Differences Between Cetirizine and Hydroxyzine for Allergic Rhinitis in Children Under 2 Years
Cetirizine is preferred over hydroxyzine for allergic rhinitis in children under 2 years due to its better safety profile, less sedation, and specific FDA approval for younger children, while hydroxyzine is a first-generation antihistamine with significant sedative and anticholinergic effects that should be avoided in this age group.
Key Differences Between Medications
Classification and Derivation
- Cetirizine is a second-generation antihistamine that is actually derived from the metabolism of hydroxyzine, with high specificity for H1 receptors 1
- Hydroxyzine is a first-generation antihistamine with significant sedative and anticholinergic properties 2
Safety Profile in Young Children
- Second-generation antihistamines like cetirizine have been shown to be well tolerated with good safety profiles in young children 3
- First-generation antihistamines like hydroxyzine should be avoided in children under 6 years due to significant safety concerns, including risk of serious adverse events and fatalities 2, 3
- Between 1969-2006, there were 69 fatalities associated with first-generation antihistamines in children, with 41 reported in children under 2 years 2
Sedative Effects
- Cetirizine may cause mild sedation at recommended doses (13.7% vs 6.3% for placebo) but generally without performance impairment 2
- Hydroxyzine has significant sedative properties and performance impairment that can persist into the next day without subjective awareness 2
- First-generation antihistamines like hydroxyzine have been associated with agitated psychosis, ataxia, hallucinations, and even death in infants and young children 2
Anticholinergic Effects
- Cetirizine has minimal to no anticholinergic effects 2
- Hydroxyzine has significant anticholinergic properties that can be problematic, especially in young children 2
Efficacy Considerations
Symptom Control
- Cetirizine effectively reduces clinical symptoms of allergic rhinitis, including sneezing, itching, rhinorrhea, and nasal congestion 4
- Cetirizine also demonstrates anti-allergic properties by reducing inflammatory cell infiltrate and mediators in nasal passages 4, 5
- Hydroxyzine, while effective for allergic symptoms, carries unnecessary risks in this age group 2
Onset and Duration
- Cetirizine has a rapid onset and long duration of action, making it suitable for once-daily dosing 5, 6
- Cetirizine has a pharmacokinetic half-life of about 7 hours in humans 6
Regulatory Considerations and Recommendations
FDA Approval Status
- Cetirizine is licensed for pediatric patients in Europe for children older than 2 years and in the USA for children older than 6 months 1
- The FDA and American Academy of Pediatrics recommend against using first-generation antihistamines like hydroxyzine in children under 6 years 2, 3
Current Guidelines
- Second-generation antihistamines such as cetirizine are recommended over first-generation antihistamines like hydroxyzine for allergic rhinitis 2
- For children under 2 years with allergic rhinitis, intranasal corticosteroids are actually recommended as first-line treatment, with second-generation antihistamines as second-line treatment 3
Important Clinical Considerations
Drug Interactions
- Cetirizine has a reduced potential for adverse drug interactions involving hepatic enzyme systems compared to other antihistamines due to its predominantly renal excretion 5
- Hydroxyzine is extensively metabolized and has greater potential for drug interactions 5, 6
Alternative Treatments for Children Under 2
- Intranasal corticosteroids are the most effective medication class for controlling symptoms of allergic rhinitis in children under 2 years 3
- Saline irrigation can be used as an adjunctive therapy with minimal side effects 3