Antihistamines Are Not Helpful for Viral Colds in Toddlers
Antihistamines should not be used to treat viral upper respiratory tract infections (common colds) in toddlers, as they provide no clinically meaningful benefit and carry potential risks in this age group. 1, 2
Evidence Against Antihistamine Use
Lack of Efficacy in Children
The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS 2020) explicitly states that antihistamines show no additive effect over standard treatment in children with post-viral acute rhinosinusitis, based on level 1b evidence. 1
A comprehensive Cochrane systematic review found no evidence of effectiveness of antihistamines in children with the common cold. 3
In adults, antihistamines showed only minimal short-term benefit (days 1-2) on overall symptom severity, but no clinically significant effect on specific symptoms like nasal congestion, rhinorrhea, or sneezing. 3
Potential Harms in Young Children
The FDA's Nonprescription Drugs and Pediatric Advisory Committees recommended that over-the-counter cough and cold medications, including antihistamines, no longer be used for children below 6 years of age. 4
Between 1969 and 2006, there were 54 documented fatalities associated with decongestants in children under 6 years, with 43 deaths occurring in infants under 1 year. 4
The FDA does not recommend the use of cough and cold products containing antihistamines in children younger than 2 years. 5
Mechanism of Potential Harm
Antihistamines may actually worsen congestion by drying the nasal mucosa in patients without an allergic component to their illness. 2
First-generation antihistamines carry additional risks of sedation and impairment of cognitive and academic function in children. 6, 7
When Antihistamines Might Be Considered (Exception)
Antihistamines may only be appropriate if the toddler has a documented allergic component (such as known allergic rhinitis) contributing to their symptoms, not for the viral cold itself. 2, 6
In such cases, second-generation antihistamines (cetirizine or loratadine) are preferred over first-generation options due to reduced sedation and cognitive effects. 6, 7
For children under 5 years of age, only cetirizine and loratadine are approved. 6
Recommended Approach for Viral Colds in Toddlers
Viral rhinosinusitis is self-limiting and typically resolves without specific treatment. 2
Nasal saline irrigation may improve quality of life and decrease symptoms without medication risks. 2
Supportive care remains the cornerstone of management in this age group. 1
Critical Pitfall to Avoid
Do not prescribe antihistamines for toddlers with viral colds simply because parents request "something to help" or because these medications are available over-the-counter. The evidence clearly demonstrates lack of benefit and potential for harm in this vulnerable population. 4, 3, 5