It’s already difficult to make a decision to start medications on a child but even more difficult when the medications are causing side effects and adverse reactions. Providers can’t ignore it or say let PCP or someone else treat this because it’s irresponsible and a liability. You can also look at it like, why should (someone else) clean up my mess. However, it doesn’t have to be a mess and that’s why we have to pay attention to the side effects before it turns into complications.
And don’t beat yourself up. Almost none of these medications are FDA approved for kids or other particular situations. It just so happened during clinical trials, some medications are more ideal for certain conditions but there are no clinical trials for 5-6 years olds with depression, and anxiety… and parents usually don’t sign their kids up to be experiments. So as you can see, providers frequently have to do things unconventional for treating kids. For the sake of simplicity, a child refers to a person before puberty. Afterward, the treatment is similar to adults, but some tips can apply to both kids and adults.
How to Avoid Poor Responses to Medications
- Start Low Go Slow: with kids, trial the microdose first. Some people think size matters or the bigger the person the higher you can start, but even if that’s the case that’s not the purpose of starting low. We want to make sure there’s not going to be a major reaction. Most young kids don’t present with known allergies like adults and can’t easily communicate if there is a problem or maybe too scared…Plus like with the elderly (starting low/go slow), we don’t want to over-medicate/sedate a kid. Anything that can compromise the breathing or the respiratory rate can increase the risk of aspiration so use precaution, start low, and titrate as tolerated.
- Know What Did/Didn’t Work: Genetic testing is usually my first priority with small kids but some providers don’t think it helps or are against it… so I listed this as the second point because whether you do genetic testing or not, medications should start off low and titrate slowly. I usually start medications and do genetic testing from day one but perhaps the person is already coming to you with a medication schedule. Try to work with what you have and either change the dosages or timing of the medications, for example, if the person is too drowsy then the decrease dose or frequency. Sometimes tweaking and making little changes is all that’s needed.
- Read the Writing on the Wall: if the sibling or parent responded well to aripiprazole then yes I’ll take it Alex for $500! with medications, don’t try to overcomplicate the situation. If we have a reliable reference point and source, then yes let’s start there. What if there’s no family history or anything? Great, go back to the standards and what has usually helped. With special populations, try to stick with the zebras and leave the unicorn meds alone at least in the beginning.
Side-Effects vs. Adverse Reactions
Quick Review: a side-effect is intended results from the medication and an adverse reaction is unintended/unpredictable results from the medications. For example, hives may be a side-effect of the medication but seizures will be an adverse reaction. The biggest complication of an adverse reaction is anaphylaxis because people shouldn’t take a medication that intends to cause death. However, these things are not readily known until the medication is at a higher dose, combined with another medication, or for many other random reasons.
The moral of this point is that I treat adverse reactions like complications. If you have a seizure while taking a stimulant, then I’m treating it as an allergy. It’s not a true allergy like a rash, but I know I don’t want to give that medication again and risk another seizure. So I would flag the medication like an allergy, though it’s just an adverse reaction. Some may consider it wrong or false, but I’ll rather be safe than sorry. If the child grows out of it, that’s beautiful but in the meantime, I don’t want to take the risk or actually induce a real seizure disorder. Side-effects are different and usually are just uncomfortable, self-limiting, or dose-related… so I’m going to mainly discuss treating the side effects. For adverse reactions, don’t prescribe the KID the medication again.
How to Deal with the FEW Side-Effects (with kids and adults)
- Nausea/Vomiting: N/V/D is tricky because it can be the medication or the kid just not tolerating it. However, regardless of the reason, I would consider it an adverse reaction after >3 episodes. We don’t want a young child consistently vomiting or getting dehydrated. If you continue the medication, tell the parent to use carbonated drinks or the kid’s favorite drink so it’s more tolerated, or see if the med can be crushed or sprinkled. Plus advise that the med may have to be taken with meals because I’ve taken vitamins that said it can be taken on an empty stomach and it’s simply not true. This is why before prescribing to kids, you have to assess the nutrition and know how well the child can tolerate medications. You may have to consider different formulations: sublingual, liquid, patch, or even smaller pills/dosages.
- Tics: this is different from a “tic disorder“, in which we want to treat the tics till remission. Tics can usually occur from antidepressants and stimulants but it can be with any medication and managed in several ways. (1) decrease the dose; sometimes going back to the previous dose is all that’s needed. (2) clonidine and guanfacine are the main medications that can treat tics, other options are risperidone and aripiprazole but it’s a safer practice to not use more medications to treat s/e. (3) consider switching the medication or only using brand names (yes it sometimes makes a huge difference). (4) Consider taking breaks over the weekend/holidays like with stimulants, which goes back to the previous point of just decreasing the dose. (5) with tics, you can increase the dosages of treatment (clonidine, guanfacine, risperidone, aripiprazole) but if the tics get worse or more frequent (unpredictable) I would treat it as an adverse reaction.
- Weight Loss: is usually a major issue with stimulants. Tell the family how it’s important to take the dose with meals, use a different formulation such as methylphenidate or consider non-stimulants, atomoxetine i.e. and remember taking those Rx holidays/weekend breaks.
- Weight Gain & Gynecomastia: If a child gains >10 pounds in a month, then the medication is problematic. Kids are still growing of course but not that quickly. I would take precautions if it’s >5lbs because again it’s easier to avoid problems if they’re caught early. Consider lowering the dose and using other medications that either decrease the appetite i.e. topiramate or is more weight neutral i.e. paliperidone or ziprasidone versus olanzapine. Continue to promote healthy eating and activities. If weight continues to go up or down, I’ll probably d/c medication. Check and monitor labs:
| AIMS | baseline -> q6 months |
| Blood Pressure | baseline -> q3months -> annually |
| Glucose | baseline -> q3 months -> annually |
| Lipids | baseline -> q3 months -> annually |
| Waist Circumference | baseline -> annually |
| Weight | baseline -> qmonth x3 -> q3 months |
Adverse Reactions
Medications usually come with a booklet of side effects but I wanted to emphasize that with kids, we want simple or only a few manageable side effects. In other words, if that side-effect is becoming more difficult, I may put it in the adverse category. Therefore, I have wayyy more red flags in the adverse category with young kids than with adults. Also, note how this difference is usually NOT reflected in the EMR so it’s truly a personal preference that has significantly helped me out.
These are the following reason why I’ll d/c a medication in children: syncope, seizure, chest/cardiac pain, DIB, hives/rash, swelling, the kid is pulling out hair or increase poor mood/agitation, decrease or change in memory, increase headaches or bleeding (increase nosebleeds with clonidine is a major d/c for me), suicidal/homicidal/severe aggression, night terrors/increase bedwetting, increase bad thoughts or hallucinations, RLS/EPS, and persistent N/V/D.
Some of these issues adults can manage such as N/V, mood, and behaviors. Other times patients would list these adverse reactions as an “allergy”, which is fine -they simply don’t want to be put on a medication that they know is going to be problematic.
I just want to be clear how this is not the same as people who are “allergic” to morphine so they want hydromorphone to get buzzed, I’m specifically talking about psych medications alone. Most of our medications are taken on an outpatient basis, so you want to pay attention to those adverse reactions where the patient is usually not in a hospital being monitored….
Think about how this adverse reaction could be inappropriate if the patient happens to be driving or working a risky job such as construction or a police officer. If my patient is doing Door Dash, I don’t want to use a medication that the person has said caused past hallucinations.
However, sometimes people would request to stay on the medication despite the reactions or grow out of it, which is fine as well but mainly for adults. For children, I just advise providers to proceed with caution (start low/go slow) and let the parent know how to handle these events and emergencies.
