Supporting Children with Challenging Behaviors — Medications — Clinical Pathway: Primary Care

Supporting Children with Challenging Behaviors Clinical Pathway — Primary Care

Medications

Goal: To reduce anxiety associated with pain related to medical care. Utilize non-pharmacologic techniques first. When non-pharmacological techniques are not adequate, medications or additional interventions may be necessary.

General Considerations

  • Use environmental modifications or de-escalation techniques, biopsychosocial pain management and non-pharmacological resources before medications.
    • e.g., ice packs, comfort positioning, buzzy
  • Review previous medications used that yielded a positive or negative response.
  • Consider current home medications, potential for increasing dosage and/or potential interactions.
  • Child may benefit from trying dose at home before appointment to assess need to increase or decrease dose for day of appointment and/or to assess for paradoxical reaction.
  • Consider giving a dose the evening before if that will help with getting to sleep and decreasing anxiety.
  • Be mindful of onset of action and give medications time to take effect.
  • Depending on the time of administration of medications, children/adolescents should not return to school or operate a vehicle or machinery.
  • Confer with Psychiatry if child linked to a provider or if additional measures are needed.

Medication Information

For additional dosing information, please see formulary.

Medication, PO Pre-visit Dose Onset Action Duration Relative Contra-indications Comments
Diphenhydramine (Benadryl)
  • Liquid 12.5 mg/5 mL
  • Tabs 25 mg, 50 mg
  • Chewable 12.5 mg
  • 2-11 yrs: 1 mg/kg
    max 25 mg
  • ≥ 12 yrs: 1 mg/kg
    max 50 mg
 15-30 min 4-6 hrs Respiratory disease
  • Administer 1 hr before visit
  • Side effects:
    • Sedation, drowsiness, cognitive impairment, paradoxical excitation, anticholinergic effects (e.g., urinary retention, confusion, constipation, dry mouth)
Hydroxyzine (Atarax/Vistaril)
  • Liquid 10 mg/5 mL
  • Tabs 10 mg, 25 mg, 50 mg
  • Cap 25 mg, 50 mg, 100 mg
  • 2-5 yrs: 0.5-1 mg/kg
    max 10 mg
  • 6-11 yrs: 0.5-1 mg/kg
    max 25 mg
  • ≥ 12 yrs: 0.5-1 mg/kg
    max 50 mg
 15-30 min 4-6 hrs
  • Hypersensitivity to cetirizine or levocetirizine
  • Prolonged QT interval
  • Respiratory disease
  • Renal impairment (use ½ dose)
  • Administer 1 hr before visit
  • Side effects:
    • Sedation, dry mouth, drowsiness, cognitive impairment, paradoxical excitation, other anticholinergic effects (e.g., urinary retention, confusion, constipation)
Lorazepam (Ativan)
  • Liquid 2 mg/1 mL
  • Tabs 0.5 mg, 1 mg, 2 mg
  • 3-18 yrs: 0.02-0.1 mg/kg
    max 2 mg
 20-30 min 6-8 hrs
  • Concomitant opioid use
  • Respiratory disease
  • History of substance use
  • Renal impairment
    (consider lower dose)
  • Do not use under 3 yrs
  • Administer 1 hr before visit
  • Side effects:
    • Sedation, anterograde amnesia, drowsiness, respiratory depression, cognitive impairment, motor incoordination, paradoxical excitation