What is an alternative to Cetirizine (hydroxyzine) for treating allergic rhinitis in children under 2 years?

Alternatives to Cetirizine for Allergic Rhinitis in Children Under 2 Years

For children under 2 years with allergic rhinitis, intranasal corticosteroids are the most effective medication class and should be considered as first-line treatment when an alternative to cetirizine is needed. 1

Second-Generation Antihistamine Options

• Desloratadine, fexofenadine, levocetirizine, and loratadine have been shown to be well tolerated with good safety profiles in young children and can be considered as alternatives to cetirizine 1, 2
• Second-generation antihistamines are effective in reducing rhinorrhea, sneezing, and itching associated with allergic rhinitis, but have limited effect on nasal congestion 2
• These medications provide effective relief of allergic symptoms with minimal or no sedation, unlike first-generation antihistamines 2

Important Safety Considerations

• First-generation antihistamines (diphenhydramine, chlorpheniramine, brompheniramine) should be strictly avoided in children under 6 years due to significant safety concerns 2, 3
• The FDA label for diphenhydramine explicitly states "Do not use" for children under 6 years of age 3
• Between 1969-2006, there were 69 fatalities associated with antihistamines in children, with 41 reported in children under 2 years 1
• In 2007, the FDA's Nonprescription Drugs and Pediatric Advisory Committees recommended against using OTC cough and cold medications (including antihistamines) in children under 6 years 1

Intranasal Corticosteroids as First-Line Alternative

• Intranasal corticosteroids are the most effective medication class for controlling symptoms of allergic rhinitis 1
• They effectively control all four major symptoms: sneezing, itching, rhinorrhea, and nasal congestion 1
• When given in recommended doses, intranasal corticosteroids are not generally associated with clinically significant systemic side effects 1
• The clinical response does not appear to vary significantly between different intranasal corticosteroid products 1

Saline Irrigation as Adjunctive Therapy

• Isotonic and hypertonic saline solutions can provide modest benefit for reducing symptoms in patients with allergic rhinitis 1
• Saline irrigation has minimal side effects, low cost, and generally good patient acceptance 1
• It can be used as either a single or adjunctive agent alongside other treatments 1

Treatment Algorithm for Children Under 2 Years with Allergic Rhinitis

1. First-line: Intranasal corticosteroids (most effective for all symptoms) 1
2. Second-line: Second-generation antihistamines (desloratadine, fexofenadine, levocetirizine, or loratadine) 1, 2
3. Adjunctive therapy: Saline irrigation to help reduce symptoms 1

Common Pitfalls and Cautions

• Never use first-generation antihistamines (diphenhydramine, chlorpheniramine) in children under 6 years due to risk of serious adverse events including fatalities 1, 3, 4
• Avoid combination products containing decongestants, as they have been associated with significant adverse events in young children 1, 4
• Be aware that continuous treatment is more effective than intermittent use for allergic rhinitis 2
• Topical decongestants should not be used for more than 3 days due to risk of rhinitis medicamentosa 1