Neurol Case Rep | Volume 8, Issue 1 | Case Report | Open Access

Paradoxical Response to Midazolam in an Extremely Premature Neonate with Refractory Seizures

Mbanga V^1*, Kaulas H^1, Abugisisa L² and Fenton G¹

¹Department of Pediatric Neurology, Saint Louis University School of Medicine, USA  ²Department of Neonatology, Saint Louis University School of Medicine, USA

^*Correspondance to: Vanessa Mbanga 

Abstract

Background: Neonatal seizures present a complex challenge in clinical management, particularly in extremely premature infants. Benzodiazepines, such as midazolam, are commonly used in seizure management, but rare paradoxical responses leading to seizure exacerbation have been documented.  Patient: We report a case of refractory status epilepticus in an extremely premature neonate born at 25 weeks and three days of gestation, with comorbidities including hyaline membrane disease, germinal matrix hemorrhages, and E. coli bacteremia with meningitis and ventriculitis. Initial treatment with phenobarbital, Levetiracetam, and fosphenytoin was ineffective, prompting the initiation of a midazolam infusion. Although initial boluses transiently suppressed seizures, midazolam paradoxically worsened them over time, with seizures becoming more prolonged and occurring in back-to-back clusters. This effect was confirmed via continuous video EEG, emphasizing the likely proconvulsant response to midazolam in this patient.  Results: Electroencephalographic monitoring revealed significant alterations in seizure patterns following midazolam initiation, illustrating its potential to exacerbate seizures in certain neonatal cases.  Conclusion: This case highlights the need for vigilance when managing neonatal seizures, particularly in extremely premature infants. Clinicians should remain aware of the potential for paradoxical responses to midazolam and consider alternative therapeutic strategies promptly to achieve effective seizure control and minimize harm.

Citation:

Mbanga V, Kaulas H, Abugisisa L, Fenton G. Paradoxical Response to Midazolam in an Extremely Premature Neonate with Refractory Seizures. Neurol Case Rep. 2025; 8(1): 1051..