What is the management approach for a pediatric patient experiencing a panic attack?

Management of Pediatric Panic Attacks

The most effective approach for managing pediatric panic attacks involves implementing non-pharmacological interventions first, focusing on creating a calming environment, using distraction techniques, and teaching relaxation strategies, before considering pharmacological options only when necessary. 1

Initial Assessment and Environment

• Create a calming physical environment:

  • Place child in a private, quiet room with minimal sensory stimulation
  • Use child-friendly decor with colorful walls, pictures on ceiling
  • Adjust lighting to be soothing and non-threatening 1
  • Remove medical equipment from immediate view when possible

• Involve parents/caregivers:

  • Allow family presence during assessment and treatment
  • Engage parents as "coaches" for the child
  • Provide clear explanations to both child and parents about what is happening 1

Non-Pharmacological Interventions

Immediate Interventions

1. Distraction techniques (first-line approach):

   • Age-appropriate entertainment (videos, music, storytelling)
   • Bubble blowers, pinwheels for younger children
   • Video goggles for school-aged children
   • Assign a specific task to focus on during distraction 1

2. Breathing techniques:

   • Guide through deep breathing exercises
   • Progressive muscle relaxation
   • Counting breaths slowly (in through nose, out through mouth)

3. Emotional support:

   • Validate the child's feelings without dismissal
   • Normalize their experience
   • Recognize and address common fears 2

Child Life Specialist Involvement

If available, a child life specialist can:

• Provide developmentally appropriate education
• Teach distraction techniques and coping strategies
• Help develop and execute coping plans
• Support family involvement in care 1

CARE Framework for Reducing Anxiety

Implement the CARE principles 2:

1. Choices: Offer control in a powerless environment

   • Let child choose position, distraction activity, or who stays with them

2. Agenda: Provide clear expectations

   • Explain what will happen next in simple terms
   • Use visual schedules for younger children

3. Resilience: Highlight strengths

   • Praise coping efforts
   • Reframe negative thoughts

4. Emotional support: Recognize fears

   • Validate feelings
   • Use age-appropriate explanations

Pharmacological Interventions (When Necessary)

Only consider medication if non-pharmacological approaches are insufficient:

For Mild to Moderate Anxiety/Agitation:

• Benzodiazepines (if needed):
  • Midazolam: 0.1 mg/kg PO/IM/IV (onset 5-30 minutes) 3
  • Lorazepam: 0.05-0.1 mg/kg PO/IM/IV 3

For Severe Agitation/Panic:

• Consider combination therapy with benzodiazepine and antipsychotic for severe cases that don't respond to other interventions 3
• Nitrous oxide may be considered as an anxiolytic option in appropriate settings (contraindicated in pneumothorax, bowel obstruction) 1

Follow-Up Care

• Provide education about panic attacks and anxiety
• Consider referral to mental health services for ongoing management
• Teach home-based coping strategies for future episodes

Common Pitfalls to Avoid

1. Rushing to medication before trying non-pharmacological approaches
2. Separating child from parents during a panic attack
3. Dismissing symptoms as "just anxiety" without proper assessment
4. Creating a threatening environment with multiple staff members
5. Failing to explain what is happening in age-appropriate language
6. Not recognizing that panic attacks can present differently in children than adults

By following this structured approach that prioritizes non-pharmacological interventions in a supportive environment, most pediatric panic attacks can be effectively managed with minimal need for medication.