acute seizures, and that it does not increase the risk of respiratory depression.