What medications are recommended for treating anxiety and stress in pediatric patients?

Medications for Pediatric Anxiety and Stress

First-Line Pharmacotherapy: SSRIs

Selective serotonin reuptake inhibitors (SSRIs) are the first-line medication for pediatric anxiety disorders, with sertraline and escitalopram as the preferred agents based on their established efficacy and favorable safety profiles. 1, 2

Sertraline Dosing for Pediatric Anxiety

• Start sertraline at 25 mg daily for children ages 6-12 years to minimize initial anxiety or agitation that can occur with SSRI initiation 1, 3
• For adolescents ages 13-17 years, start at 25 mg daily for the first week, then increase to 50 mg daily after week 1 1, 3
• Titrate by 25-50 mg increments every 1-2 weeks as tolerated, targeting a therapeutic dose range of 50-200 mg/day 1, 3
• The lower body weight of children compared to adults should be considered when advancing doses to avoid excess dosing 3

Fluoxetine as Alternative First-Line Option

• Start fluoxetine at 10 mg daily and increase by 5-10 mg increments every 1-2 weeks 1, 4
• Target therapeutic dose is 20-40 mg daily by weeks 4-6, with maximal benefit expected by week 12 1, 4
• Fluoxetine's longer half-life may be beneficial for patients who occasionally miss doses 2
• For adolescents and higher weight children with OCD, initiate at 10 mg/day, then increase to 20 mg/day after 2 weeks, with a dose range of 20-60 mg/day 4

Fluvoxamine Dosing

• Start fluvoxamine at 25 mg/day for pediatric patients 5
• This agent is effective but may have more discontinuation symptoms compared to sertraline or escitalopram 2

Expected Response Timeline and Monitoring

• Statistically significant improvement may begin by week 2, with clinically significant improvement expected by week 6, and maximal therapeutic benefit achieved by week 12 or later 1, 2
• Do not abandon treatment before 12 weeks, as full response requires patience due to the logarithmic response curve of SSRIs 1
• Monitor closely for suicidal thinking and behavior, especially in the first months and following dose adjustments, with a pooled risk of 1% versus 0.2% for placebo (NNH = 143) 1

Common Side Effects

• Nausea, headache, insomnia, nervousness, and initial anxiety/agitation are common early side effects that typically resolve with continued treatment 1, 2
• Most adverse effects emerge within the first few weeks of treatment 2
• Systematic tracking of treatment-emergent adverse events including headaches, stomach aches, behavioral activation, worsening symptoms, and emerging suicidal thoughts is essential 5

Combination Therapy: Medication Plus CBT

Combining an SSRI (particularly sertraline) with cognitive behavioral therapy provides superior outcomes compared to either treatment alone and should be the preferred approach for moderate to severe pediatric anxiety. 1, 6

• The Child-Adolescent Anxiety Multimodal Study (CAMS) demonstrated that combination therapy (sertraline + CBT) achieved an 80.7% response rate, compared to 59.7% for CBT alone and 54.9% for sertraline alone 6
• A treatment course of 12-20 structured CBT sessions targeting anxiety-specific cognitive distortions and exposure techniques is recommended 1
• Individual CBT is prioritized over group therapy due to superior clinical and cost-effectiveness 2

Second-Line Options: SNRIs

• Venlafaxine extended-release (SNRI) can be considered if SSRIs are not tolerated or effective, though it ranks lower than SSRIs in overall tolerability 1, 2
• Venlafaxine requires blood pressure monitoring due to risk of sustained hypertension 2

Medications to Avoid in Pediatric Anxiety

• Paroxetine should be avoided due to higher risk of discontinuation syndrome and potentially increased suicidal thinking compared to other SSRIs 1, 2
• Benzodiazepines should be avoided as first-line treatment due to lack of efficacy data in pediatric anxiety and risks of dependence, tolerance, and withdrawal 7, 8
• Buspirone (5HT1A agonist) does not have evidence supporting efficacy in pediatric anxiety disorders 7

Treatment Duration and Discontinuation

• Continue medication for approximately 1 year following remission of symptoms to prevent relapse 1, 5
• When discontinuing, taper gradually to avoid withdrawal symptoms, particularly with shorter half-life SSRIs like sertraline 1
• Choose a stress-free time of year for discontinuation, and if symptoms return, seriously consider medication re-initiation 5

Critical Pitfalls to Avoid

• Do not escalate doses too quickly—allow 1-2 weeks between increases to assess tolerability and avoid overshooting the therapeutic window 1
• Do not use dose intervals less than 1 week given sertraline's 24-hour elimination half-life 3
• Do not abandon treatment prematurely—full response may take 12+ weeks, and patience in dose escalation is crucial for optimal outcomes 1