This section has been revised in the light of the recent NICE guidelines. Following this publication we have removed specific drug protocols as it is clear that medication should only be prescribed by Psychiatrists. For further information about treatment of depression please refer to NICE clinical guidance – Depression in children and young people (CG28).
Drug treatment is not recommended for mild depression in children.

Children with moderate/severe depression should be offered a specific psychological therapy (e.g. Cognitive Behavioural Therapy) as first line.

If depression is not responsive to psychological therapy, young people (12-18 years) may be offered fluoxetine. Fluoxetine may be cautiously considered for 5-11 year olds but there is less evidence to support its use.

Antidepressants must only be prescribed following assessment and diagnosis by a child and adolescent psychiatrist and in combination with a psychological therapy.

Professionals must monitor response to antidepressants and be vigilant for adverse drug effects.

Difficulty sleeping

Management

General measures

• Address the child’s fears/concerns if possible
• Consider sleep pattern: the child may be sleeping a lot in the day and may be reversing day/night pattern. It may be appropriate to keep the child awake more in the day or to provide extra stimulation during the day - this will depend on the child’s stage of illness. The child may not be aware of when he is expected to sleep if a lot of intervention is given around the clock.

Consider any underlying disability and the impact this has on sleep patterns – e.g visual impairment, autism, seizures.

• Optimise bedtime routine: bath if possible, story or if appropriate, songs, hot drink, lights low. The key is to repeat this regularly so that it, and falling asleep after it, becomes a habit. Likewise optimise daytime waking routine, be consistent in terms of timing and use triggers such as opening curtains, and allowing noise from around house to filter through.
• Consider complementary therapies to aid relaxation
• Over night try and disturb as little as possible, this may mean rescheduling medications
• Gentle exercise during the day may improve fatigue and aid sleep

Medication

Melatonin

Form

Tablet (modified release): 2mg
Capsule (immediate release): 1mg, 2mg, 2.5mg, 3mg, 5mg and 10mg named patient from ‘specials’ manufacturers

Dose (oral)

1 month-18 years: initial dose 2–3mg, increasing every 1–2 weeks dependent on effectiveness up to maximum 12mg daily.

Use for Sleep disturbance due to disruption of circadian rhythm (not anxiolytic). Can combine instant release and modified release formulations to tailor to need.

Licence: Unlicensed. for children. M/R tablets (Circadin®) licensed for use in elderly. Instant release available on named patient basis.

Chloral Hydrate

Form

Tablet: chloral betaine 707mg = choral hydrate 414mg - Welldorm®10mg, Oral solution: 500mg in 5mL, 200mg in 5mL (both from ‘specials’ manufacturers)
Suppositories : 25mg, 50mg, 60mg, 100mg, 200mg, 500mg from ‘specials’ manufacturers).

Dose (Oral or Per rectum)

Neonate: initial dose of 30mg/kg as a single dose at night. May be increased to 45mg/kg at night or when required,
1 month–12 years: initial dose of 30mg/kg as a single dose at night. May be increased to 50mg/kg at night or when required. Maximum single dose 1g,
12–18 years: initial dose of 500 mg as a single dose at night or when required. Dose may be increased if necessary to 1-2 g. Maximum single dose 2 g.

Contraindications and warnings: Accumulates on prolonged use and should be avoided in severe renal or hepatic impairment.

Licence: Licensed for use in children >2yr.

Promethazine hydrochloride

Form

Tablet: 10mg, 25mg
Elixir: 5mg in 5mL
Injection: 25mg in 1mL as 1 mL ampoule.

Dose (oral)

2-5yr: 15-20mg nocte
5-10yr: 20-25mg nocte
10-18yr: 25-50mg nocte

Contraindications and warnings: Porphyria; CNS depression; hypersensitivity to phenothiazines. Do not use with, or within 2 weeks of taking MAOIs. Advised for short term use only.

Licence: Licensed for use in children >2yr.

Temazepam

Form

Tablet: 10mg, 20mg.
Capsules: 10mg, 15mg, 20mg, 30mg. Oral solution: 10mg in 5mL.

Dose (oral)

Adult: 10–20mg at night. Dose may be increased to 40mg at night in exceptional circumstances

Contraindications and warnings: caution in severe liver disease. Avoid in CNS depression and acute pulmonary insufficiency. Interactions: see appropriate text.

Licence: not licensed for use in children.