Treatment of Acute Agitation in Pediatrics
The treatment of acute agitation in pediatrics should follow a stepwise approach, beginning with verbal de-escalation techniques, followed by pharmacologic intervention with benzodiazepines or antipsychotics when necessary, with the combination of a benzodiazepine and an antipsychotic frequently recommended for severe cases. 1
Step 1: Non-Pharmacological Interventions
Verbal De-escalation Techniques
- Implement Fishkind's "Ten Commandments of De-escalation":
- Respect personal space
- Do not provoke
- Establish verbal contact
- Be concise and simple
- Identify wants and feelings
- Listen closely
- Agree or agree to disagree
- Set clear limits
- Offer choices and optimism
- Debrief patient and staff 1
Environmental Modifications
- Create a calming physical environment with decreased sensory stimulation
- "Safety-proof" rooms by removing or securing objects that could be used as weapons
- Modify or eliminate triggers of agitation (e.g., argumentative family members, long wait times)
- Involve child life specialists to help calm agitated children 1
Step 2: Pharmacological Interventions
Drug Selection Considerations
Based on suspected etiology of agitation:
| Suspected Etiology | Mild/Moderate Agitation | Severe Agitation |
|---|---|---|
| Medical/Intoxication | Benzodiazepine | Benzodiazepine first, consider adding first-generation antipsychotic |
| Psychiatric | Benzodiazepine or antipsychotic | Antipsychotic |
| Unknown | Benzodiazepine or antipsychotic | Consider combination therapy |
First-Line Medications
Benzodiazepines
Lorazepam: 0.05-0.1 mg/kg PO/IM/IV (most commonly used drug for acute pediatric agitation)
Midazolam: 0.1 mg/kg PO/IM/IV
Antipsychotics
Haloperidol:
- Child: 0.25-0.5 mg
- Adolescent: 0.5-1 mg
- May repeat IM every 20-30 minutes 1
Risperidone:
Combination Therapy
- For severe agitation, a combination of a benzodiazepine and an antipsychotic is frequently recommended 1
- Older adolescents (>16 years): Haloperidol + lorazepam or midazolam 1
- This combination produces faster sedation than monotherapy in psychiatric patients with agitation 2
Special Considerations
Patients with Autism Spectrum Disorder or Developmental Disabilities (ASD-DD)
- No controlled trials of medications for acute agitation or sedation in this population
- No known contraindications to using common sedating medications
- Consider:
- Starting with lower medication dosages
- Inquiring about previous medication reactions
- Potential for idiosyncratic, disinhibition, or paradoxical reactions 1
- Sensory interventions may be helpful:
- Weighted blankets (radiology lead vest as substitute)
- Light touch massage with gauze
- Distraction with "fidget toys"
- Rocking in a chair 1
Medication Safety Precautions
- Monitor for respiratory depression, especially when combining with other CNS depressants
- Use caution in patients with respiratory compromise
- Lower doses for elderly or frail patients
- Reduced doses for patients with COPD due to risk of respiratory depression
- Lower doses when co-administered with antipsychotics to avoid oversedation 2
Pitfalls to Avoid
- Misidentifying the cause of agitation: Always consider medical causes before assuming psychiatric etiology
- Inadequate assessment of respiratory status: Benzodiazepines can cause respiratory depression
- Overlooking drug interactions: Be cautious when combining medications
- Using medications punitively: Treatment should be for patient safety, not staff convenience 4
- Skipping verbal de-escalation: Non-pharmacological approaches should always be attempted first 5, 6, 7
By following this stepwise approach, clinicians can effectively manage acute agitation in pediatric patients while prioritizing safety and minimizing adverse effects.