Kids Health Info

Buccal midazolam

  • This factsheet answers some common questions about your child's medicine. It does not contain all available information. It does not take the place of talking to your child's doctor or pharmacist. This information may be different from the information in the manufacturer's consumer information. The information in this factsheet reflects the usage of medicine under medical supervision by patients of The Royal Children's Hospital (RCH). Medicine may be used in children in different ways or for different reasons than in adults - for more information see the Kids Health Info factsheet: Medicines for Children. 

    Midazolam is a benzodiazepine medication like diazepam and clonazepam. Midazolam works more quickly than diazepam but does not last as long.

    What is midazolam used for?

    Midazolam is used for:

    • Emergency treatment of seizures.
    • Sedation during medical procedures.
    • Premedication prior to medical procedures.

    How is midazolam given for seizures?

    Midazolam can be:

    • Trickled inside the cheek - buccal.
    • Sprayed or dripped into the nose - intranasal.
    • injected into a vein or muscle - intravenous (IV) or intramuscular (IM).

    Ambulance officers and emergency doctors give midazolam by injection into a muscle or vein.

    Buccal midazolam is absorbed directly into the blood stream through the lining of the inside of the cheek.

    Swallowing midazolam is not recommended as it is not absorbed well through the stomach.

    Although the plastic ampoules are labelled 'for slow IV or IM injection', they can be used for buccal and intranasal use.  

    When is buccal midazolam used?

    Buccal midazolam can be used for the emergency treatment of seizures. Buccal midazolam may be prescribed for a child with epilepsy who:

    • has prolonged seizures
    • has a pattern of seizures that recur close together
    • lives a long way from emergency services

    Buccal midazolam is not necessary for all children with epilepsy. Your doctor will tell you whether your child might benefit from you being able to give buccal midazolam.

    First aid

    First aid for seizures is very important. It includes:

    • Preventing injury, for example by moving things away from the child.
    • Keeping your child's airway open and clear by positioning your child on their side in the coma position.
    • Timing how long the seizure lasts.
    • See the Kids Health Info factsheet: Seizures-Safety issues and how to help.
    • Unless your doctor gives you different instructions, call 000 for an ambulance BEFORE giving midazolam. Don't wait for the ambulance to arrive before giving the midazolam.

    How to give buccal midazolam

    Use only 1ml plastic ampoules containing 5mg of midazolam. Do not use midazolam in glass ampoules.

    Each ampoule delivers approximately 18 drops (the volume can vary slightly from 16-20 drops, but this is OK).

    Buccal midazolam can be given by either drops squeezed directly from the ampoule (ampoule method) or from drops trickled from a syringe into which the midazolam has been drawn up (syringe method).

    Ampoule method

    1: Open the plastic ampoule of midazolam by twisting off the top.

    Midazolam appl-1-RCH

     

     

    2: Drip onto a tissue the drops that you do NOT need. For example, if your doctor prescribes half the contents of one ampoule (2.5 mg), first drip out nine drops so that nine drops remain in the ampoule to give to your child. If by accident you drip out eight or 10 drops, just give the remainder as it is still a safe dose.

    Midazolam appl-2-nasal-RCH


    3: Lay your child on their side in the first aid (coma) position. Open their lips and squeeze the remaining midazolam from the ampoule into the inside of the lower cheek (closest to the ground), between the lips and side teeth. There is no need to open your child's jaw. The solution does not need to be swallowed. Give three squeezes of the ampoule to make sure it has all been given. Remove the ampoule to check that all of the solution has been squeezed out. If any remains, reinsert the ampoule and give three more squeezes.

      midazolam_image006


    4: Watch your child's breathing and seizure activity while they remain lying on their side in the first aid (coma) position.

    5: Write down the time that the seizure started, when the midazolam was given and when the seizure stopped.

    Syringe method

    1: Open the plastic ampoule of midazolam by twisting off the top.

    Midazolam appl-1-RCH


    2: Insert the syringe into the ampoule and hold the ampoule and syringe upright with the ampoule above the syringe. Withdraw the required dose as prescribed by your doctor into a 1ml syringe. Push out any big air bubbles and check the amount of midazolam in the syringe. Pull the ampoule and the syringe apart.

    Midazolam appl-2-RCH

     

     

    3: Lay your child on their side in the first aid (coma) position. Open their lips and slowly trickle the midazolam from the syringe into the inside of the lower cheek (closest to the ground), between the lips and side teeth. There is no need to open your child's jaw. The solution does not need to be swallowed.

     misaz3 new image

    4: Watch your child's breathing and seizure activity while they remain lying on their side in the first aid (coma) position.

    5: Write down the time that the seizure started, when the miadzolam was given and when the seizure stopped.

    Side effects of midazolam

    • Midazolam has a sedative effect and your child may be sleepy for some time afterwards. Headache, nausea (feeling sick), vomiting, coughing and hiccups may also happen. Rarely, your child may become agitated, hostile or aggressive after having midazolam.
    • Your child may have shallow or slow breathing after midazolam. If this happens, your child may need mouth-to-mouth resuscitation and you will need to call an ambulance.  DIAL 000 for an ambulance.

    Important points to remember

    • Use the plastic ampoules containing 5mg midazolam in 1ml, NOT glass ampoules or plastic ampoules of other sizes or strengths.
    • Midazolam needs to travel where your child goes, in case of a seizure when away from home.
    • It is very important to follow your doctor's advice on when and how to give midazolam, when to phone an ambulance, and when to take your child to hospital.
    • It is helpful for families and people who care for your child to do a first aid course to improve their ability and confidence in emergency situations. Contact: RCH safety centre (03) 9345 5085,  St John's Ambulance (03) 9696 0000 or your local community health service.
    • Midazolam needs to be stored at normal room temperature (below 25ºC)
    • Midazolam needs to be protected from light (wrapped in foil). Take note of the date midazolam is taken out of its prescribing box and wrapped in foil as it needs to be discarded eight months after exposure to light. Take note of the use by date.
    • Keep midazolam locked away out of the reach of children and keep in a "snap lock" type container.
    • Keep a record of your child's seizures and use of midazolam.
    • Specific details for administration of midazolam in your child should be documented on an Emergency Medication Management Plan and referenced to a general Epilepsy Management Plan.

    For more information

    • Contact your child's paediatrician or neurologist.
    • Medicines Information Centre, Pharmacy Department, The Royal Children's Hospital. Tel (03) 9345 5208 (business hours).
    • Neurology Department, The Royal Children's Hospital. Tel (03) 9345 5661 (business hours).
    • Emergency Department, The Royal Children's Hospital. Tel (03) 9345 6592 (after hours).
    • Epilepsy Foundation of Victoria, Surrey Hills, Victoria. Tel (03) 8809 0600.



    Produced in consultation with the RCH Children's Neuroscience Centre & RCH Pharmacy. First published Jan 2006. Updated April 2014.

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Disclaimer 
This information is intended to support, not replace, discussion with your doctor or healthcare professionals. The authors of these consumer health information handouts have made a considerable effort to ensure the information is accurate, up to date and easy to understand. The Royal Children's Hospital, Melbourne accepts no responsibility for any inaccuracies, information perceived as misleading, or the success of any treatment regimen detailed in these handouts. Information contained in the handouts is updated regularly and therefore you should always check you are referring to the most recent version of the handout. The onus is on you, the user, to ensure that you have downloaded the most up-to-date version of a consumer health information handout.