Buccal Midazolam May Be Superior to Rectal Diazepam in
Emergency Treatment of Pediatric Seizures

Buccal midazolam may be slightly more effective in the emergency treatment of acute tonic-clonic seizures in children, with fewer adverse effects than occur with the use of rectal diazepam, researchers reported at the American Epilepsy Society's Annual Meeting on Dec. 7, 2004. Drug administration using a “buccal” route means that medicine is placed between the cheek and gums for absorption through the mucosa or lining of the mouth. It is not necessary for the drug to be swallowed, but if the drug is swallowed accidentally, it will cause no harm.

A multicenter comparative randomized trial showed that buccal midazolam reversed acute seizures more rapidly than diazepam in the 219 patients studied, without producing the serious respiratory depression seen in some children, according to Richard Appleton, MD, neurologist, Roald Dahl EEG Unit, Royal Liverpool Hospital, Liverpool, UK. In the trial, patients (median age 3 years) received either buccal midazolam or rectal diazepam for acute seizure. Seizure reversal within 10 minutes occurred in 65% of buccal midazolam subjects versus 41% of diazepam subjects, and the percentage of patients requiring add-on IV lorazepam for continued seizure activity was 36% in the buccal midazolam group compared to 57.3% in the diazepam group.

In the United Kingdom, a flavored, sugar-free palatable  formulation containing midazolam 10mg/ml (as the maleate) is available and is dispensed with 1ml oral syringes and instructions for use. Although it uses a different salt than the injection, there is no indication that this makes any difference clinically, and this preparation is much easier to administer, especially by lay persons such as parents, in an emergency setting. If necessary, midazolam may be pre-packed into oral syringes for short periods, and can also be given intranasally.

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http://www.pslgroup.com/dg/24826A.htm"
http://www.ukmicentral.nhs.uk/pressupp/reports/docs/Buccalmidazolam.pdf

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