Rectal diazepam is the established first-line drug for children admitted to hospital with epileptic seizures who are unable to have intravenous treatment. There is a risk of seizure recurrence or respiratory depression in patients who take diazepam. Midazolam is an alternative drug that can be given via the buccal cavity.

John McIntyre at the Derbyshire Childrens Hospital in Derby, UK, and colleagues compared the safety and effectiveness of rectal diazepam with buccal midazolam. Four UK hospitals participated in the study. The investigators randomly selected weekly blocks of treatment for each of the four participating centres. Between October 2000 and February 2004 there were 219separate episodes of seizures involving 177 children aged 6 months and older. For buccal midazolam treatment was successful in 61 of 109 (56%) episodes and for rectal diazepam 30 out of 110 (27%) episodes were successfully treated.

Dr McIntyre concludes: “In our study, buccal midazolam ended seizuires more rapidly than rectal diazepam and stopped seizures within 10 minutes in more children. The study confirms the rapid clinical effect of buccal midazolam, but has also identified important clinical advantages over rectal diazepam in both speed of onset and duration of action.”

In an accompanying comment, Max Wiznitzer of the Rainbow Babies and Childrens Hospital, Ohio, USA, states: “Transmucosal administration of a benzodiazepine can be rapidly done and, potentially, reduces the length of seizure duration and possible morbidity. He also raised questions about the issue: “Is a comparative study of buccal and intranasal midazolam needed? Does every child with seizures need a transmucosal benzodiazepine prescription?”; Source: The Lancet