OBJECTIVE: To compare the safety and efficacy of buccal midazolam as opposed to rectal diazepam in the treatment of acute seizures in children less than 18 years old. METHODOLOGY: This is a meta-analysis of randomized controlled trials comparing the use of buccal midazolam and rectal diazepam as treatment for acute seizures in children less than 18 years old. The total population of each study are as follows: 330 patients (Mpimbaza, 2008), 43 patients (Baysun, 2005), and 17 patients, all less than 18 years old, coming into the emergency department due to seizures. RESULTS: There is no significant difference in the mean duration of seizure in minutes and seizure cessation in ten minutes between the buccal midazolam and rectal diazepam groups (Mean difference 0.39; 95% Confidence interval [CI] -0.18 to 0.96; p=0.17; Risk ratio [RR] 0.99; 95% CI 0.83 to 1,19, p=0.2). There is no significant difference in the risk of respiratory depression between buccal midazolam and rectal diazepam (RR 0.96; 95% CI 0.22 to 4.13; p=0.61). CONCLUSION The administration of buccal midazolam and rectal diazepam are similar in terms of efficacy and safety in terms of time to seizure cessation, termination of seizure within ten minutes, and risk of respiratory depression.