Can propranolol (beta blocker) cause suicidal ideation in children?

Propranolol and Suicidal Ideation in Pediatric Patients

Propranolol does not directly cause suicidal ideation in children, but its CNS effects warrant monitoring for mood changes and sleep disturbances that could theoretically impact mental health. The available pediatric guidelines do not identify suicidal ideation as a recognized adverse effect of propranolol in children 1.

Evidence from Pediatric Guidelines

The most comprehensive pediatric data comes from the 2019 American Academy of Pediatrics guidelines on propranolol use in children with infantile hemangiomas, which systematically reviewed adverse effects:

Documented CNS Effects:

• Sleep disturbances (nightmares, night terrors, agitation) occur in 2-18.5% of pediatric patients 1
• Theoretical concerns exist about effects on brain development due to propranolol's lipophilic properties allowing blood-brain barrier penetration 1
• Adult studies show impairments in memory, psychomotor function, and mood, raising questions about pediatric CNS effects 1

Critical Long-term Safety Data:

• A large prospective randomized trial found no appreciable neurodevelopmental differences between propranolol-treated groups and placebo at 96 weeks of follow-up 1
• This provides reassuring evidence against significant psychiatric sequelae in the pediatric population 1

Clinical Monitoring Recommendations

Clinicians should evaluate patients for and educate caregivers about potential adverse effects of propranolol, including sleep disturbances, which represent the primary CNS concern 1. The American Academy of Pediatrics recommends:

• Systematic inquiry about sleep quality, nightmares, and behavioral changes 1
• Dose modification (reduction, earlier-evening dosing) if sleep disturbances occur 1
• Recognition that sleep disturbances may require treatment discontinuation in 3 of 6 reported series 1

Context: Suicidal Ideation and Medications

The 2001 American Academy of Child and Adolescent Psychiatry guidelines on suicidal behavior address medication-induced suicidality specifically in the context of antidepressants (particularly SSRIs), not beta-blockers 1. The concern centers on:

• Psychopharmacological activation or disinhibition with antidepressants 1
• SSRI-induced akathisia potentially linked to suicidal ideation 1
• No mention of beta-blockers causing suicidal ideation in comprehensive psychiatric guidelines 1

Adult Data and Toxicology Context

While not directly applicable to pediatric prescribing, recent adult data shows:

• Propranolol involvement in suicides has increased (3.4% to 12.3% between 2010-2021), but this reflects its use as a means of intentional overdose, not causation of suicidal ideation 2
• Deaths involving propranolol typically occur in patients already diagnosed with depression (39.1%) and anxiety (22.2%), with 81.8% having antidepressants detected post-mortem 2
• This indicates propranolol is prescribed to populations already at elevated suicide risk, not that it induces suicidality 2

Clinical Algorithm for Pediatric Propranolol Use

When prescribing propranolol to children:

1. Screen for pre-existing psychiatric conditions that independently increase suicide risk

2. Monitor specifically for:

   • Sleep disturbances (most common CNS effect at 2-18.5% incidence) 1
   • Behavioral changes or mood alterations 1
   • Nightmares or night terrors requiring dose adjustment 1

3. Adjust dosing if CNS effects occur:

   • Reduce dose 1
   • Administer earlier in evening 1
   • Consider discontinuation if symptoms persist 1

4. Distinguish propranolol effects from underlying psychiatric illness in patients with comorbid depression or anxiety

Important Caveats

• Do not confuse propranolol's involvement in completed suicides (as a toxic agent) with causation of suicidal ideation 2
• The lipophilic nature of propranolol allows CNS penetration, but long-term pediatric studies show no neurodevelopmental harm 1
• Sleep disturbances are the primary CNS concern requiring clinical attention, not suicidal ideation 1
• Patients prescribed propranolol for anxiety may have underlying psychiatric conditions that independently confer suicide risk 2