Pediatric patient depression

Pediatric patients should be observed closely for suicidality, worsened depression, agitation, irritability, and unusual changes in behavior, especially during the initial few months of therapy or at times of dosage changes. Furthermore, families and caregivers should be advised to monitor patients for such symptoms. 

Antidepressant medications appear to be useful for certain children and adolescents, particularly those who have severe or psychotic depression, fail psychotherapeutic measures, or experience chronic or recurrent depression. SSRIs generally are considered the initial antidepressants of choice, although comorbid conditions may favor alternative agents. Clinicians should be aware of the possibility of behavioral activation with the SSRIs, including such symptoms as impulsivity, silliness, daring conduct, and agitation.44 Desipramine should be used with caution in this population because of several reports of sudden death, and a baseline and follow-up electrocardiogram (ECG) may be warranted when this medication is used to treat pediatric patients.9... 

Suicidality in children and adolescents Antidepressants increased the risk of suicidal thinking and behavior (suicidality) in short-term studies in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of trazodone or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber. Trazodone not approved for use in pediatric patients (see Clinical worsening and suicide risk and Children sections in Warnings). 

Pediatric patients who develop psychiatric syndromes in association with chronic illness (e.g., major depression in a patient with cystic fibrosis)... 

The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric. 

Labeling of most drugs in this group was recently revised to include a warning statement concerning a worsening of depression and treatment-emergent suicidality in both adult and pediatric patients. 

The lack of classic muscarinic effects does not exelude the possibility of cholinesterase inhibitor poisoning in young children with central nervous system depression. In one ease series, tearing and diaphoresis were not observed in pediatrie patients (Lifshitz et al, 1999). Miosis was absent in a number of pediatric patient cases reported in the literature with 27% of children in one case series lacking miosis on admission (Zwiener and Ginsburg, 1988). The percentage was 20% in another case series of pediatric patients (Sofer et al, 1989). 

U.S. Food and Drug Administration. Reports of suicidality in pediatric patients being treated with antidepressant medications for major depressive disorder. FDA Public Health Advisory, October 27, 2003. http //fda.gov/ cder/drug/advisory/mdd.html. Accessed January 15, 2004. 

The most common adverse reaction is somnolescence (although agitation and hyperactivity may be seen in pediatric patients), followed by sedation depression and. infrequently, psychosis. Nausea and vomiting may also occur. 

Relative they are contraindicated in the management of acute or post-operative pain. They are not indicated for use in opioid non-tolerant patients. The safety and efficacy of fentanyl buccal tablets and fentanyl oralet have not been establidied in pediatric patients below the age of 16 years. They ould be used cautiously in patients with a history ofbradyarrhthymias, or with evidence of increased intracranial pressure or impaired consciousness, or with history of chronic obstructive pulmonary disease, or preexisting medical conditions predisposing them to respiratory depression. 

For pediatric patients undergoing posterior spinal fusion and segmental spinal administration for idiopathic scoliosis, a dose of pre-operative intrathecal morphine ranging from 9 to 19 (xg/kg with a mean of 14 (Xg/kg provided effective analgesia with a low frequency of respiratory depression and intensive care unit admission [5]. Another report of pediatric spinal fusion patients showed no advantage of 15 pg/kg intrathecal morphine over a dose of 5 pg/kg [6]. 

Nosocomial lower respiratory tract infections (LRI) represent a significant concern to those caring for hospitalized infants and children because of both their frequency and their potential severity. Pneumonia is the second most common nosocomial infections in all patients hospitalized in the United States regardless of age (1,2). Data from the National Nosocomial Infections Surveillance (NNIS) System documents that nosocomial pneumonia is the second most frequent hospital-acquired infection in critically ill infants and children as well (2,3). Many of the significant risk factors for the development of nosocomial pneumonia previously identified in adult patients, such as severe underlying cardiopulmonary disease, immunosuppression, depressed sensorium, and prior thoracoabdominal surgery, are present in pediatric patients and place them similarly at risk for nosocomial lower respiratory tract infections. In addition, there are specific clinical situations that are unique for neonatal and pediatric patients that provide additional risks for severe nosocomial lower respiratory tract infections (Table 1). 

Suicide risk Patients with major depressive disorder, both adult and pediatric, may experience worsening of their depression and/or the emergence of suicidal ideation and behavior (suicidality), whether or not they are taking antidepressant medications, and this risk may persist until significant remission occurs. 

Table 10.1 summarizes the results of available pediatric neuroimaging studies in depressed patients. Given the limited amount of available data, published papers and professional presentations are reviewed. Two of the eight studies included seven or fewer depressed subjects, and two had no normal control comparisons. Results from the three largest-scale studies suggest that there are some neuroanatomical correlates of depression that may be evident across the life cycle (e.g., frontal lobe and amygdala volume changes), and others... 

Controlled studies involving lipid manipulation in children date back to the 1920s, when the ketogenic diet was pioneered to control treatment-resistant seizures in select pediatric populations (Freeman et al., 1998). However, no controlled evidence is available in children with depression, bipolar disorder, behavioral problems, or ADHD. In the absence of definite empirical data about effectiveness, treatment with EFA supplements should be considered unproven and patients ought to be advised accordingly. 

As may be expected, studies of antidepressants in treatment of ADHD have not shown a differential effect in ADHD children with or without conduct disorder, depression, or anxiety (Biederman et ah, 1993b). While DMI-treated ADHD children showed a substantial reduction in depressive symptoms compared with placebo-treated patients (Biederman et ah, 1989), DMI appears not to be as powerful an antidepressant in children as the SSRls. (Bostic et ah, 1999). The safety and efficacy of combined SSRl and stimulant pharmacotherapy has been addressed in two open studies and is currently being evaluated in a prospective study conducted by the Resarch Units in Pediatric Psychopharmacology (RUPP) Network (B. Vitiello, personal communication). 

The MAOIs have been found to be beneficial for patients who have not responded to other medications (Thase and Rush, 1997 APA, 2000). An open study suggested that adolescents with depression who did not respond to TCAs responded to MAOIs (Ryan et ah, 1988b). However, it is possible that these adolescents did not respond to TCAs because this group of medications is not efficacious for the treatment of pediatric MDD (Birmaher et ah, 1996a). 

Medical illness or medication side effects may directly affect cognition virtually all classes of medication have been implicated. In adult patients, glucocorticoids can impair memory at relatively low doses (Keenan et ah, 1995 Newcomer et ah, 1999), as there are postulated effects on hippocampal neurons. Newcomer et ah, (1999) have reviewed the literature on illnesses in adults in which memory inversely correlates with cortisol levels, such as in Cushing s disease, Alzheimer s dementia, schizophrenia, and depression. There is no similar literature on the pediatric population. The risk of memory impairment puts chronic steroid treatment, such as that seen in certain pediatric rheumatologic disorders and severe asthmatics, for example, into a different perspective, however. Documentation of memory both before and during chronic steroid treatment might help determine detrimental effects in the pediatric population. 

Investigators from the Department of Pediatrics in Johns Hopkins Hospital, after seeing a neonate who had marked leukocytosis temporally related to alprostadil, conducted a retrospective study of neonatal leukocytosis induced by alprostadil in 45 neonates (5). They concluded that alprostadil infusion is a predictable cause of leukocytosis in neonates with congenital heart disease. Alprostadil-induced leukocytosis was especially prominent in three patients with splenic disorders associated with the hetero-taxy syndrome. Many of the other adverse effects of alprostadil, including respiratory depression, hypotension, fever, and lethargy, were also associated with sepsis. The authors considered that it is reasonable to look for sepsis in infants receiving alprostadil, but that it is equally reasonable to withdraw empirical therapy once infection has been ruled out. Leukocytosis associated with alprostadil infusion has not been previously reported and is not listed in the alprostadil package insert. 

Neuroleptic drug poisoning in 86 children has been retrospectively studied in two pediatric hospitals in the USA (1987-1997), with about 9000 and 11 000 annual admissions (617). Most (70%) occurred in children under 6 years of age over two-thirds of the cases (78%) were unintentional. The owner of the medication, when identified (85% of cases), was the grandmother (22%), another family member (21%), the patient (13%), or a non-family caregiver (8%) the most common places where ingestion occurred were the patient s home (64%) or a relative s home (22%). There was a depressed level of consciousness in 91% and a dystonic reaction in 51% there were no deaths. 

Nervous system stimulation is less frequent than nervous system depression, but when it occurs it causes insomnia, irritability, and tremor nightmares, and hallucinations. In overt intoxication, these effects may be related to anticholinergic effects. In an analysis of 113 200 admissions to a pediatric hospital there were only two patients with excitation, insomnia, visual hallucinations, and seizures, followed by coma (71). 

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