Prolonged seizures can cause significant morbidity and mortality in children. If seizures last longer than five minutes, status epilepticus is likely to occur, with potentially serious consequences. Prompt, effective treatment at home or school could improve outcomes and possibly prevent hospital admission, but the treatment must be provided in a form suitable for administration by parents, teachers or caretakers. Many caretakers report that the use of rectal diazepam is unacceptable or inconvenient. In addition, there is some concern that rectal administration could contribute to allegations of sexual abuse. Liquid medications absorbed directly through the buccal mucosa may provide an alternative to rectal diazepam. Scott and colleagues compared the effectiveness of rectal diazepam with that of buccal liquid midazolam in children with continuous seizures of more than five minutes' duration.
Students living in a residential school for patients with severe disability were included in the study. The midazolam was administered by squirting 2 mL (10 mg) of liquid medication into the side of the mouth using a syringe. When a seizure lasted more than three minutes, treatment was selected by drawing a card to establish randomization. The selected treatment (rectal diazepam or buccal midazolam) was administered unless the jaws were too tightly clenched to administer the liquid midazolam. In these cases, rectal diazepam was administered, but the seizure episode was not included in the study. If the seizure continued for 10 minutes after administration of the study medication, additional therapies were used.
Buccal midazolam was used in 40 episodes and rectal diazepam in 39 episodes of seizure during the study. The treated patients did not differ in age, sex, type of seizure or seizure frequency. Although more patients responded to buccal midazolam (30 of 40 episodes, or 75 percent, compared with 23 of 39 episodes, or 59 percent) and the median time from the administration of medication until termination of the seizure was shorter (six minutes for midazolam compared with eight minutes for diazepam), these differences were not statistically significant. No clinically significant differences in blood pressure, oxygen saturation or other variables were detected between the treatment groups.
The authors conclude that buccal midazolam is effective in the acute treatment of seizures. They report that placing the syringe between the teeth and cheek was readily accomplished even in patients undergoing tonic seizures, and staff members found the administration of small quantities of midazolam easy. They discuss the advantages of the buccal route of administration, especially in adolescents and older children, and conclude that the buccal route may become the preferred method of administration of anti-seizure medications, particularly for seizure events occurring in the community.