This was a metanalysis which included 5 studies of 3933 pediatric patients requiring seizure management without IV access, mostly in the prehospital setting.
Bottom line: IM midazolam appears superior to IN midazolam as a first-line non-IV benzodiazepine for pediatric seizures in the prehospital setting, though IN remains a clinically effective alternative — particularly when caregiver acceptability and ease of administration are prioritized.
Additional Information
IM midazolam reduced the need for rescue therapy compared to IN midazolam in pediatric seizures (RR 1.29, 95% CI 1.15–1.45), a finding consistent across prehospital subgroups and studies using the standard 0.2 mg/kg dose.
IM midazolam terminated seizures ~24 seconds faster than IN midazolam (MD 23.60 s, 95% CI 2.31–44.89; p = 0.03).
References
Mohnkern JD, Khalid A, Ibrahim M, Dave V, Chierighini PP, Riaño AS, Ajibade T, Martins Shehan TS. Intranasal Versus Intramuscular Midazolam in Pediatric Seizure Control: A Systematic Review and Meta-Analysis. Prehosp Emerg Care. 2026 May 6:1-9. doi: 10.1080/10903127.2026.2658592. Epub ahead of print. PMID: 41996547.