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Pediatric Palliative Care
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     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.3,4,5 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

    References

    Himelstein BP, Hilden JM, Boldt AM, Weissman D. Pediatric palliative care. N Engl J Med 2004;350:1752-1762.

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

    Curry JF. Specific psychotherapies for childhood and adolescent depression. Biol Psychiatry 2001;49:1091-1100.

    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.

    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.

    The authors reply: 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

    References

    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.

    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.