Is hydroxyzine safe for pediatric patients to treat anxiety?

Hydroxyzine Safety for Pediatric Anxiety Treatment

Hydroxyzine can be used as a second-line treatment for anxiety in pediatric patients, but SSRIs and cognitive behavioral therapy should be considered first-line options due to stronger evidence for long-term efficacy and safety. 1

Efficacy and Safety Profile

Hydroxyzine is FDA-approved for the symptomatic relief of anxiety and tension associated with psychoneurosis, though its long-term effectiveness (beyond 4 months) has not been assessed by systematic clinical studies 2. The American Academy of Child and Adolescent Psychiatry recommends SSRIs and SNRIs as first-line pharmacotherapy for anxiety disorders, with hydroxyzine considered a second-line option 1.

Safety Considerations:

• Short-term use: Hydroxyzine is generally safe for short-term management of anxiety in pediatric patients, particularly for anxiolysis during medical procedures 3

• Long-term concerns: A 2021 population-based longitudinal study found that frequent hydroxyzine use in children under 5 years was associated with higher rates of:

  • Tic disorders (OR 1.55)
  • Anxiety (OR 1.34)
  • Conduct disturbances (OR 1.34)
  • Non-significant increased trends for ADHD and emotional disturbances 4

• Side effects: Common side effects include:

  • Sedation/drowsiness (most common)
  • Potential anticholinergic effects
  • Potential QT prolongation (rare but serious) 2

Treatment Algorithm for Pediatric Anxiety

First-Line Options:

1. Cognitive behavioral therapy (CBT) - Highly effective and recommended either alone or in combination with medication 1

2. SSRIs (if pharmacotherapy needed):

   • Fluoxetine
   • Sertraline
   • Escitalopram
   • These have stronger evidence for long-term efficacy 1, 5

Second-Line Options:

1. Hydroxyzine - Consider when:

   • Rapid anxiolysis is needed
   • First-line treatments are ineffective or contraindicated
   • Short-term management is appropriate 1

2. SNRIs (e.g., venlafaxine) - Comparable efficacy to SSRIs 1

Dosing and Administration Considerations

When using hydroxyzine in pediatric patients:

• Start with the lowest effective dose
• Use for the shortest duration possible to minimize potential neurodevelopmental effects 4
• Monitor for sedation, which may affect school performance
• Avoid combining with other CNS depressants as hydroxyzine potentiates their effects 2

Important Precautions

• Drug interactions: Hydroxyzine potentiates CNS depressants (narcotics, analgesics, barbiturates) - dosage reduction of these medications may be necessary 2

• Cardiac considerations: Use with caution in patients with risk factors for QT prolongation or concomitant medications known to prolong QT interval 2

• Driving/machinery: Warn patients about potential drowsiness and caution against driving or operating dangerous machinery 2

• Monitoring: Regular reassessment of the medication's usefulness is recommended, especially for long-term use 2

Conclusion

While hydroxyzine can be used for pediatric anxiety, the evidence suggests it should be reserved as a second-line option after SSRIs and CBT. The 2021 longitudinal study raising concerns about potential neurodevelopmental effects with frequent use 4 suggests that hydroxyzine should be used for the shortest possible duration in children, particularly in preschool-aged patients.