Providers must take responsibility for monitoring and addressing adverse reactions, as ignoring them can lead to complications. Key Strategies for Avoiding Poor Responses:
- Start Low, Go Slow: Begin with micro doses to minimize adverse reactions, especially since children may not articulate problems well. Gradual titration ensures safety. In addition, like with the elderly (starting low/slowly increasing dose), you 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.
- Medication History: consider using genetic testing when possible and adjust existing medication schedules based on improving the positive effects.
- Consider Family History: If a parent or sibling has responded well to a medication, it’s a logical safe starting point. Otherwise, stick to established standards before exploring less common options.
The overall message is to proceed cautiously, prioritize safety, and adapt treatment based on individual responses and available evidence.
Side-Effects vs. Adverse Reactions
A Quick Review: a side-effect is the intended results from the medication and an adverse reaction is the 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 reactions may not be 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 someone having 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, DO NOT 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 medication 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 smaller pills/dosages.
- Tics: this is different from a “tic disorder“, in which Tourette’s is permanent….With tics from a medication you prescribed, you want to treat it until remission. Tics usually occur from antipsychotics 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 side-effects. (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 and discontinue the medication.
- 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 for example and consider taking those Rx holidays/weekend breaks. If the child is losing <2-5 pounds per month, I’ll treat it as an adverse reaction.
- 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 continuously goes 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 |
About Adverse Reactions
Medications usually come with a booklet (insert) of side-effects but I wanted to emphasize that with kids, we want only a few manageable side effects if any… 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 discontinue a medication in children: syncope, seizure, chest/cardiac pain, breathing risks, 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 or distress, 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….Another rule of thumb for me is I would think how this adverse reaction could be inappropriate if the person was driving, at school, 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 hallucinations in the past.
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 family or patients know how to handle these unforeseen events or circumstances.
