What are the potential side effects of beta blockers in pediatric patients?

Side Effects of Beta Blockers in Pediatric Patients

Beta blockers in pediatric patients can cause significant side effects including growth impairment, school performance issues, depression, fatigue, bradycardia, hypotension, hypoglycemia, bronchospasm, and sleep disturbances. 1

Common Side Effects

• Cardiovascular effects: Bradycardia, hypotension, and heart block are common side effects due to the negative chronotropic and inotropic properties of beta blockers 1
• Central nervous system effects:
  • Sleep disturbances, nightmares, and night terrors occur in 2-18.5% of pediatric patients 1
  • Depression and impaired school performance, particularly concerning in children and adolescents 1, 2
  • Fatigue and lethargy 2
• Metabolic effects:
  • Hypoglycemia, especially in infants and children during fasting (e.g., preparation for surgery) 3, 4
  • Masking of hypoglycemic symptoms in diabetic patients 3, 1
• Respiratory effects:
  • Bronchospasm and respiratory disorders in 0.9-12.9% of patients, particularly with non-selective beta blockers 1, 3
  • Wheezing and bronchiolitis 1
• Growth effects: May affect growth in young children 1

Specific Concerns by Beta Blocker Type

• Non-selective beta blockers (e.g., propranolol):

  • Higher risk of bronchospasm and increased airway resistance 1
  • May lower HDL cholesterol, increase triglycerides 1
  • Can cause male impotency 1
  • Higher risk of masking hypoglycemia symptoms 3

• Beta-1 selective agents (e.g., atenolol, metoprolol):

  • Generally better tolerated in patients with respiratory conditions 1
  • Still carry risks of bradycardia and hypotension 4

High-Risk Scenarios

• Overdose situations: Can cause lethargy, respiratory depression, wheezing, bradycardia, heart block, hypotension, and hypoglycemia 4
• Patients with asthma or reactive airway disease: Increased risk of bronchospasm, especially with non-selective agents 3
• Diabetic patients: Masking of hypoglycemic symptoms and potential for prolonged hypoglycemia 3, 1
• Infants: Particularly susceptible to hypoglycemia; verapamil (calcium channel blocker sometimes used instead of beta blockers) is contraindicated in infants due to risk of sudden death 1

Monitoring Recommendations

• Growth parameters: Regular monitoring of growth in young children 1
• School performance: Assessment of academic performance and cognitive function 1
• Psychological status: Monitoring for depression and other mood changes, particularly in adolescents 1
• Cardiovascular parameters: Regular monitoring of heart rate and blood pressure 1
• Blood glucose: Consider monitoring in high-risk patients, particularly during fasting 3

Precautions and Contraindications

• Beta blockers are not recommended as initial treatment for hypertension in children due to their expanded adverse effect profile compared to other agents 1
• Use with caution in children with:
  • Asthma or reactive airway disease 3
  • Diabetes 3
  • Heart failure 3
  • Impaired hepatic or renal function 3
• Careful dose selection is critical: Start at the low end of the dosing range and titrate slowly 1

Special Considerations for Specific Indications

• Hypertrophic cardiomyopathy: Propranolol dosing up to 2 mg/kg in children, but monitor closely for side effects 1
• Infantile hemangiomas: When using propranolol, administer with feeds and hold therapy during times of restricted oral intake to prevent hypoglycemia 1
• Vasovagal syncope: Beta blockers are not beneficial and may have a higher recurrence rate than conventional therapy 1

Beta blockers should be used judiciously in pediatric patients with careful monitoring for adverse effects, particularly in young children and those with comorbid conditions that may increase risk of side effects.