W11 Pediatric Clinical Reference Tool

Week 11 Discussion 1: Pediatric Clinical Reference Tool

Kathryn Sutherland, Lisa Liddell & Luis Cabrera

Regis College School of Nursing

NU 643 Advanced Psychopharmacology

Dr. Nicole Walters

November 12, 2021

Group 2: Depression

Child (Ages 5-10)

Adolescent (10-19) (Ok to type “same as child” if

appropriate)

Notable differences from adults (if applicable)

Description of the Disorder in Pediatric Populations

● MDD affects 2% of children ● Irritable or depressed mood

as observed by self-report or observed by others.

○ Irritability may present as angry or hostile behavior.

○ Children seven and younger may have a difficult time describing internal mood states.

○ Children may describe depressive symptoms in vague somatic pain or symptoms.

○ Children may be observed to have sad facial expressions, tearful, or are physically not engaging (poor eye contact).

● Loss of interest may be observed in peer play and in school activities and may be indicative of a loss of interest.

● The child may be observed with weight loss which could be indicative of depression.

● Fatigue may be observed as school refusal and school absences.

● Poor school performance may be indicative of a diminished ability to concentrate.

● The child may be observed

Same as a child with the addition of:

● MDD affects 8% of adolescents.

● Depression may be self-medicated with substances in the adolescent population.

● MDD in adolescents has been linked to more chronic and recurrent depression in adulthood.

● Diagnostic criteria for children, adolescents, and adults are essentially the same and are based on the DSM-5. However, children and adolescents may not be able to accurately describe and identify internal mood states and it is important to watch for specific signs as described in the descriptions.

● Insomnia or hypersomnia is present in both children, adolescents and adults with depression.

to give away favorite items and may be indicative of suicidal ideation/planning with or without intent.

● MDD and dysthymic disorder can both be present in childhood.

● Daily living, and family and peer relations functions are impaired by depression as described above.

● Providers should be on the lookout for insomnia and weight loss, attentional difficulties, irritability, aggression, and social or academic impairment in depression in children.

Treatment Recommen dations (place asterisk next to treatments that are FDA approved)

● For mild depression, cognitive behavioral therapy should be used.

● Interpersonal psychotherapy adapted for adolescents (IPT-A) is also a recommended therapy.

● In severe depression, psychotherapy should be used alongside medication

● First-line recommended treatment for MDD in children: Fluoxetine (approved ages 8+)*

● Second-line: ○ Sertraline (Zoloft) ○ Escitalopram

(Lexapro) ○ Citalopram

(Celexa) ● APA recommends NOT

using: ○ Clomipramine ○ Imipramine ○ Mirtazapine ○ Paroxetine

● Same as child ● Escitalopram (approved

ages 12+)* ● Venlafaxine may be

effective for adolescent depression, not found to be better than placebo for children 7-17 years

● First-line treatment options include psychotherapy and/or pharmacotherapy.

● Pharmacological first-line agents include: Bupropion or an SSRI such as sertraline or escitalopram. They have minimal drug interactions and minimal side effects.

*FDA Approved

○ Venlafaxine

In the treatment of depression in children/adolescents.

Safety Issues (Include any medications /treatments that are contraindica ted in pediatric populations or have warnings)

● FDA black box warning for all antidepressants regarding risk of suicidal ideation and behavior in children and adolescents under age 25

● Sudden death has occured in children taking tricyclic antidepressants at therapeutic dose

● Tricyclic antidepressants toxic in overdose

● Paroxetine not recommended for use in children due to severe discontinuation symptoms and risk of suicide.

● Untreated depression in children can impair cognitive, emotional, and social skill development.

● Abuse can contribute to signs and symptoms of depression in children

● Antidepressant black box warning for suicide, same as child

● Children and adolescents with depression are at higher risk for substance use disorders, physical illness, poor work and academic performance, legal problems, and early pregnancy.

● No known increase in suicide risk for adults taking antidepressants, decreased risk for adults 65 and older

● Tricyclic antidepressant overdose risk same as for children and adolescents

References

Bhatia, S. K., & Bhatia, S. C. (2007). Childhood and adolescent depression. American family

physician , 75 (1), 73–80.

Birmaher, B. & Brent, D. (2007). Practice parameter for the assessment and treatment of children

and adolescents with depressive disorders. Journal of the American Academy of Child &

Adolescent Psychiatry , 46(11), 1503-1526. https://pubmed.ncbi.nlm.nih.gov/18049300/

Cheung, A. H., Zuckerbrot, R. A., Jensen, P. S., Laraque, D., Stein, R. E., & Glad-PC Steering

Group. (2018). Guidelines for adolescent depression in primary care (GLAD-PC): Part II.

Treatment and ongoing management. Pediatrics , 141 (3).

Clark, M. S., Jansen, K. L., & Cloy, J. A. (2012). Treatment of childhood and adolescent

depression. American family physician , 86 (5), 442-448.

Feder, J., Tien, E., & Puzantian, T. (2018). Child medication fact book for psychiatric practice .

Newburyport, MA. Carlat Publishing, LLC.

Moreland, C. S. & Bonin, L. (2021). Pediatric unipolar depression and pharmacotherapy:

Choosing a medication. UpToDate . Retrieved November 11, 2021 from

https://www.uptodate.com/contents/pediatric-unipolar-depression-and-pharmacotherapy-

choosing-a-medication?topicRef=1231&source=see_link#H359886

National Institute for Health and Care Excellence. (2019). Depression in children and young

people: Identification and management. NICE . https://www.nice.org.uk/guidance/ng134

Oberlander, T. F., & Miller, A. R. (2011). Antidepressant use in children and adolescents:

Practice touch points to guide paediatricians. Paediatrics & child health , 16 (9), 549–553.

https://doi.org/10.1093/pch/16.9.549