Correspondence

Pediatric Palliative Care

N Engl J Med 2004; 351:301-302July 15, 2004

Article

To the Editor:

In the review of pediatric palliative care by Himelstein et al. (April 22 issue),1 it clearly is impossible to detail patient care in such a wide population. Thus, it is appropriate to mention one drug in each group, even though morphine, for example, does not alone solve the problem of pain or dyspnea. We wish, however, to stress an important area of care overlooked in this article. Many pediatric patients have mood and anxiety disorders, especially when trying to cope with major life-threatening diseases.2 It is important to diagnose mood and anxiety disorders, since cognitive behavioral therapy and selective serotonin-reuptake inhibitors can help children and adolescents with depression and anxiety.3-5 Although empirical data concerning the efficacy of these treatments in children and adolescents who are coping with chronic medical illnesses are relatively limited, psychiatric evaluation and a clear treatment plan are imperative for such children, particularly those receiving palliative care. Ignoring these coexisting psychiatric disorders can interfere with the success of the whole palliative care program.

Doron Gothelf, M.D.
Ian J. Cohen, M.D.
Schneider Children's Medical Center of Israel, Petah Tiqwa 49202, Israel
gothelf@post.tau.ac.il

5 References

1. 1

   Himelstein BP, Hilden JM, Boldt AM, Weissman D. Pediatric palliative care. N Engl J Med 2004;350:1752-1762
   Full Text | Web of Science | Medline

2. 2

   Lavigne JV, Faier-Routman J. Psychological adjustment to pediatric physical disorders: a meta-analytic review. J Pediatr Psychol 1992;17:133-157
   CrossRef | Web of Science | Medline

3. 3

   Curry JF. Specific psychotherapies for childhood and adolescent depression. Biol Psychiatry 2001;49:1091-1100
   CrossRef | Web of Science | Medline

4. 4

   The Research Unit on Pediatric Psychopharmacology Anxiety Study Group. Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 2001;344:1279-1285
   Full Text | Web of Science | Medline

5. 5

   Wagner KD, Ambrosini P, Rynn M, et al. Efficacy of sertraline in the treatment of children and adolescents with major depressive disorder: two randomized controlled trials. JAMA 2003;290:1033-1041
   CrossRef | Web of Science | Medline

Author/Editor Response

We appreciate the comments of Drs. Gothelf and Cohen regarding our review. Mood and anxiety disorders certainly can complicate the course of life-threatening conditions of childhood. We have successfully treated children who have depression and life-threatening or life-limiting illnesses with tricyclic antidepressants1 (especially in pediatric patients with coexisting neuropathic pain, sleep disturbances, or both) or methylphenidate2 (especially in children with opiate or disease-related somnolence). However, the empirical support for the use of selective serotonin-reuptake inhibitors is lacking, suggesting a path for future research in the field.

Providing psychiatric care for every child who is coping with a chronic illness is certainly desirable, but as indicated in our review, the demographic features of life-threatening illnesses, as well as the current state of reimbursement for even basic palliative services in the United States, might preclude access for some. The generalist should therefore be familiar with basic treatment options for mood and anxiety disorders. We appreciate having this oversight brought to our attention.

Bruce P. Himelstein, M.D.
Medical College of Wisconsin, Milwaukee, WI 53201
bhimelstein@chw.org

Joanne M. Hilden, M.D.
Children's Hospital at the Cleveland Clinic, Cleveland, OH 44195

2 References

1. 1

   Hazell P, O'Connell D, Heathcote D, Henry D. Tricyclic drugs for depression in children and adolescents. Cochrane Database Syst Rev 2002;2:CD002317-CD002317
   Medline

2. 2

   Rozans M, Driesbach A, Lertora JJ, Kahn MJ. Palliative uses of methylphenidate in patients with cancer: a review. J Clin Oncol 2002;20:335-339
   CrossRef | Web of Science | Medline

Citing Articles (2)

Citing Articles

1. 1

   Leslie S. Kersun, Eyal Shemesh. (2007) Depression and Anxiety in Children at the End of Life. Pediatric Clinics of North America 54:5, 691-708
   CrossRef

2. 2

   DORON GOTHELF, MALY RUBINSTEIN, EYAL SHEMESH, ORIT MILLER, ILANA FARBSTEIN, ANAT KLEIN, ABRAHAM WEIZMAN, ALAN APTER, ISAAC YANIV. (2005) Pilot Study: Fluvoxamine Treatment for Depression and Anxiety Disorders in Children and Adolescents with Cancer. Journal of the American Academy of Child & Adolescent Psychiatry 44:12, 1258-1262
   CrossRef