Cetirizine is Preferred Over Symdex for Pediatric Allergic Rhinitis
For allergic rhinitis in children 6 years and older, cetirizine is the appropriate choice, while OTC cough and cold combination products (like Symdex) should be avoided due to lack of efficacy and significant safety concerns. 1
Critical Safety Concerns with OTC Cough and Cold Medications
Controlled trials have demonstrated that antihistamine-decongestant combination products are not effective for children. 1
Between 1969 and 2006, there were 54 fatalities associated with decongestants and 69 fatalities associated with antihistamines found in OTC preparations, with drug overdose and toxicity being common events. 1
The FDA's Nonprescription Drugs and Pediatric Advisory Committees recommended in 2007 that OTC cough and cold medications no longer be used for children below 6 years of age. 1
Oral decongestants in infants and young children have been associated with agitated psychosis, ataxia, hallucinations, and even death. 1
Cetirizine Safety and Efficacy Profile
Second-generation antihistamines such as cetirizine, when used in young children, have been shown to be well tolerated and to have a very good safety profile. 1
Age-Appropriate Dosing:
For children 6 years and older: Cetirizine 10 mg once daily provides effective 24-hour relief of sneezing, runny nose, itchy watery eyes, and itchy throat or nose. 2
For children 2-5 years: Cetirizine can be dosed at 2.5 mg once or twice daily with FDA approval. 3
For infants 6-11 months: Cetirizine can be administered at 0.25 mg/kg twice daily (approximately 2.5 mg twice daily for a 10 kg infant) in controlled settings. 3
Clinical Evidence:
Cetirizine 10 mg once daily produced significantly greater symptom reduction compared to placebo in children ages 6-11 years with seasonal allergic rhinitis (mean total symptom severity score reduction of 3.2 vs placebo, P < 0.05). 4
In a head-to-head comparison, cetirizine was statistically significantly more efficacious than placebo in treating seasonal allergic rhinitis symptoms in children ages 6-11 years, while loratadine showed no significant difference from placebo. 5
Cetirizine demonstrated superior efficacy compared to levocetirizine for perennial allergic rhinitis in children ages 6-12 years at weeks 8 and 12. 6
Important Caveats About Cetirizine
Cetirizine 10 mg may be associated with mild drowsiness (13.7% in patients age 12 years) compared with placebo (6.3%), though typically without performance impairment at standard doses. 1
Patients with low body mass for whom a standard dose (based on age) is prescribed may reach elevated dosage levels (on a milligram per kilogram basis) and develop drowsiness. 1
The most commonly reported adverse reactions are headache, pharyngitis, and abdominal pain, which do not occur with statistically different incidence from placebo. 4
First-Line Treatment Algorithm for Pediatric Allergic Rhinitis
Intranasal corticosteroids are the most effective medications for treating allergic rhinitis and should be considered first-line therapy. 1
Treatment Hierarchy:
First-line: Intranasal corticosteroids control all four major symptoms (sneezing, itching, rhinorrhea, nasal congestion) with onset of therapeutic effect between 3-12 hours. 1, 3
Second-line: Second-generation oral antihistamines like cetirizine for symptom relief, particularly for sneezing, rhinorrhea, itching, and ocular symptoms. 3
Adjunctive therapy: Saline irrigation provides modest benefit with minimal side effects and low cost. 3
What to Avoid
Never use first-generation antihistamines (like diphenhydramine) in children under 6 years due to significant safety concerns. 3
Avoid intranasal antihistamines (azelastine, olopatadine) in children under 6 years due to lack of approval. 3
Do not use oral decongestants in children under 6 years except with extreme caution, as risks outweigh benefits. 1
Avoid topical decongestants for continuous use due to risk of rhinitis medicamentosa, which may develop within 3 days of use. 1