What are the treatment options for agitation in children?

Treatment of Agitation in Children

For acute agitation in children, prioritize verbal de-escalation and environmental modification first, then use benzodiazepines (lorazepam 0.05-0.1 mg/kg) for medical/intoxication-related agitation or antipsychotics (haloperidol 5-10 mg IM for adolescents) for psychiatric-related agitation, with physical restraint reserved only as a last resort when the child poses imminent danger. 1

Initial Assessment and Safety

Before any intervention, rapidly assess for reversible medical causes:

• Perform immediate point-of-care glucose testing on all agitated children, as hypoglycemia is rapidly reversible and potentially fatal 2
• Obtain vital signs to identify fever, tachycardia, hypertension, or respiratory compromise that indicate specific etiologies 2, 3
• Assess for signs of intoxication or withdrawal (alcohol, cocaine, stimulants), as these require specific management 1, 2
• Evaluate cognitive function to distinguish delirium from primary psychiatric causes 2, 4

First-Line Approach: Behavioral De-Escalation

Verbal de-escalation must always be attempted before pharmacologic or physical interventions 1, 3, 5:

• Maintain two arms' length distance from the patient to respect personal space 1, 2
• Create a calming environment with decreased sensory stimulation and remove potential weapons 1
• Use empathetic, non-confrontational language: "It'll help me if you sit and calm yourself. I can better understand you if you calmly tell me your concerns" 1
• Set clear, non-punitive limits on unacceptable behaviors 1
• Offer realistic choices to empower the patient: "Instead of violence, what else could you do? Would [offer choice] help?" 1
• Minimize bargaining and deception 1
• Remove staff neckties, stethoscopes, and secure long hair before approaching 1, 2

Pharmacologic Management

Drug selection depends on the suspected etiology of agitation 1, 6:

For Medical/Intoxication-Related Agitation

• Benzodiazepines are first-line 1, 2
• Lorazepam is preferred: 0.05-0.1 mg/kg PO/IM/IV 1, 2
  • Onset: 5-15 min IV, 15-30 min IM, 20-30 min PO 1
  • Duration: 6-8 hours 1
  • May repeat every 30-60 minutes 1
• Lorazepam has fast onset, rapid and complete absorption, and no active metabolites 1
• Preferred for alcohol withdrawal, cocaine intoxication, and substance-related agitation 1, 2

For Psychiatric-Related Agitation

For mild to moderate agitation: Either benzodiazepine or antipsychotic 1

For severe agitation: Antipsychotic is preferred 1, 6

• Haloperidol (first-generation antipsychotic):

  • Adolescents: 5-10 mg IM 1
  • Children: 0.5-2 mg IM 1
  • Onset: 10-20 min IM, 45-60 min PO 1
  • May repeat every 2 hours 1
  • Maximum: 30 mg daily 1

• Risperidone (second-generation antipsychotic):

  • Younger adolescents (12-16 years): 10 mg 1
  • May be better tolerated with fewer extrapyramidal symptoms than first-generation agents 1

For Unknown Etiology

• Give a dose of benzodiazepine or antipsychotic 1
• Consider a dose of the other medication if the first dose is not effective 1

Combination Therapy

• For older adolescents (>16 years) with severe agitation: Haloperidol plus lorazepam or midazolam 1, 2
• This combination is frequently recommended by experts for acutely agitated patients 1

Critical Contraindications and Precautions

Benzodiazepines:

• Contraindicated in intoxication scenarios where they may worsen respiratory depression 1
• Use with caution in patients with respiratory compromise 1, 2
• Patients over 50 years may have more profound and prolonged sedation 2
• Avoid in suicidal patients when possible, as they may reduce self-control and disinhibit aggression 1

Antipsychotics:

• Higher risk of extrapyramidal symptoms, especially with first-generation agents 1
• Avoid in anticholinergic delirium or intoxication 2
• Monitor for postinjection delirium/sedation with risperidone 1

Medications to avoid:

• Do not prescribe tricyclic antidepressants due to high lethal potential in overdose 1
• Avoid phenobarbital in suicidal patients due to high lethality and potential for disinhibition 1

Monitoring Requirements

• Monitor vital signs, level of sedation, and respiratory status closely after medication administration 2
• Watch for respiratory depression, especially with IV lorazepam 2
• Observe for extrapyramidal symptoms with antipsychotics 1, 2
• Maintain unobstructed airway and have resuscitation equipment available 2

Physical Restraint: Last Resort Only

Physical restraints should be reserved as a last resort when verbal de-escalation and pharmacologic interventions have failed and the patient poses imminent danger 2, 3, 5:

• Use the least restrictive means possible 5
• Minimize restraint time 3
• Always debrief with the patient afterward to restore the working relationship 1, 2:
  • Explain why the intervention was necessary 1
  • Ask the patient to explain their perspective 1
  • Review alternative strategies if the situation arises again 1

Common Pitfalls to Avoid

• Never use pharmacologic treatment for punishment or staff convenience 4
• Do not skip the medical evaluation—agitation has a broad differential diagnosis including toxicologic, neurologic, infectious, and metabolic causes 4, 3
• Avoid combining benzodiazepines with antipsychotics in unknown etiology without trying one agent first 1
• Midazolam does not decrease recovery agitation when used with ketamine (if ketamine is being considered for procedural sedation) 1