Along with lithium, valproate is a first-line antimanic agent for acute manic episodes in kids.

Here are some hard-won tips and pearls that you might find useful in your practice.

Lower risk for EPS and a broad spectrum of efficacy make this an appealing first-choice agent. However, sedation, weight gain, and orthostasis may limit use. 

Although clinicians often try other medications first due to both the relative complexity of managing lithium as well as bias from the public, lithium, along with several second-generation antipsychotics, is FDA indicated and considered first line for treating pediatric bipolar disorder.

Not for first-line use for most kids due to limited data (open-label studies only), long titration required, and increased relative risk of rash in pediatric population.

Not a first-line treatment for bipolar disorder in kids due to limited data, side effect profile, and high likelihood of significant interactions.

Risperidone offers more efficacy and safety data in kids than other antipsychotics and is often used first-line in autistic kids, but you need to expect and monitor for EPS, prolactinemia, and weight gain.

Compared to carbamazepine, oxcarbazepine poses less concern for drug interactions and for hepatic or hematologic toxicities; it also does not require serum level monitoring.

Not as good a choice as we used to think for minimizing risk of weight gain and metabolic side effects, and beware of akathisia.

Ramelteon is a melatonin receptor agonist with no data in pediatric patients.