BNF for Children 2011-2012

238 4.10 Drugs used in substance dependence BNFC 2011–20124 Central nervous systemtremor or tremor associated with anxiety or thyrotoxicosis.BOTULINUM TOXIN TYPE ACautions neurological disorders (can lead to increasedsensitivity and exaggerated muscle weakness);excessive weakness or atrophy in target muscle; historyof dysphagia or aspiration; chronic respiratorydisorderContra-indications generalised disorders of muscleactivity (e.g. myasthenia gravis); infection at injectionsitePregnancy low risk of systemic absorption but avoidunless essentialBreast-feeding low risk of systemic absorption butavoid unless essentialSide-effects increased electrophysiologic jitter insome distant muscles; misplaced injections mayparalyse nearby muscle groups and excessive dosesmay paralyse distant muscles; influenza-like symptoms,rarely arrhythmias, myocardial infarction, seizures,hypersensitivity reactions including rash, pruritusand anaphylaxis, antibody formation (substantialdeterioration in response); very rarely exaggeratedmuscle weakness, dysphagia, and aspiration (seekmedical attention if swallowing, speech, or respiratorydisorder)Specific side-effects in paediatric cerebral palsy Drowsiness,paraesthesia, urinary incontinence, myalgiaIndication and doseIn children over 2 years for dynamic equinus footdeformity caused by spasticity in ambulant paediatriccerebral palsy for dose consult product literature(important: information specific to each individualpreparation and not interchangeable)Botox c (Allergan) AInjection, powder for reconstitution, botulinum toxintype A complex, net price 50-unit vial = £77.50; 100-unit vial = £138.20; 200-unit vial = £276.40Dysport c (Ipsen) AInjection, powder for reconstitution, botulinum typeA toxin-haemagglutinin complex, net price 300-unitvial = £92.40; 500-unit vial = £154.004.10 Drugs used in substancedependenceThis section includes drugs used in the treatment ofneonatal abstinence syndrome and cigarette smoking.Treatment of alcohol or opioid dependence in childrenrequires specialist management. The UK health departmentshave produced guidance on the treatment of drugmisuse in the UK. Drug Misuse and Dependence: UKGuidelines on Clinical Management (2007) is availableatwww.nta.nhs.uk/uploads/clinical_guidelines_2007.pdf.Neonatal abstinence syndrome Neonatal abstinencesyndrome occurs at birth as a result of intrauterineexposure to opioids or high-dose benzodiazepines.Treatment is usually initiated if:. feeding becomes a problem and tube feeding isrequired;. there is profuse vomiting or watery diarrhoea;. the baby remains very unsettled after two consecutivefeeds despite gentle swaddling and the use of apacifier.Treatment involves weaning the baby from the drug onwhich it is dependent. Morphine or methadone (section4.7.2) can be used in babies of mothers who havebeen taking opioids. Morphine is widely used becausethe dose can be easily adjusted, but methadone mayprovide smoother control of symptoms. Weaning babiesfrom opioids usually takes 7–10 days.Weaning babies from benzodiazepines that have a longhalf-life is difficult to manage; chlorpromazine (section4.2.1) may be used in these situations but excessivesedation may occur. For babies who are dependent onbarbiturates, phenobarbital (section 4.8.1) may be tried,although it does not control gastro-intestinal symptoms.4.10.1 Alcohol dependenceClassification not used in BNF for Children.4.10.2 Nicotine dependenceSmoking cessation interventions are a cost-effectiveway of reducing ill health and prolonging life. Smokersshould be advised to stop and offered help with followupwhen appropriate. If possible, smokers should haveaccess to smoking cessation services for behaviouralsupport.Therapy to aid smoking cessation is chosen accordingto the smoker’s likely compliance, availability of counsellingand support, previous experience of smokingcessationaids, contra-indications and adverse effects ofthe preparations, and the smoker’s preferences. Nicotinereplacement therapy is an effective aid to smokingcessation. The use of nicotine replacement preparationsin an individual who is already accustomed to nicotineintroduces few new risks and it is widely accepted thatthere are no circumstances in which it is safer to smokethan to use nicotine replacement therapy.Some individuals benefit from having more than onetype of nicotine replacement therapy prescribed, suchas a combination of transdermal and oral preparations.Concomitant medication Cigarette smokingincreases the metabolism of some medicines by stimulatingthe hepatic enzyme CYP1A2. When smoking isdiscontinued, the dose of these drugs, in particulartheophylline p. 142 and some antipsychotics (includingclozapine p. 178, olanzapine p. 179, chlorpromazinep. 174, and haloperidol p. 174), may need to be reduced.Regular monitoring for adverse effects is advised.