Recommended Antihistamines for Pediatric Use
Second-generation antihistamines—specifically cetirizine, loratadine, desloratadine, fexofenadine, and levocetirizine—are the recommended first-line oral antihistamines for children, with cetirizine and loratadine approved for use starting at age 2 years, making them the preferred choices for young children. 1, 2
Age-Specific Oral Antihistamine Recommendations
Children Age 2-5 Years
- Cetirizine: 2.5 mg once or twice daily (available OTC) 1
- Loratadine: 5 mg daily (available OTC) 1
- Desloratadine: 1.25 mg daily (prescription) 1
- Levocetirizine: 1.25 mg daily (prescription) 1
These second-generation agents have demonstrated excellent safety profiles with minimal sedation compared to first-generation antihistamines 1, 2. The American Academy of Allergy, Asthma, and Immunology specifically endorses these medications for young children due to their tolerability and low adverse event rates 2.
Children Age 6-11 Years
- Cetirizine: 5-10 mg daily (OTC) 1
- Loratadine: 10 mg daily (OTC) 1
- Fexofenadine: 30 mg twice daily (OTC) 1
- Desloratadine: 2.5 mg daily (prescription) 1
- Levocetirizine: 2.5 mg daily (prescription) 1
Children Age 12 Years and Older
- Cetirizine: 10 mg daily (OTC) 1, 3
- Loratadine: 10 mg daily (OTC) 1
- Fexofenadine: 60 mg twice daily or 180 mg daily (OTC) 1
- Desloratadine: 5 mg daily (prescription) 1
- Levocetirizine: 5 mg daily (prescription) 1
Intranasal Antihistamine Options
For children age 6 years and older with allergic rhinitis, intranasal antihistamines provide superior efficacy compared to oral antihistamines, particularly for nasal congestion. 1
Available Intranasal Formulations (Age ≥6 Years)
- Azelastine 0.1%: 1 spray per nostril twice daily (ages 6-11); 1-2 sprays twice daily (age ≥12) 1
- Azelastine 0.15%: Same dosing as 0.1% formulation 1
- Olopatadine 0.6%: 1 spray per nostril twice daily (ages 6-11); 2 sprays twice daily (age ≥12) 1
Intranasal antihistamines demonstrate equal or superior efficacy to oral antihistamines in head-to-head trials, with somnolence rates (0.4%-3%) comparable to placebo 1. The main limitation is bitter taste, which varies between formulations—if taste aversion occurs, switching to an alternative intranasal formulation is reasonable 1.
Critical Safety Considerations
Avoid in Children Under Age 2 Years
OTC cough and cold combination products containing antihistamines should NOT be used in children under 2 years due to serious safety concerns, including 69 reported fatalities between 1969-2006. 1, 4 The FDA and multiple advisory committees have recommended against their use in this age group due to overdose risks and lack of proven efficacy 1.
First-Generation Antihistamines: Use With Extreme Caution
First-generation antihistamines (diphenhydramine, chlorphenamine, hydroxyzine) should generally be avoided in children under 6 years. 4, 5 These agents cause significant sedation (>50% of patients), impair learning and cognitive function, and carry higher toxicity risks 6. Diphenhydramine is specifically contraindicated in children under 6 years per FDA labeling 5.
If a sedating antihistamine is deemed necessary for nighttime use in older children, options include:
- Chlorphenamine: 4-12 mg at bedtime (ages ≥6 years) 1
- Hydroxyzine: 10-50 mg at bedtime (ages ≥6 years) 1
However, adding a sedating antihistamine to a second-generation agent provides minimal additional benefit for symptom control if H1 receptors are already saturated 1.
Special Populations
Renal Impairment
- Halve the dose of cetirizine, levocetirizine, and hydroxyzine in moderate renal impairment 1, 2
- Avoid cetirizine and levocetirizine in severe renal impairment (creatinine clearance <10 mL/min) 1
- Avoid acrivastine in moderate renal impairment 1
Hepatic Impairment
- Avoid alimemazine (hepatotoxic) and chlorphenamine/hydroxyzine (inappropriate sedation) in severe liver disease 1
Before Allergy Testing
- Discontinue cetirizine 5-7 days before skin prick testing 2
- Discontinue desloratadine 6 days before testing (longest elimination half-life at 27 hours) 1
Common Pitfalls to Avoid
Do not use antihistamines as monotherapy for anaphylaxis—they should never replace epinephrine for severe allergic reactions 2
Do not assume all second-generation antihistamines are interchangeable—individual patient responses vary, so offer at least two different options if the first is ineffective 1
Do not combine multiple OTC cold/cough products—this was a common cause of overdose fatalities in the FDA adverse event review 1
Do not use topical decongestants for more than 3 days—rhinitis medicamentosa (rebound congestion) can develop as early as day 3-4 1
For children under 2 years requiring allergy treatment, consider intranasal corticosteroids as first-line therapy rather than antihistamines, as they are the most effective medication class for allergic rhinitis 4