Efficacy, safety, route of administration of midazolam and diazepam for pediatric status epilepticus: systematic review, meta-analysis, and trial sequential analysis

Midazolam demonstrates superior efficacy over diazepam, particularly via buccal and intramuscular routes. It addresses critical prehospital delays by bypassing the high failure rates associated with pediatric vascular access. Intramuscular administration matches intravenous efficacy while enabling immediate intervention without specialized equipment. Additionally, buccal and nasal formulations represent the most cost-effective non-intravenous rescue options available. Guidelines must prioritize these practical routes for EMS settings, necessitating policy updates to remove insurance barriers.