Hydroxyzine is an antihistamine medication that is used to treat a variety of conditions in both adults and children. Some of the uses of hydroxyzine in pediatric patients include:
- Allergic reactions – Hydroxyzine blocks the effects of histamine, which is released during an allergic reaction. This helps reduce symptoms like itching, sneezing, and hives.
- Anxiety – Hydroxyzine has anxiolytic (anti-anxiety) properties and can be used to treat generalized anxiety disorder, social anxiety disorder, and situational anxiety in children.
- Itching – In addition to allergies, hydroxyzine can also help relieve itching due to other causes like eczema, chickenpox, and hives.
- Nausea and vomiting – The antihistamine properties of hydroxyzine help reduce nausea and vomiting associated with motion sickness, chemotherapy, or post-surgery.
- Sedation – Hydroxyzine is sedating and can be used short-term to induce sleep in children with insomnia or before medical procedures that require sedation.
Hydroxyzine is available in tablet, capsule, and liquid forms. The liquid form is often easier to administer to small children. The dose of hydroxyzine is determined based on the child’s weight and the condition being treated.
Mechanism of action
Hydroxyzine’s main mechanism of action is blocking the effects of histamine by binding to histamine H1 receptors. Histamine is responsible for many of the symptoms experienced during an allergic reaction, like:
- Itching
- Hives
- Sneezing
- Runny nose
- Watery eyes
By occupying H1 receptor sites, hydroxyzine prevents histamine from binding and activating these receptors. This provides relief from the typical symptoms associated with allergies.
In addition to its antihistamine effects, hydroxyzine also has some anticholinergic and antiserotonergic properties. Anticholinergic effects can help dry up secretions during colds or allergic reactions. The antiserotonergic effects may contribute to hydroxyzine’s anti-nausea and anti-anxiety effects.
Uses of hydroxyzine in children
Some of the most common uses of hydroxyzine in pediatric patients include:
Allergic reactions
Hydroxyzine is commonly used to treat allergic reactions in children to foods, medications, insect bites/stings, and other environmental triggers. It can provide relief from:
- Hives (urticaria)
- Itching
- Rash
- Swelling
- Runny nose
- Watery eyes
- Sneezing
- Anaphylaxis (life-threatening whole-body reaction)
For mild to moderate reactions, hydroxyzine helps alleviate symptoms. It can also be used in conjunction with epinephrine for anaphylaxis.
Anxiety disorders
Hydroxyzine has demonstrated efficacy in treating several anxiety disorders in children, either alone or as an adjunct to behavioral therapy. Some conditions it may be used for include:
- Generalized anxiety disorder
- Social anxiety disorder
- Separation anxiety
- Phobias
- Test anxiety
- Performance anxiety
Since hydroxyzine has a sedating effect, it can help calm children with anxiety before school, tests, public performances, or social events.
Sedation
The drowsiness caused by hydroxyzine is useful for inducing sleep in children with insomnia. It can be used short-term to establish healthy sleep patterns. Hydroxyzine sedation is also helpful before medical procedures like MRIs, endoscopies, and dental work that require the child to remain very still.
Itching
In addition to allergic reactions, hydroxyzine can also provide relief from generalized itching caused by:
- Chickenpox
- Hives (chronic urticaria)
- Eczema flares
- Contact dermatitis
- Bug bites
- Dry, itchy skin
The antihistamine properties of hydroxyzine block the histamine response that induces itching, providing symptomatic relief.
Nausea and vomiting
Hydroxyzine can reduce nausea and vomiting in children associated with:
- Motion sickness
- Gastroenteritis (stomach flu)
- Chemotherapy
- Post-surgery
It is thought to have central antiemetic effects due to serotonin antagonism. Hydroxyzine may be used alone or with other anti-nausea medications.
Dosage
Hydroxyzine dosage for children is based on the child’s weight and the condition being treated. Some general dosage guidelines include:
- Children under 6 years: 0.5-1 mg/kg/dose every 4-6 hours as needed
- Children 6-12 years: 25-50 mg dose every 4-6 hours as needed
- Adolescents over 12 years: 50-100 mg dose every 4-6 hours as needed
Hydroxyzine comes in 10mg/5mL oral syrup, 10mg, 25mg, and 50mg tablets, and 10mg/mL and 50mg/mL injectable solutions. Lower doses are recommended for sedation and higher doses for severe allergic reactions or anxiety.
Here is an example dosage chart based on weight:
| Weight | Dosage |
|---|---|
| 15-20 lbs | 7.5 mg (0.75 mL) every 6 hours |
| 21-30 lbs | 10 mg (1 mL) every 6 hours |
| 31-45 lbs | 15 mg (1.5 mL) every 6 hours |
| 46-59 lbs | 20 mg (2 mL) every 4-6 hours |
| 60-74 lbs | 25 mg (2.5 mL) every 4-6 hours |
Doctors may adjust the dose and frequency based on the severity of symptoms and how the child responds.
Side effects
Hydroxyzine is generally well tolerated in most children but can cause some mild side effects including:
- Drowsiness
- Headache
- Dry mouth
- Dizziness
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Appetite changes
- Excitation in some children
- Skin rash
These effects are usually transient and subside with continued use. However, hydroxyzine should be used with caution in children with a history of seizures as it may lower the seizure threshold.
Signs of hydroxyzine overdose include extreme drowsiness, dilated pupils, fast heart rate, tremors, anddelirium. Seek immediate medical attention if an overdose is suspected.
Some rare but serious side effects reported with hydroxyzine include:
- Heart arrhythmias
- Heart failure
- Severe skin reactions (Stevens-Johnson syndrome)
- Blood disorders
- Seizures
Hydroxyzine should be discontinued if any concerning reactions develop. Children may also build a tolerance over time, needing higher doses for the same effect. This is why hydroxyzine use is usually temporary.
Warnings
There are some important safety warnings to consider with hydroxyzine use in children:
- Central nervous system depression – Hydroxyzine causes drowsiness and can exacerbate issues like hyperactivity, seizures, or developmental delay in some children. Use with caution in children with CNS issues.
- Urinary retention – Hydroxyzine has anticholinergic effects that can lead to urinary retention. This is a particular concern in children unable to communicate this symptom.
- Paradoxical reactions – Some children may experience overstimulation and agitation rather than sedation with hydroxyzine.
- Masking serious illness – The antiemetic and analgesic properties of hydroxyzine can mask signs of serious illness like appendicitis. Discontinue use if symptoms persist or worsen.
Hydroxyzine has not been extensively studied in children under 2 years old. Use in infants is generally not recommended. Also avoid use with other sedating drugs and alcohol due to increased risk of dangerous CNS and respiratory depression.
As with any medication, balance the benefits of hydroxyzine against potential risks before prescribing for children. Monitor closely for side effects and adjust dosage as needed.
Interactions
Hydroxyzine can interact with a number of other medications. Some notable drug interactions in children include:
- CNS depressants – Increased sedation with drugs like anti-anxiety medications, anticonvulsants, sleep aids, and narcotics.
- Anticholinergics – Increased anticholinergic effects with tricyclic antidepressants, antipsychotics, bladder antispasmodics, and Parkinson’s medications.
- QT interval prolongation – Increased risk when combined with macrolide antibiotics or methadone.
- CYP enzymes – Hydroxyzine metabolism may be impacted by CYP inhibitors like cimetidine and azole antifungals.
Check for interactions before starting hydroxyzine and avoid combining it with contraindicated drugs. The sedating effects are of particular concern with other CNS depressants. Monitor children closely when combining medications.
Contraindications
Some contraindications for hydroxyzine use in children include:
- Known hypersensitivity – Do not use in children with previous hydroxyzine allergy.
- Prolonged QT interval -High risk for dangerous arrhythmias.
- Porphyria – Exacerbation of this metabolic disorder.
- Pregnancy/breastfeeding – Safety not established, avoid unless benefits outweigh potential fetal/infant risks.
- Preexisting CNS depression – Severe impairment with other CNS depressants.
- MAOIs – Serious drug interactions possible. Avoid MAOIs for 2 weeks before and after hydroxyzine.
- Neonates and premature infants – increased risk for anticholinergic and CNS effects.
Alternatives
Some alternatives to hydroxyzine for pediatric use include:
Allergies
- Cetirizine (Zyrtec)
- Loratadine (Claritin)
- Fexofenadine (Allegra)
- Diphenhydramine (Benadryl)
Anxiety
- SSRIs like sertraline (Zoloft) or fluoxetine (Prozac)
- Buspirone
- Clonidine
- Guanfacine
Sedation
- Melatonin
- Lorazepam
- Zolpidem
- Promethazine
Itching/nausea
- Ondansetron
- Promethazine
- Diphenhydramine
- Famotidine
- Ranitidine
When possible, choose alternatives with less sedation to avoid excessive drowsiness in children. Consider trialing non-pharmacological therapies as well.
Conclusion
Hydroxyzine can be a useful medication for treating several conditions in pediatric patients, including allergic reactions, anxiety, insomnia, nausea, vomiting, and generalized itching. However, the sedating effects mean it must be used judiciously in children. Monitor children closely for side effects like oversedation, urinary retention, or paradoxical excitation. Use the lowest effective dose for the shortest duration needed. Consider safer alternatives in young or medically complex children. When prescribed responsibly, hydroxyzine can provide symptom relief and comfort for children suffering from various ailments.
