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H1-antihistamines in children
1University of Manitoba, Winnipeg, Manitoba, Canada.
Insights
H1-antagonists effectively treat allergic rhinoconjunctivitis in children. However, newer, non-sedating options are preferred over older ones, except in specific severe cases like intractable itching or anaphylaxis.
Area of Science:
- Pediatric Allergy and Immunology
- Pharmacology
- Clinical Therapeutics
Background:
- H1-antagonists are widely used in pediatric populations for allergic conditions.
- Evidence supports their efficacy in allergic rhinoconjunctivitis but not broadly for other common childhood illnesses.
- Safety and efficacy profiles vary significantly between first-generation and second-generation H1-antagonists.
Purpose of the Study:
- To review the evidence for H1-antagonist use in pediatric allergic and non-allergic conditions.
- To delineate appropriate uses and contraindications for first- and second-generation H1-antagonists in children.
- To highlight the benefits of newer, non-sedating H1-antagonists in pediatric care.
Main Methods:
- Systematic review of pediatric clinical trials and evidence-based guidelines.
- Analysis of pharmacokinetic and pharmacodynamic data for different H1-antagonist generations.
- Evaluation of adverse event profiles, particularly central nervous system (CNS) effects.
Main Results:
- Strong evidence supports H1-antagonist use for pediatric allergic rhinoconjunctivitis.
- Limited scientific rationale exists for their use in upper respiratory infections or otitis media.
- First-generation H1-antagonists can impair CNS function; their use should be restricted to severe pruritus or anaphylaxis.
- Second-generation H1-antagonists are recommended for most pediatric allergic conditions due to their safety profile.
Conclusions:
- Second-generation H1-antagonists (cetirizine, fexofenadine, loratadine) are the preferred choice for children due to minimal CNS side effects.
- First-generation H1-antagonists should be used judiciously in specific pediatric cases.
- Further research is needed on the role of H1-antagonists in preventing asthma development in high-risk infants.
Abstract:
In children, as in adults, H1-antagonists are useful in the treatment of allergic rhinoconjunctivitis. Level 1 evidence for their efficacy in this disorder has been obtained in many well-designed pediatric studies. The widespread use of H1-antagonists in upper respiratory tract infections or otitis media in children is not supported by a strong scientific rationale. H1-antagonists are not harmful in children with asthma and, indeed, may have some beneficial effects in children with mild asthma. Their role in delaying or preventing asthma from developing in high-risk infants and toddlers is currently an important area of clinical investigation. The evidence base for their use in children with urticaria or atopic dermatitis still contains large gaps. First-generation H1-antagonists are presumed to be safe for use in infants and children. While they have undoubtedly been administered without apparent harm to millions in this age group, they impair CNS function far more commonly than is generally realized. Their use should be restricted to two uncommon situations: children with urticaria or atopic dermatitis whose pruritus is so severe that the sedation produced by an old H1-antagonist, such as hydroxyzine, is a benefit rather than a risk; and children with anaphylaxis who require intravenous diphenhydramine as adjunctive treatment to epinephrine and other modalities. Apart from these exceptions, in patients of all ages, second-generation H1-antagonists free from CNS adverse effects are clearly the medications of choice. Pediatric formulations of the new H1-antagonists cetirizine, fexofenadine, and loratadine are now available for use.