Which form of hydroxyzine, pamoate or HCl (hydrochloride), is recommended for treating anxiety in children?

Hydroxyzine Pamoate vs. Hydrochloride for Treating Anxiety in Children

For treating anxiety in children, hydroxyzine hydrochloride (HCl) is recommended over hydroxyzine pamoate due to its more established use in pediatric anxiety management and better pharmacokinetic profile for this indication. 1

Comparison of Formulations

• Hydroxyzine is an effective sedative antihistamine approved for anxiolytic use in both Europe and the United States for children 1
• Both formulations (pamoate and HCl) contain the same active ingredient but differ in their salt forms, affecting:
  • Absorption rates
  • Onset of action
  • Duration of effect 2
• Hydroxyzine HCl is generally preferred for anxiety treatment due to its more predictable absorption profile 1, 2

Efficacy for Pediatric Anxiety

• Hydroxyzine has demonstrated efficacy as an anxiolytic in children with few contraindications 1
• It serves as an alternative to benzodiazepines, which are generally not recommended in children under 16 years of age 1
• Studies show hydroxyzine is more effective than placebo for anxiety disorders with acceptable tolerability 2

Clinical Considerations for Children

• Hydroxyzine HCl offers several advantages for pediatric use:
  • Available in syrup form, making dosing easier for children 1
  • More rapid onset of action compared to pamoate, which is beneficial for acute anxiety situations 2, 3
  • Better absorption profile, leading to more predictable clinical response 2

Safety Profile

• Common side effects include:
  • Drowsiness/sedation (most common) 4
  • Dry mouth
  • Dizziness 1
• Hydroxyzine has fewer safety concerns in children compared to benzodiazepines 1, 5
• No evidence of dependency or withdrawal symptoms upon discontinuation 3

Treatment Approach

• For mild to moderate anxiety in children, cognitive-behavioral therapy (CBT) should be considered first-line treatment 1
• When medication is necessary:
  • Selective serotonin reuptake inhibitors (SSRIs) have the strongest evidence base for long-term treatment of anxiety disorders in children 1
  • Hydroxyzine is appropriate for short-term or situational anxiety management 1, 3
• Hydroxyzine can be used as an adjunct to SSRIs or as monotherapy for milder cases 6, 7

Important Considerations

• Hydroxyzine should be used at the lowest effective dose to minimize sedation 5
• It should not be combined with other medications having anticholinergic properties 5
• Non-pharmacological approaches (distraction, relaxation techniques) should be incorporated alongside medication when possible 1

Common Pitfalls to Avoid

• Avoid using hydroxyzine as the sole treatment for severe, chronic anxiety disorders where SSRIs would be more appropriate 1
• Be cautious about long-term use due to potential tolerance development 5
• Monitor for excessive sedation that might interfere with school performance 5, 4
• Don't overlook the importance of combining medication with appropriate behavioral interventions 1