Pediatric Subtopic #P4.2.2

Background: Fast Fact #P4.2.1 discussed relevant definitions and assessment strategies for acute anxiety in children and adolescents with serious illnesses. This Fast Fact will highlight suggested management strategies.

Importance of multimodal management strategies: The management of acute anxiety in children living with serious illness should involve: maximization of non-pharmacologic management, particularly by way of the interdisciplinary team (IDT), and consideration of medication. In general, pharmacologic adjuncts are considered when anxiety is severe enough to impact a child’s quality of life and is refractory to non-pharmacologic interventions.

Non-pharmacologic management strategies: An important initial step is to identify and (if possible) minimize any underlying stressors. Even if a stressor cannot be modified, there is often tremendous therapeutic value to name the stressor along with its anxiety-related sequelae. Pediatric IDTs, including palliative and supportive care teams, play an important role in framing the stressor and anxiety reaction as well as addressing concerns honestly (1). Goals of management should include alleviating pain/discomfort, anticipating anxiety (e.g., anxiety expected to follow a painful procedure should warrant preparation of the child pre-procedure), addressing parental anxiety, assuring non-abandonment, and screening for related mood symptoms such as depression. Other evidence-based non-pharmacologic management strategies include:

• Cognitive behavioral therapy (CBT): usually led by a mental health professional, CBT can include the use of guided imagery and relaxation techniques appropriate to a child’s age (2).
• Other psychosocial interventions have been associated with more hopeful thinking; this may mitigate manifestations of psychosocial stress (3).
• Complementary and alternative therapies such as aromatherapy (4) have been shown to reduce anxiety, though studies specific to children demonstrating benefit are lacking (5).

Pharmacologic management strategies and special considerations in children:

• First, review the medication list. Anxiety can stem from medication side effects for which simple modifications can be effective, e.g., dosing corticosteroids in the morning to reduce nighttime activation and interference with sleep.
• For children with acute situational anxiety (i.e., prior to procedures, treatments, hospital visits) not sufficiently relieved with child life or other behavioral interventions, benzodiazepines such as midazolam or lorazepam (shorter-acting) as well as clonazepam (longer-acting) may be used on a short-term basis (6). Lorazepam can also be useful in the treatment of anxiety due to the anticipation of nausea/vomiting prior to medical interventions.
• For children with generalized anxiety, including those with a pre-existing anxiety disorder prior to the diagnosis of a serious illness, a selective serotonin reuptake inhibitor (SSRI) or, in cases of concomitant neuropathic pain or depression, serotonin norepinephrine reuptake inhibitor (SNRI) may be considered. The SSRIs and SNRIs approved for children by the U.S. Food and Drug Administration (FDA) are fluoxetine, sertraline, fluvoxamine (7) and duloxetine (8), though others are commonly used off-label in children.
• For children and adolescents with limited prognosis (i.e., less than 2 months), benzodiazepines are the mainstay of pharmacologic therapy for anxiety.
• Indications for consulting pediatric behavioral medicine experts include refractory symptoms to first-line pharmacologic therapy, suicidality, a previously established relationship with a mental health provider, or a dual diagnosis with substance use disorder (SUD), bipolar disorder, or major depressive disorder.

Summary: Acute anxiety is a common and often treatable symptom experienced by seriously ill children of all ages. Management strategies should focus on non-pharmacologic treatments. When necessary, benzodiazepines and/or SSRIs (or potentially SNRIs) can be considered. All management strategies for anxiety in seriously ill children should begin with open communication and attempts to identify and name any trigger(s) present. IDTs play an important role in the multimodal assessment and management of anxiety among children living with serious illness.

References

1. Himelstein BP, Hilden JM, Boldt AM, et al. Pediatric palliative care. N Engl J Med.  2004; 350:1752-1762.
2. Wang Z, Whiteside SPH, Sim L, et al. Comparative Effectiveness and Safety of Cognitive Behavioral Therapy and Pharmacotherapy for Childhood Anxiety Disorders: A Systematic Review and Meta-analysis. JAMA Pediatr. 2017 Nov 1;171(11):1049-1056.
3. Rosenberg AR, Bradford MC, Barton KS, et al. Hope and benefit finding: Results from the PRISM randomized controlled trial. Pediatr. Blood Cancer. 2019;66(1):e27485.
4. Gong M, Dong H, Tang Y, Huang W, Lu F. Effects of aromatherapy on anxiety: A meta-analysis of randomized controlled trials. J Affect Disord. 2020 Sep 1;274:1028-1040.
5. Ndao DH, Ladas EJ, Cheng B, Sands SA, Snyder KT, Garvin JH Jr, Kelly KM. Inhalation aromatherapy in children and adolescents undergoing stem cell infusion: results of a placebo-controlled double-blind trial. Psychooncology. 2012 Mar;21(3):247-54.
6. Kersun LS, Shemesh E. Depression and anxiety in children at the end of life. Pediatr. Clin North Am. 2007 Oct;54(5):691-708, xi.
7. Marcdante KJ, Kliegman RM. Anxiety and Phobias. In: Marcdante KJ, Kliegman RM, eds. Nelson Essentials of Pediatrics, 7th edition. St. Louis, MO: Elsevier Saunders; 2015.
8. Walter, HJ, et al. “Clinical practice guideline for the assessment and treatment of children and adolescents with anxiety disorders.” Journal of the American Academy of Child & Adolescent Psychiatry 59.10 (2020): 1107-1124.

**Connotes Pediatric Palliative Care Topic #4: Non-pain Symptom Assessment and Management; Subtopic 2 (Anxiety); 2nd article.

Conflict of Interest: None to report
Version History:  first electronically published in April 2023; originally edited by Julie SW Childers MD
Authors’ Affiliations: OhioHealth Riverside Methodist Hospital, Columbus, OH; University of Pittsburgh School of Medicine and UPMC Children’s Hospital, Pittsburgh, PA.