Behavioral Concerns, EEG Monitoring — Medication Options — Clinical Pathway: Inpatient and Outpatient Specialty Care

Behavioral Concerns, Child Undergoing EEG Monitoring Clinical Pathway — Inpatient and Outpatient Specialty Care

Medication Options for Children with Behavioral Concerns Undergoing EEG

Some medications can impact EEG data. Clinicians should attempt non-pharmacologic methods for children with behavioral concerns prior to ordering the medications below.

Pre-medication for Treatment of Anticipated Agitation

For mild behavioral concerns, the first line approach should be behavioral interventions. Medications may be needed for more moderate or severe behavioral concerns.

  • Outpatient: Neurology clinician should order and instruct parent/caregiver on use. Generally administer about 15 minutes prior to EEG appointment.
  • Inpatient: Neurology clinician should note preferred option and discuss with parent/caregiver. The inpatient care team will order the medication and adjust the plan, if needed. Consider Behavioral Health Integrated Program (BHIP) consult for further advice via PHL Psych Cnslt.

For most children, the order of preference is:

  1. Clonidine
  2. Risperidone
  3. Quetiapine
  4. Olanzapine
  5. Hydroxyzine (preferred over diphenhydramine)

Medication Options for Anticipated Agitation

Drug Class Route Dose Onset Action Duration Side Effects/Comments
Clonidine α-2 Adrenergic Agonist PO
  • < 45 kg: 0.05 mg
  • ≥ 45 kg: 0.1 mg
 30 min 6 hrs
  • Bradycardia
  • Hypotension
  • Preferred agent for children with autism spectrum disorder or developmental delays
Risperidone Antipsychotic PO
  • 15-35 kg: 0.25 mg ODT
  • ≥ 35 kg: 0.5 mg ODT
  • Can repeat after 60 min
    if not effective
 < 60 min 15 hrs
  • QT prolongation
  • Tachycardia
  • Hypertension
Quetiapine PO
  • 15-35 kg: 12.5 mg
  • ≥ 35 kg: 25 mg
 15-30 min 5 hrs
  • Consent is required for < 2 yrs of age
  • QT prolongation
  • Orthostatic hypotension
  • Extrapyramidal symptoms (EPS)
Olanzapine PO
  • 30-60 kg: 2.5 mg
  • ≥ 60 kg: 5 mg ODT
 20-30 min 24 hrs
  • Consent is required for &tl; 4 yrs of age
  • QT prolongation
  • Orthostatic hypotension
  • IM olanzapine is restricted to behavioral health,
    see CHOP formulary for olanzapine usage.
  • IM olanzapine should not be given any sooner than 3 hrs after IV/IM benzodiazepines
Hydroxyzine Antihistamine PO
  • 0.5 mg/kg
  • Can repeat after
    30 mins if not effective
  • (Max total 50 mg)
 15-30 min 4-6 hrs
  • Drowsiness
  • Dizziness
  • Cognitive dysfunction
  • QT prolongation
  • Preferred over diphenhydramine

Medication Options for Agitation

For most patients, the order of preference is:

  1. Risperidone PO
  2. Olanzapine PO
  3. Midazolam IN, PO or IV
    • Note dosing differences based on route.
    • Try to avoid benzodiazepines, given the goal of capturing seizures and events
  4. Haloperidol IM

Agitation Medications

Drug Class Route Dose Onset Action Duration Side Effects/Comments
Risperidone Antipsychotic PO
  • 15-35 kg 0.25 mg ODT
  • ≥ 35 kg 0.5 mg ODT
  • Can repeat after 60 min if not effective
 < 60 min 15 hrs
  • QT prolongation
  • Tachycardia
  • Hypertension
Olanzapine PO
  • 30-60 kg: 2.5 mg
  • ≥ 60 kg: 5 mg ODT
 20-30 min 24 hrs
  • Consent is required for < 4 yrs of age
  • QT prolongation
  • Orthostatic hypotension
  • IM olanzapine is restricted to behavioral health,
    see CHOP formulary for olanzapine usage
  • IM olanzapine should not be given any sooner than 3 hrs after IV/IM benzodiazepines
Haloperidol PO

IM
  • < 35 kg: 0.025-0.075 mg/kg
  • ≥ 35 kg: 2.5 mg
  • May repeat x 1 in 30 min

10-20 min

Full effect may take 30 min
 3-6 hrs
  • Consent is required for < 4 yrs of age
  • QT prolongation
  • Extrapyramidal symptoms
  • If dystonia or extrapyramidal symptoms recommend
    • Benztropine IM
      • < 20 kg: 0.05 mg/kg
      • ≥ 20 kg: 1 mg
Midazolam Benzodiazepine IN
  • 0.3 mg/kg
  • (Max 5 mg)
  • May repeat in 20 min
 1-20 min 18-40 min
  • Respiratory depression
  • Disinhibition
  • Onset and duration variable based on route given
PO
  • 0.25-0.5 mg/kg
  • (Max 10 mg)
IV
  • 0.035 mg/kg
  • (Max dose 2 mg)