Download PaedCh 14_Psychiatry RN_4C_ March 2017

PAEDIATRIC HOSPITAL LEVEL ESSENTIAL MEDICINES LIST
CHAPTER 14: CHILD AND ADOLESCENT PSYCHIATRY
NEMLC 2 MARCH 2017
CHAPTER NAME:
The Paediatric Committee recommended that the chapter name be changed from 'Paediatric Psychiatry'
to 'Child and Adolescence Psychiatry. Since adolescence is not covered by the Adult STG and EML, it is
important to incorporate this group in the chapter.
NEW SECTIONS ADDED:
The following new sections were added:
 Elimination Disorders: Enuresis (transferred from Nephrological and Urological Chapter - with a
referral from this chapter) and Encopresis
 Bipolar Disorder: included under Mood disorders
 Feeding and Eating Disorders section was added: This section contains sub-sections, Pica,
Avoidant/restrictive food intake disorder, Anorexia nervosa, and Bulimia Nervosa.
 Autism Spectrum Disorder added:
 The 'Substance Abuse' section was amended to 'Substance use disorder' and the following subsections were incorporated: Substance induced psychotic disorder; substance induced mood
disorder; substance withdrawal (including: alcohol withdrawal and alcohol withdrawal delirium,
opioid withdrawal; stimulant/methaqualone/cannabis withdrawal; benzodiazepine withdrawal)
 Behavioural problems associated with intellectual disability
Diagnostic Criteria
The diagnostic criteria were aligned to the Diagnostic and Statistical Manual of Mental Disorders (DSM5), updated from the DSM IV.1
MEDICINE AMENDMENTS
SECTION
14.2.1 Enuresis
Medicine Treatment
MEDICINE
Desmopressin
14.3 Attention Deficit Hyperactivity Disorder (ADHD)
Medicine Treatment
Methylphenidate long acting
14.4.2 Bipolar Disorder
Risperidone
Medicine Treatment
Sodium Valproate
Lithium Carbonate
14.4.3 Disruptive mood dysregulation disorder (DMDD)
Medicine Treatment
Risperidone
ADDED/DELETED/NOT ADDED
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Not added
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Removed
1
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5).
May 2013.
PaedCh14_Child and Adolescent Psychiatry_ 4N_March 2017
14.5.1 Generalised Anxiety Disorder (GAD)
Medicine Treatment
Citalopram
14.6 Obsessive Compulsive Disorder (OCD)
Medicine Treatment
Citalopram
14.7 Post Traumatic Stress Disorder (PTSD)
Medicine Treatment
Citalopram
14.10 Tic Disorders
Haloperidol
Medicine Treatment
14.12 Autism Spectrum Disorder
Medicine Treatment
14.13.3.1 Alcohol withdrawal
Risperidone
Thiamine
Diazepam
14.13.3.2 Alcohol withdrawal delirium
Thiamine, IV and oral
Benzodiazepines (diazepam,
Medicine Treatment
clonazepam, lorazepam)
Haloperidol IV, IM
14.13.4 Opioid withdrawal
Hyoscine
Loperamide
Medicine treatment
Morphine, oral/IV
Phenobarbitone , oral
Phenytoin, oral
14.14 Behavioural problems associated with intellectual disability
Medicine Treatment
Risperidone
Medicine Treatment
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Removed
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14.2 Enuresis
Desmopressin: Added
The Paediatric Committee recommended enuresis should be moved from the Nephrological and
Urological Chapter to the Psychiatry Chapter, Elimination disorders. Desmopressin was the previous
recommendation, and recommended to be retained, for use short term use only.
14.3 Attention Deficit Hyperactivity Disorder (ADHD)
Methylphenidate long-acting: Not added
See Review-Motivation, and Discussion documents for further details.
14.4.2 Bipolar Disorder
Risperidone: Added
PaedCh14_Child and Adolescent Psychiatry_ 4N_March 2017
Sodium Valproate: Added
Lithium: Added
An antipsychotic agent is usually the first line therapy for patients presenting with psychosis or
behavioural disturbances, and will have a more rapid response rate than mood stabilisers such as
lithium. Treatment can then be augmented with a mood stabiliser in partial responders. 2
Risperidone is the antipsychotic agent recommended for first line therapy in the Standard Treatment
Guidelines. There are limited studies in children, however an industry -conducted double-blind
randomised placebo-controlled trail in children aged 10-17 showed risperidone to be significantly
superior to placebo in reducing Young Mania Rating Scale (YMRS) scores. In an open-label study in
children aged 4-6 years also showed risperidone to be effective, however outcome measure is not
universally accepted. 2
Lithium and sodium valproate were the added mood stabiliser options. These agents are currently
available on the Essential Medicines List for Adults. Lithium has shown to have positive effects in both
acute treatment and maintenance. Sodium Valproate has been shown to be effective in reducing
severity of mania.2
The following text was added:
Acute phase treatment
» Refer patients with a suspected manic episode or suicidal ideation immediately to a psychiatrist for
assessment and possible admission.
» Sedate before transfer. Refer to section 14.1: Sedation of an acutely disturbed child or adolescent.
» If no previous medication used, while awaiting admission and in consultation with a psychiatristinitiate atypical antipsychotic and mood stabilizer:
•
Risperidone, oral
5-12 years (under 50kg):
o Starting dose: 0.01 mg/kg/day
o Maintenance dose: 0.02 - 0.04 mg/kg/day
13-17years:
o Starting dose: 0.5 mg daily
o Maximum dose: 3 mg daily
o Use lowest effective dose to limit adverse long term side effects and to facilitate adherence.
o Increase dose by 0.25–0.5 mg daily every 1–2 weeks, depending on tolerability and age.
Mood stabiliser: lithium carbonate or sodium valproate:
• Lithium carbonate: oral (for patients aged 12-17 years)
o Initial dose 20 mg/kg/day in 2-3 divided dosages. Lithium level after 5 days. Increase accordingly.
Therapeutic range 0.6-0.8 mmol/l. Be careful of narrow therapeutic margin-risk of toxicity.
o Ensure investigations prior to initiation of treatment.
o Haematological investigations: FBC and P, urea, creatinine and electrolytes, CMP, TSH and
BHCG.
2
Taylor D, et.al. The Maudsley Prescribing Guidelines, 10th Edition. Informa Healthcare. 2009.
PaedCh14_Child and Adolescent Psychiatry_ 4N_March 2017
o
o
•
Cardiac investigation includes: ECG.
Ongoing monitoring: lithium levels 1-3 monthly: TSH and creatinine 6-12 monthly.
Sodium valproate: oral
o 20 mg/kg/day: divided 12 hourly
o Usual range: 20-30 mg /kg/day
Maintenance treatment
» If previously on maintenance medication: re-initiate treatment in consultation with a psychiatrist.
» Ongoing psychoeducation regarding the illness, medication, compliance etc.
» Once stabilised, the patient can be referred for individual psychotherapy.
» The family may benefit from referral for family therapy.
Level of Evidence: II - mainly open labels trials
14.4.3 Disruptive mood dysregulation disorder (DMDD)
Risperidone: Removed
There are no specific recommendations for the management of DMDD. The Paediatric Committee
recommended that these patients may be treated as ADHD, however most patients will require referral
to a psychiatrist.
14.5.1 Generalised Anxiety Disorder (GAD)
Citalopram: Added
The Paediatric Committee recommended that citalopram be added as an alternative to fluoxetine
where there is a poor response to fluoxetine after 4-6 weeks, and in the case where doses smaller then
20mg are required (fluoxetine only available as a 20mg capsule).
The text was amended as follows:
 Fluoxetine, oral, 0.5 mg/kg/day
o Dose range: 20–40 mg daily
o Recommended average dose: 20 mg/day
However, fluoxetine may only be available in 20mg capsules, in which case citalopram tablets can be
used initially, titrated to 20mg and then changed to fluoxetine 20mg
If there is a poor response to fluoxetine after an adequate trial of treatment, i.e. 4–6 weeks- consider an
alternative SSRI.

Citalopram, oral, 0.4 mg/kg/day
o Dose range: 5–40mg daily
o Recommended average dose: 10–20 mg/day
PaedCh14_Child and Adolescent Psychiatry_ 4N_March 2017
14.6 Obsessive Compulsive Disorder (OCD)
Citalopram: Added
Added as an alternative to fluoxetine, as outlined above.
14.7 Post Traumatic Stress Disorder (PTSD)
Citalopram: Added
Added as an alternative to fluoxetine, as outlined above.
14.10 Tic Disorders
Haloperidol: Removed
Risperidone has been shown to be more effective than placebo in a small randomised study (n=34). 3
Haloperidol was not shown to be statistically significantly better than placebo in a small double-blind,
placebo controlled study. 4 Additionally haloperidol is poorly tolerated in children and adolescents.2
The Paediatric Committee thus recommended that risperidone be used to manage severe symptoms,
and haloperidol be removed.
The text was amended as follows:
Medication is used when the tics impair functioning and ideally for short periods only in order to reduce
severe symptoms. The natural course of tics is to ‘wax and wane’.
 Risperidone, oral.
o Starting dose: starting at 0.25mg/day (<20kg) and 0.5 mg/day (>20kg)
o Recommended average dosage 1 mg/day
o Dosage range: 0.25 mg - 3 mg
For severe and frequent tics that seriously impact on child's functioning:
 Haloperidol, oral, 0.02-0.12 mg/kg/day
o Dose range: 0.25-1.75 mg 12 hourly
o Recommended average dose: 0.5-2 mg/day
o Monitor for extrapyramidal and anticholinergic side effects.
If poor response:
 Risperidone, oral, 0.5 mg/day
o Dose range, 0.5-3 mg/day
o Recommended average dosage 1mg/day.
Level II: Small RCTs
3
Scahill L et al. A placebo-controlled trial of risperidone in Tourette syndrome. Neurology 2003; 60:1130–1135.
Sallee FR et al. Relative efficacy of haloperidol and pimozide in children and adolescents with Tourette disorder.
Am J Psychiatry 1997; 154:1057–1062.
4
PaedCh14_Child and Adolescent Psychiatry_ 4N_March 2017
14.12 Autism Spectrum Disorder
Risperidone: Added
Pharmacotherapy is often needed in addition to psychological intervention. The bulk of the evidence of
efficacy in management is for risperidone.2 The Paediatric Committee thus recommended the addition
of risperidone as a treatment option.
The following text was added:
MEDICATION TREATMENT
Not for core autistic symptoms.
For irritability, severe aggression and self-injurious behaviour:
• Risperidone: 5-12 years under 50kg
o Oral, starting dose: 0.01 mg/kg/day
o Maintenance dose: 0.02 - 0.04 mg/kg/day
14.13.3.2 Alcohol withdrawal delirium
Thiamine, oral/IV: Added
Benzodiazepines (diazepam, clonazepam, lorazepam): Added
Haloperidol IV/IM: Added
Management of alcohol withdrawal delirum was aligned with the Adult Standard Treatment Guidelines
and Essential Medicines List.5
14.13.4 Opioid Withdrawal
Hyoscine: Added
Loperamide: Added
Morphine oral/IV: Added
Phenobarbitone, oral: Added
Phenytoin, oral: Added
Hyoscine butyl bromide was added for stomach cramps associated with opioid withdrawal, in line with
the pain and palliative care chapter. Loperamide was added for consideration in the management of
diarrhoea associated with opioid withdrawal. Morphine IV and oral were added as part of the weaning
protocol for opioid withdrawal. Since nervous system disturbances, such as seizures, may occur with
opioid withdrawal, management was added.
The following text was added:
For stomach cramps:
 Hyoscine butyl bromide: oral
5
National Department of Health. Adult Hospital Level Standard Treatment Guidelines and Essential Medicines LIst.
2014.
PaedCh14_Child and Adolescent Psychiatry_ 4N_March 2017
o
o
o
1-3 years: 5-10 mg 8 hourly
3-6 years: 10 mg 8 hourly
6-18 years: 10-20 mg 8 hourly
For diarrhoea:
 Loperamide: oral
o Over 2 years: initially 1mg/12.5kg body mass. Followed by 0.5mg/12.5kg after each loose stool.
Alternatively, 0.08-0.24mg/kg/day in 2-3 divided doses.
o 12-18 years: initially 4 mg. Followed by 2 mg after each loose stool. Maximum dose of 6mg in 24
hours.
The weaning protocol should take into account the length of opioid exposure and total daily opioid
dose. The generally approach is to transition to a longer-acting opioid formulation, such as extendedrelease morphine. Weaning is usually accomplished by steps of a 10% to 20% decrease in the original
dose every 24 to 48 hours.
 Morphine
o Oral: 0.05 mg/kg/dose 3 hourly
o IV: 0.02 mg/kg/dose 3 hourly
Weaning after 48 hours:
o Oral: 0.01 mg/kg/dose 3 hourly
o IV: 0.005 mg/kg/dose 3 hourly
For CNS disturbances (e.g. seizures):
 Phenobarbitone: oral
o 5mg/kg/dose 12 hourly or daily
OR
 Phenytoin: oral
o 5mg/kg/day in 2-3 divided doses
o Maximum dose: 300mg daily
o Maintenance dose: 5-8mg/kg/day
14.14 Behavioural problems associated with intellectual disability
Risperidone: Added
Risperidone is registered for children with developmental disorders from 5 years of age. The Paediatric
Committee recommended the addition of risperidone as part of a multidisciplinary diagnostic and
therapeutic intervention.
The following text was added:
For disruptive behaviour disorders in intellectual disability:
 Risperidone is registered for children with developmental disorders >5 years old. Dose 5-12 years:
0.01mg/kg/day. Maintenance 0.02-0.04mg/kg/day
 Do baseline blood tests and ECGs, particularly in children with underlying medical conditions.
 Start with the lowest doses possible.

Increase dosages cautiously as children with intellectual disability may be more susceptible to
adverse effects such as extrapyramidal side effects (EPSEs), neuroleptic malignant syndrome (NMS)
or the disinhibiting effects of benzodiazepines.
PaedCh14_Child and Adolescent Psychiatry_ 4N_March 2017
PaedCh14_Child and Adolescent Psychiatry_ 4N_March 2017