In conversation with Dr Honey Heussler and Associate Professor Daryl Efron - Exploring Medications in Child Development

This conversation focuses on prescribing medications for children with complex developmental and mental health issues, covering topics like antihistamines, melatonin, CBD oil, and medications for anxiety, tics, and sleep disorders. Experts discussed concerns about long-term medication use, the role of alternative treatments, and the importance of careful documentation and reassessment in prescribing.

Transcript

Wei Wei 0:11
Hi, everyone. We're at day two of the ASDP conference here on the Gold Coast, and it's been a really good day so far. We've just finished the breakout session on Basics to break through, which sort of took us through a prescribing journey of medications in children with complex developmental and mental health difficulties. So I've got paediatrician and behavioural specialist Dr. Honey Heussler and Associate Professor Daryl Efron from Melbourne with me. Just to go through a number of questions that we didn't manage to cover because we kind of ran out of time and because there were so many questions. So we might jump straight into it because there's quite a few. We might start with you, honey, to answer some questions around sleep. So the first one, which we had quite a few of, was around the role of antihistamines in Sleep. So I think we talked about melatonin, clonidine, a number of other drugs, but antihistamines didn't come up. What are your thoughts around that? 

Honey 1:09
I think they're very commonly used. I don't always prescribe them except in exceptional circumstances. And some of the challenges with antihistamines is this idea of receptor tachyphylaxis where you need more and more of the drug to be able to get the same effect. So if you use it every night and continuously, sooner or later you're going to be going up, up, up on the dose and then trying to wean off and get back to a more pragmatic sense is actually really, really challenging and really challenging for families because they say that they wean it a bit and then things go a bit pear shaped, they start a bit, they increase the dose without ever actually being able to get off it properly. So it causes more problems in that sort of longer term issues. Then intermittently, whereas by the time kids usually come to see me, they may have tried some over the counter for Nick, and it's either been a disaster with the kids getting extremely disregulated or it's worked really well. And in that circumstance I'll suggest they only use it for a few selected nights of the week. Crop of then continuously. 

Wei Wei 2:28
Excellent. The second question then is on melatonin. So in your opinion, is I herb melatonin okay to use? 

Honey 2:39
I think there's a lot of challenges in terms of accessing medications on the Internet. Now, while I Herb has been a fairly standard product and very widely used, the principles of accessing medication of which we have no control over the quality is kind of problematic in my head. I would far rather we determined wise of accessing good quality products. Now, if Herb seems to have a bit of a track record, but there are lots of other melatonin products out there, as evidenced by the study done in the States and Canada, I think not so long ago where there was extremely variable content of melatonin and indeed CBD in some of the online available melatonin products. I try to discourage families from actually accessing online medication because once they do it, I think the boundaries in terms of accessing other melatonin products online is a bit tricky. I think you have to be very specific around it. So it's more a principles based 

disquiet than an actual no, don't ever, I think Good. 

Wei Wei 4:04
And sticking with melatonin, then there were questions around, is there potential long term side effects if a child stays on regular melatonin over a period of time? 

Honey 4:18
I think it's very tricky and I don't know that we completely know the impact on the body's own production and regulation of melatonin in the very long term. Certainly up to a couple of years. We're probably okay. But there are children out there who have been on it for ten years or more and how that is going to impact on their own production is kind of unknown. I think these there's been two studies now that I'm aware of that have really not evidenced any of the 

physiological concerns that have come out of some of the animal models and so I'm not as concerned about those physiological concerns, particularly about the fertility issues, because we know that if you don't sleep, you don't produce FSA anyway. So it's kind of, you know, a bit chicken and egg, that one. But certainly the long term follow up studies have not suggested an impact on fertility or puberty. What I'm not sure of and I don't think we really understand yet, is that long term regulation of melatonin production itself are these people who are be producing very little melatonin through their adult life? I don't know. 

Wei Wei 5:38
Yeah. And so that makes dependents the question of independence a little bit difficult to answer as well, then, I guess. 

Honey 5:43
Yeah, it does come back to that dependence issue. I am somebody who always advocates for a melatonin on holiday at least once a year, if not a little bit more frequently, to just see whether kids can tolerate of it. And in fact, I do advocate very strongly for some placebo trials. So previously where I worked, we had the capacity to develop placebos so that we would then trial with the parent's consent with the children, which really indicated that many of the kids had more of a psychologic dependency than an actual physiological dependency. 

Yeah, so I have had some very creative mothers who develop their own bland brand of placebo and to this day give their child a couple of drops of some sort of cortisol as their melatonin for the night. And those kids are happily going to sleep very well. 

Wei Wei 6:50
Can't argue with. 

Honey 6:51
That. Exactly. 

Wei Wei 6:54
And honey, is there a role for magnesium in helping sleep in children? 

Honey 7:00
Listen, I haven't seen great evidence of that in children. And certainly I am aware of a couple of studies in adults that really haven't shown significant benefits. There have been some trends towards slightly better quality of sleep. Now, that buys into that really difficult thing when you're looking at outcome measures. And while it's been a sad ject of improvement in quality, it hasn't always translated to objective measures in terms of sleep efficiency and things. However, magnesium is not something that's stored necessarily in the body very easily. And so provided you're not developing, you know, high levels of magnesium, it's probably not going to hurt too much. If people want to try it. I actually suggest they try, you know, magnesium baths or Epsom salts baths, where they will absorb some through that process. But the body then determines that a level of that absorption and some people find that helpful. But it's a case of try to do no harm. I think where the evidence is a bit wobbly. 

Wei Wei 8:18
And then final question on sleep. So as I think as a general paediatrician, I kind of agree with the statement that, you know, sleep onset often is the more manageable level of, you know, the spectrum of sleep difficulties to manage. But do you have any tips or tricks on how to, I guess, manage that the child that kind of wakes early in the morning, like really early in the morning and stays awake and disrupts the whole family? And, you know. 

Honey 8:47
I think this is probably the harder thing to manage the real challenges for these kids to try and determine whether they've got an advanced sleep phase. So going to sleep too early and waking too early. Now, for many of the kids we see with neurodevelopmental disorders, it's more that they have a short sleep rather than an advanced sleep phase. They go to sleep roughly the right time and just wake up early. The challenge is then is if you medicate, what you'll sometimes do is get a hangover and a bleed into the next day because you can't really turn off a medication that you might use to help that child sleep longer, to finish before they have to go to school. So you often get hangovers and bleeds into the next day with hyper somnolence in the morning, which then creates a whole additional raft of problems trying to get the kids to school. So it's particularly challenging. What I will often do is flip the coin and try and get the family to set rules about when the child can get up, what the child can be doing, give them strategies to amuse themselves and stay quiet in bed for that period of time. And that will sometimes work. You know, clocks that, you know, you can get up on a timer that turns the light on at six, which means that's the time you can get up. But until then, you have to stay in bed. Those sorts of strategies I find, are often as good as we can get in that population. It's tricky, really tricky. Sometimes using some of the more complex medications, if you've got other things, will help with that. Extending it out a little bit, but it's incremental, not going to fix the problem 100% often.I  say to families, well, if they're waking at two, if I can get you to 330, is that a good thing or is it, you know, that sort of discussion needs to be had often.

Wei Wei 10:59
A bit like choosing your battles and small wins. 

Honey 11:03
Small wins in the right direction, Yeah. 

Wei Wei 11:06
Okay. We might switch tact up a bit and answer some questions on CBD oil. So, Darrell, the question guess is in families where you know that they will sell source their CBD regardless of clinician advice, do you point them in a direction? Do you get those specific brands to purchase or any recommendations? 

Daryl 11:30
So the important principle is that family, you know, we win families Trust so that whatever they're doing, including unregulated cannabis or anything else they're doing, it's good if they tell us what they're intending to do or have been doing that so we can work together with what they're doing these days. That's becoming and sourcing unregulated medicinal cannabis from places like northern New South Wales is less common because there's more and more cannabis clinics opening up, usually around by GPS. So much more common scenario is families are getting it from so-called cannabis clinics, which are kind of weird because these are usually run by GPS who are not expert in any particular clinical condition. They're just expert in types of cannabis for whatever problem the patient has and however old the patient is. So it's not uncommon these days that paediatricians managing a patient, including prescribing some meds and alongside that, the family going to one of these cannabis clinics to get CBD. And I think that's actually fine some paediatricians don't like that. I personally don't have a problem with it as long as we know what the child's taking. And yeah, I think developmental paediatricians who are used to prescribing all sorts of psychotropic meds should be open to prescribing CBD themselves. But I know that many are still not comfortable for various reasons. It's unfamiliar. There's a TGA regulatory process which is seems cumbersome, although it's not actually too difficult once you've done a couple of times. But you know, I'd encourage paediatricians to prescribe themselves, but if they're not, then working alongside of families who are getting it from other sources I think is fine in terms of which product, it doesn't really matter. To be honest, I prefer they got it prescribed rather than unregulated because of the unregulated products. Of course, we don't know exactly what's in them. 

Wei Wei 13:16
That Segways nicely into the next question, because you've just said that you would encourage paediatricians to consider prescribing. So this leads to your overall thoughts on CBD oil and its place, I guess, in management of challenging behaviours, ADHD, anxiety. 

Daryl 13:33
Yeah, Well, for those of you who might have been at the session, as Honey and I both said, that CBD seems to be a good anxiolytic for a proportion of patients that you try it on. The main effect seems to be anxiolytic anti-anxiety effect, but it's unpredictable for some kids. It doesn't seem to have any effect at all, at least in the doses the parents are prepared to try, given the cost. So sometimes it hasn't been given a proper go because the parents can't afford a good dose. But sometimes very small doses can be effective. I think it's a minority of patients that get a good benefit, but a significant minority. So I don't know, maybe a quarter or a third. And sometimes that's a really powerful effect enough that they can come off other medications, which is fantastic. 

Wei Wei 14:17
And Daryl just for those that weren't with us at the conference today, a ballpark figure of cost of CBD oil. 

Daryl 14:27
Yeah, I've been into this area for five or six years and the costs have come down just a bit. Not a lot They are coming down, but it's not rapidly. It's a very expensive product to manufacture. So the cost depends on how much you take. And as I've just said, that depends on how the child responds. But it usually comes in small bottles of 30 mls. Is the common to some companies make 50 mil bottles. The comments were 30 ml bottle and that product with high CBD ratios, which is the ones that I suggest paediatricians use, are more expensive because the plants are bred to be higher in THC. So to produce a pure CBD product is actually really expensive. In the order of $200 to $250, sometimes a bit under $200 for some I've heard recently for 30 mls. Now how long that can last depends how much they take, but it might only be a couple of weeks. So you might be talking, you know, $100 a week, which is unaffordable for many families. 

Wei Wei 15:19
Now we are going to move on to some general questions that came from the floor that we are going to try to answer. So we will stick with you Daryl for the moment. Your experience in using Alprazolam?

Daryl 15:33
Yeah. So I Alprazolam it's a benzodiazepine. It's I think it's a very good drug. It's one that I use quite a lot. And Xanax is the common trade name. And it's a very good drug for situational anxiety or panic attacks. So I use it quite a lot in kids who get overwhelmed it's best if there's predictable situations.For  example, I've had some families that go interstate to visit relatives at times and going through the airport, kids with autism, they get overwhelmed and have a meltdown some kids getting to school on certain days, not every day where it's really, really difficult just to get through the school gates and a very small dose. It comes in different sizes, but I tend to use the 0.5 mg tablets half a tablet to start with, 25. or maybe one tablet 5. can be really helpful on a PRN basis. I'm not talking about using it regularly. The other one I use just while we're in that room is lorazepam, which is very, very similar. 

Wei Wei 16:23
And would you reserve that just for use in the older children? 

Daryl 16:26
No, no, no. Any age really good drug. 

Wei Wei 16:30
And then there was a question, I guess, on the medication management or approach to the management, I guess of children with tics. So that's involuntary motor movements, not the bug that causes significant functional impairment. Any thoughts on that? 

Daryl 16:45
Yeah, well, look, the medications are a number of medications that can be used for tics. None of them are very effective in terms of effect size. But the the first line is usually clonidine or the alpha agonist I think contains better than guanfacine. it's better than placebo but not amazing as people would know. You need to use that two or sometimes three times a day. It's relatively short acting in small doses, it can be effective known side effects being sedation and dizziness. the most powerful anti tic medications are the antipsychotics. But of course they have a much higher rate of serious side effects. But in very severe Tourette syndrome, we do use those. 

Wei Wei 17:25
I think we talked a lot on risperidone and, you know, the pros and cons. And when we use it, this question is more around the role of metformin alongside risperidone in young people, where, you know, we know that the weight will or is already a problem. 

Daryl 17:42
Yes. So metformin can be really helpful in weight control in some patients, not all. In some it causes intolerable nausea. The extended release product is less likely to cause nausea, but it certainly can stabilize weight gain in kids on antipsychotics. There is good scientific evidence for this now in kids with antipsychotic psychotic associated weight gain and sometimes it can help with weight loss. So good drug and certainly worth trying in those situations. 

Wei Wei 18:15
Awesome. And we'll finish this one last question. So we'll stay with you Daryl. And this is a bit of a wordy one, but how do we as a group safeguard against being complicit in perpetuating inadequate systems of care through dependence on medication prescribing? So I guess the question is, you know, best practice prescribing and your thoughts on that in a couple of minutes. 

Daryl 18:38
Well, I'll respond if honey promises to give a better response than me afterwards, because it's a good question, but a very difficult one to answer at all, let alone succinctly. Look, it's a really important question, and it's the question kind of implies that sometimes we prescribed medication because we haven't got what might be considered more important systems of support around families and children. And I understand and I agree with that, you know, we should be as paediatricians, I think we do try our best to advocate for family support for, non-pharmacological interventions for kids, for care, support for kids with severe disabilities. And all of these things are as important, if not more important than medication. So, of course, the mantra that medication alone is never or almost never sufficient is true. I think it's there are some cases straightforward ADHD or something, but that's not what we're talking about here. So a medication on its own is hardly ever sufficient for the sorts of kids we're seeing with with complex developmental problems and we should keep working to. It's part of our role, I think, is to advocate for a whole range of services to work alongside medication. Medication is a very legitimate role in complex family situations. And even kids with, you know, kids we've been talking about at this conference with severe psychosocial adversity as well as developmental intrinsic developmental difficulties. It has a legitimate role. We shouldn't shy away from that, but it needs to be used alongside other supports. But I'm interested in Honey's response as well. 

Honey 20:17
I think that's a such a great question as well. I try to I'm not always successful to really try and be really mindful of when I see a family and I'm thinking about medication, thinking about two things. First of all, thinking more about what can I remove before I add something else, thinking about really what you're trying to target and how that might interact and being really mindful of one thing at a time. I'm always told that I'm not allowed to go shopping without taking something out of the house and I think this is a really good mindset to try and get yourself into. I've been trying very much because I see a lot of kids with lots of polypharmacy to think about. Every time I see them. I double check every medication and then I think about, okay, so what can I remove? Because it's very likely that some of them are causing more problems than helping. And so thinking first more, what can I remove before you think? What can I add? Then also making sure that in your documentation you clearly define what your target symptoms are and then your medication. So I document that first and then having a fixed timeline for a trial and a reassessment with the plan after that. So if you really clear and it's all really clearly documented, I think it makes you think through the process and I think it helps a kneejerk reaction more than anything. So I think the key thing to trying to ensure that you are not too complicit in this sort of area is really just to be really mindful. I think first what you can take away rather than add and then really clear documentation about why and the limitations and what you're trying to do. You know, I used to always love the way Michael McDowell always used to talk about. Actually, medication is an opportunity to learn new strategies and talk about that like that with families. And once you've had your opportunity, it's a trial off and seeing how you go like that, that's kind of how I would really advocate that people think, be that as it may, there will be kids who might need some polypharmacy, but it's you have to be mindful about how you do it. I think complicated answer to a really good question. 

Wei Wei 23:13
It is a good question. 

Honey 23:14
All struggle with. 

Wei Wei 23:15
Thank you so much. Both of you, for your wisdom and your time and for sharing your insights with us. I hope you're enjoying the virtual applause that's kind of reverberating around the online world. So, yes, thank you very much. I hope people enjoy the rest of the conference.