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`Nasal/buccal midazolam use in the community
`
` 
`M T Wilson, S Macleod and M E O’Regan
` 
`Arch. Dis. Child.
` 2004;89;50-51
`doi:10.1136/adc.2002.019836
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`50
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`SHORT REPORT
`Nasal/buccal midazolam use in the community
`M T Wilson, S Macleod, M E O’Regan
`. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
`
`Arch Dis Child 2004;89:50–51. doi: 10.1136/adc.2002.019836
`
`to evaluate the
`A telephone survey was carried out
`effectiveness and convenience of nasal/buccal midazolam
`in terminating prolonged seizures in the community. A total
`of 33/40 (83%) families who had used it found it effective
`and easy to use; 20/24 (83%) preferred using midazolam to
`rectal diazepam.
`
`S tatus epilepticus is a life threatening condition asso-
`
`ciated with long term morbidity that occurs mainly in
`childhood and becomes more refractory with duration.1
`Until recently standard treatment of children with a history
`of prolonged (.10 minutes) seizures has been to provide
`families with rectal diazepam to terminate the seizure as soon
`as possible.
`Rectal diazepam has many problems when used outside
`the hospital setting: it is difficult to administer to wheel-
`chair users; tonic seizures make administration difficult;
`constipation and bowel movements can interfere with
`absorption;
`it becomes more socially unacceptable with
`increasing age; and is detrimental to the self esteem of
`children and teenagers.
`In our experience schools are
`uncomfortable with rectal administration. Midazolam has
`been used nasally since 1988 as a preanaesthetic agent2
`and an anxiolytic in accident and emergency departments.3
`Following a study in 1996 showing its effectiveness in
`abolishing epileptiform abnormalities
`in children with
`subclinical status epilepticus,4 we began to offer families
`the choice of midazolam or rectal diazepam for home and
`school use. The aims of this survey were to assess the
`effectiveness of buccal and nasal midazolam in terminating
`prolonged seizures in the community, evaluate how easy
`parents found it to use, and in the families who had
`previously used rectal diazepam, establish which was the
`preferred treatment.
`
`METHOD
`As nasal/buccal midazolam is unlicensed for use as an
`anticonvulsant, prescriptions were issued from the hospital.
`Copies of these prescriptions over a 16 month period were
`obtained and 53 children were identified (table 1). Their
`parents were then contacted by telephone (table 2).
`We use the intravenous preparation of 10 mg/2 ml at a
`dose of 0.2 mg/kg. The different methods of administration
`are discussed with the parents and a decision made on the
`most appropriate route, taking into account previous seizure
`patterns, practical issues, and parental preference. The buccal
`surface area is greater and parents prefer this route as they
`turn the child onto one side during a seizure, which is the
`preferred position for buccal administration. We suggest
`nasal administration in the following situations, however: if
`copious saliva has been produced in previous seizures; if the
`child is resisting administration; and for focal seizures with
`altered awareness (the midazolam is usually swallowed in
`this situation).
`
`After demonstration, parents and carers have supervised
`practice in breaking the ampoule, drawing up, and admin-
`istering a solution on a doll. Written guidelines on admin-
`istration are provided. Filter straws are used to draw up the
`medication and protective ampoule breakers are provided.
`
`RESULTS
`Midazolam had been used for 40 of the 53 children (74%)
`and 33 (83%) of those found it effective. Twenty four of the
`40 families had also used rectal diazepam, and 20/24 (83%) of
`those expressed a preference for midazolam. The most
`commonly stated reasons for this preference were: personal
`dignity (all of the respondents); more socially appropriate;
`ease of administration in wheelchair users; and quicker
`response than rectal diazepam.
`Analysis of the seven families who found it ineffective was
`as follows: two of the children were also unresponsive to
`rectal diazepam; one parent had only used it once as a
`‘‘preventative’’ and not as recommended; and one mother
`thought it had been lost in saliva. In all but one case the
`midazolam had been given buccally.
`rectal
`Four
`families had expressed a preference for
`diazepam. The reasons given by two were familiarity and
`ease of administration at night (although one of them carries
`midazolam for day use); one child was said to be euphoric
`after midazolam administration, and the fourth parent gave
`it buccally and felt some was expelled in saliva.
`
`DISCUSSION
`Midazolam given buccally and nasally is an effective
`treatment for prolonged seizures in the community and is
`preferred to rectal diazepam by most families in this cohort.
`Scott and colleagues5 showed that buccal midazolam was at
`least as effective as rectal diazepam in the termination of
`prolonged seizures in a residential school for young people
`with difficult epilepsy, and our study supports these findings
`when used by parents at home. Drawing up and measuring
`the contents of midazolam is a more complicated procedure
`than using a tube of rectal diazepam, but only one parent
`experienced difficulty with administration without help
`because of her daughter’s resistance. For the majority the
`social benefits exceeded the disadvantages. Filter straws and
`ampoule breakers have made the process easier.
`
`Table 1 Demographic and clinical details
`
`Demographics
`No. of patients
`Age range (years)
`Special needs schools
`Mainstream education
`Seizure type
`Febrile status
`Generalised
`Symptomatic partial
`Cryptogenic partial
`
`53
`3–21
`30
`20
`
`1
`11
`30
`11
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`Midazolam use in the community
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`51
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`Table 2 Telephone questionnaire
`
`Has midazolam been used?
`Was it effective in stopping the seizure?
`How easy did you find it to use on a scale 1–5 (1 = very easy, 5 = very
`difficult)
`Have you previously used rectal diazepam?
`Which method was preferable?
`Any comments?
`
`Midazolam allows families a choice in rescue medication
`and how they manage prolonged seizures in the community.
`Some families use either rectal diazepam or buccal/nasal
`midazolam depending on the social situation. There is no
`difference between the cost of rectal diazepam and mid-
`azolam.
`The current preparation remains unlicensed for use in
`epilepsy, which can cause problems with prescribing. There is
`now a preparation of midazolam syrup for buccal use, which
`the manufacturers state can also be administered nasally.
`This preparation is more expensive but we intend to explore
`its use in the termination of prolonged seizures. It dispenses
`with the use of glass ampoules, filter straws, and ampoule
`breakers, simplifying administration.
`
`ACKNOWLEDGEMENTS
`We would like to thank the pharmacy staff and the families who
`helped us with this survey.
`
`. . . . . . . . . . . . . . . . . . . . .
`Authors’ affiliations
`M T Wilson, S Macleod, M E O’Regan, Royal Hospital For Sick Children,
`Glasgow, UK
`
`Correspondence to: M T Wilson, Fraser of Allander Neurosciences Unit,
`Royal Hospital For Sick Children, Yorkhill, Glasgow G3 8SJ, UK;
`margaret.wilson@yorkhill.scot.nhs.uk
`
`Accepted 2 September 2003
`
`REFERENCES
`1 Kendal JL, Reynolds M, Goldberg R. Intranasal midazolam in patients with
`status epilepticus. Annf Emerg Med 1997;29:415–17.
`2 Malinovsky J-M, Lejus C, Servin F, et al. Plasma concentrations of midazolam
`after IV, rectal or nasal administration in children. Br J Anaesth
`1993;70:617–20.
`3 Connors K, Tendrup TE. Nasal versus oral midazolam for sedation of anxious
`children undergoing laceration repair. Ann Emerg Med 1994:245.
`4 O’Regan ME, Brown JR, Clarke M. Nasal rather than rectal benzodiazepines
`in the management of acute childhood seizures? Dev Med Child Neurol
`1996;38:1037–45.
`5 Scott RC, Besag FMC, Neville BGR. Buccal midazolam and rectal diazepam
`for treatment of prolonged seizures in childhood and adolescence: a
`randomised trial. Lancet 1999;353:623–6.
`
`ARCHIVIST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
`Bicycle helmet campaigns and poverty
`
`B icycle helmet campaigns increase helmet use but there is uncertainty about their effect
`
`on head injuries. During and after a campaign in Quebec, Canada (Farley et al.
`J Epidemiol Community Health 2002;57:668–72) head injuries were reduced in children in
`both poor and more affluent communities.
`The campaign took place in spring and summer during the years 1990 to 1993 and
`involved schools, police, community organisations, and retailers. It targeted 140 000
`children aged 5–12 years. A different community with 83 500 children of that age but
`without a bicycle helmet campaign served as control. In the target community 24 of 210
`municipalities were classified as poor (20% or more of households of low income) and in the
`control community 27 of 98. Previous reports from the study showed that the campaign
`increased helmet ownership and use but was three times more effective in these respects in
`more affluent municipalities than in poor municipalities. This paper reports that, despite
`this lesser response in poor communities, the effect on head injuries in cyclists was similar
`in both poor and non-poor municipalities. Before the campaign the incidence of head
`injuries in poor municipalities was three times greater in the target community than in the
`control community and in non-poor municipalities it was 50% greater in the target
`community. After the campaign the incidence fell in both poor and non-poor municipalities
`in the target community but did not change in the control community. In the target
`community the incidence of head injuries due to cycling accidents fell by 55% in poor
`communities and by 45% in non-poor communities when the 3 years before the campaign
`(1988–90) were compared with the 3 years after the campaign (1994–96).
`The campaign was followed by a reduction in head injuries in both poor and non-poor
`municipalities despite a lesser uptake of helmets in the poor municipalities. The reasons for
`this apparent discrepancy are unclear.
`
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