Propranolol Dosing for Anxiety in a 9-Year-Old
Propranolol is not routinely recommended for generalized anxiety in children, but when used for situational/performance anxiety with prominent somatic symptoms (tremor, palpitations, sweating), start at 0.5-1 mg/kg/day divided into 2-3 doses, with careful cardiovascular screening beforehand. 1
Critical Pre-Treatment Assessment Required
Before prescribing propranolol to any pediatric patient, you must exclude absolute contraindications:
- Second or third-degree heart block 1
- Asthma or reactive airway disease 2, 1
- Decompensated heart failure 2, 1
- History of hypoglycemic episodes 2, 1
- Sinus node dysfunction without pacemaker 1
Perform baseline cardiovascular assessment including heart rate, blood pressure measurement, and cardiac auscultation. 2, 1 Screen specifically for history of bronchospasm, diabetes, and any medications affecting cardiac conduction. 1
Pediatric Dosing Algorithm
For a 9-year-old with anxiety:
- Starting dose: 0.5-1 mg/kg/day divided into 2-3 doses (e.g., if child weighs 30 kg, start with 15-30 mg daily in divided doses) 1, 3
- Maximum dose: Up to 3-4 mg/kg/day if needed for inadequate response 1, 3
- For situational/performance anxiety only: 10-20 mg as a single dose 30-60 minutes before the anxiety-provoking event (lower end of adult dosing, adjusted for weight) 1
The liquid formulation (10 mg/ml) allows for more accurate dose adjustments in younger children compared to tablets. 3
Patient Selection: Who Benefits Most
Propranolol is only effective for anxiety with prominent somatic/autonomic symptoms such as tremor, palpitations, tachycardia, and sweating—not for purely cognitive or psychological anxiety symptoms. 2, 1, 4 If the child's anxiety is predominantly worry, fear, or psychological distress without physical manifestations, propranolol will likely be ineffective. 4, 5
Propranolol is specifically deprecated for generalized social anxiety disorder but remains effective for performance anxiety and specific situational triggers. 2
Administration and Monitoring
- Give with food to reduce hypoglycemia risk 2
- Hold doses during vomiting or significantly reduced oral intake 2
- Monitor for hypotension and bradycardia, especially during dose escalation 2, 1
- Lower doses may be required if adverse effects develop 2
Common adverse effects include fatigue, bradycardia, hypotension, dizziness, and cold extremities. 2, 6
Critical Safety Warning
Never abruptly discontinue propranolol—this can precipitate rebound hypertension or tachycardia. 2, 1 Taper gradually over several weeks when discontinuing, especially after chronic use. 1
Propranolol may mask hypoglycemia symptoms in diabetic or susceptible patients, requiring additional counseling. 2, 6
Clinical Context and Limitations
The evidence base for propranolol in pediatric anxiety is limited. The available pediatric data primarily addresses cardiac conditions (dysrhythmias, hypertrophic cardiomyopathy) and infantile hemangiomas at doses of 0.5-4 mg/kg/day. 3 Adult anxiety studies used 80-320 mg daily (occasionally up to 1200 mg for severe symptoms), but these cannot be directly extrapolated to children. 7
Given the lack of robust pediatric anxiety data, propranolol should be reserved for situational use in children with clear somatic anxiety symptoms, not as chronic treatment for generalized anxiety. 2, 4 Consider first-line psychological interventions and other evidence-based treatments for pediatric anxiety before resorting to off-label propranolol use.