Abstract
Background
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Importance of Multimodal Management Strategies
The management of acute anxiety in children living with serious illness should involve maximization of nonpharmacological management, particularly by way of the interdisciplinary team (IDT), and consideration of medication. In general, pharmacological adjuncts are considered when anxiety is severe enough to impact a child's quality of life and is refractory to nonpharmacological interventions.
Nonpharmacological 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.
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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 preprocedure), addressing parental anxiety, assuring nonabandonment, and screening for related mood symptoms such as depression. Other evidence-based nonpharmacological management strategies include the following:
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.
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Other psychosocial interventions have been associated with more hopeful thinking; this may mitigate manifestations of psychosocial stress.
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Complementary and alternative therapies such as aromatherapy
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have been shown to reduce anxiety, although studies specific to children demonstrating benefit are lacking.
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Pharmacological 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, for example, dosing corticosteroids in the morning to reduce night-time activation and interference with sleep.
For children with acute situational anxiety (i.e., before procedures, treatments, and 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 before medical interventions.
For children with generalized anxiety, including those with a preexisting anxiety disorder before 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 although others are commonly used off-label in children.
For children and adolescents with limited prognosis (i.e., less than two months), benzodiazepines are the mainstay of pharmacological therapy for anxiety.
Indications for consulting pediatric behavioral medicine experts include refractory symptoms to first-line pharmacological therapy, suicidality, a previously established relationship with a mental health provider, or a dual diagnosis with substance use disorder, 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 nonpharmacological 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.