Propranolol Dosing for Anxiety in Children
Direct Answer
Propranolol is not established as a first-line treatment for anxiety in children, but when used for situational anxiety with prominent somatic symptoms (tremor, palpitations, tachycardia), start with 0.5–1 mg/kg/day divided into 2–3 doses, with careful monitoring for hypoglycemia, bradycardia, and bronchospasm. 1
Clinical Context and Evidence Limitations
The available pediatric guidelines focus primarily on propranolol for cardiac conditions (tachyarrhythmias, infantile hemangiomas) rather than anxiety disorders. 2, 1 The anxiety-specific evidence in children is limited to small case series and adult extrapolation. 3, 4 Therefore, this recommendation synthesizes pediatric safety data from cardiac indications with adult anxiety dosing principles.
Dosing Regimen
Starting Dose
- Begin with 0.5–1 mg/kg/day divided into 2–3 doses (e.g., a 30 kg child would start at 15–30 mg/day in divided doses). 1, 5
- For situational/performance anxiety, a single dose of 0.3–0.5 mg/kg (maximum 20 mg) taken 30–60 minutes before the anxiety-provoking event may be used instead of chronic dosing. 6, 4
Titration Schedule
- If using chronic dosing, increase by 0.5 mg/kg/day increments every 3–7 days based on symptom response and tolerability. 1, 7
- Monitor heart rate and blood pressure 1–2 hours after each dose increase. 7
Maximum Daily Dose
- Do not exceed 2–3 mg/kg/day in children, which aligns with pediatric cardiac dosing guidelines. 2, 1
- In absolute terms, this typically translates to 60–120 mg/day maximum for most school-age children, though some sources describe adult-equivalent dosing up to 160 mg/day in adolescents. 2, 4
Dosing Frequency
- Administer 2–3 times daily (every 8–12 hours) with immediate-release formulations to maintain therapeutic effect. 2, 7
- Always give with or immediately after food to reduce hypoglycemia risk. 2, 6
Mandatory Pre-Treatment Assessment
Absolute Contraindications (Screen Before Prescribing)
- Asthma or obstructive airway disease (propranolol can precipitate life-threatening bronchospasm). 6, 1
- Second- or third-degree heart block without a pacemaker. 6, 1
- Decompensated heart failure or severe left ventricular dysfunction. 6, 1
- Sinus bradycardia (baseline heart rate below normal for age). 1
- History of hypoglycemic episodes or poorly controlled diabetes. 2, 8
Required Baseline Evaluation
- Measure resting heart rate and blood pressure (compare to age-appropriate norms). 1, 7
- Auscultate lungs for wheezing or evidence of reactive airway disease. 6, 1
- Obtain ECG if heart rate is abnormal for age, there is a heart murmur, or family history of sudden cardiac death. 1
- Screen for diabetes and counsel about hypoglycemia masking. 2, 8
Critical Safety Precautions
Hypoglycemia Prevention (Most Important in Children)
- Hold doses during illness with vomiting, diarrhea, or reduced oral intake to prevent hypoglycemia-induced seizures. 2, 8
- Never allow dosing intervals to exceed 8 hours (or 6 hours in infants/young children). 2, 1
- Educate caregivers that propranolol masks typical warning signs of low blood sugar (tremor, tachycardia, sweating); rely instead on hunger, confusion, or lethargy as hypoglycemia cues. 6, 8
- A 4-year-old on chronic propranolol developed a hypoglycemic seizure after refusing food for 3 days, underscoring this risk. 8
Cardiovascular Monitoring
- Check heart rate and blood pressure 1–2 hours after the first dose and after any dose increase ≥0.5 mg/kg. 7
- Watch for excessive beta-blockade: heart rate <50 bpm (or below age-appropriate norms), systolic BP <90 mm Hg, dizziness, marked fatigue. 6, 1
Respiratory Monitoring
- Immediately discontinue if wheezing develops requiring treatment. 6
- Even in children without known asthma, propranolol can unmask reactive airway disease. 1
Drug Interactions
- Avoid combining with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to severe bradycardia and heart block risk. 6, 7
Discontinuation Protocol
- Never stop propranolol abruptly after >2 weeks of regular use, as rebound tachycardia and hypertension can occur. 6, 1
- Taper gradually over 1–3 weeks by reducing the dose by 25–50% every 3–7 days. 6, 7
Evidence Quality and Clinical Judgment
Guideline Evidence
The strongest pediatric evidence comes from 2019 AAP guidelines for infantile hemangiomas (Grade A recommendation for 2–3 mg/kg/day dosing with strict hypoglycemia precautions) 2 and 2011 AAP cardiovascular guidelines (listing propranolol dosing for cardiac conditions). 2 These provide the safety framework but do not address anxiety as an indication.
Anxiety-Specific Evidence
A 2001 French case series (3 children aged 8–13 with school refusal anxiety) reported benefit from low-dose propranolol for somatic symptoms, with better tolerability than benzodiazepines. 3 A 1978 pediatric cardiac study established that 0.5–4 mg/kg/day is safe and effective in children. 5 Adult studies suggest 40–160 mg/day is effective for situational anxiety. 9, 4
Clinical Synthesis
Given the lack of controlled pediatric anxiety trials, the recommendation prioritizes safety data from cardiac indications (where propranolol is well-established) and applies conservative dosing principles. Start low (0.5–1 mg/kg/day), titrate slowly, and maintain vigilance for hypoglycemia—the most serious pediatric risk. 2, 8
Common Pitfalls to Avoid
- Underdosing for chronic anxiety: A single 10 mg dose may be insufficient; most children require 0.5–1 mg/kg/day divided doses for sustained effect. 5, 4
- Forgetting to hold doses during illness: This is the leading cause of hypoglycemic seizures in children on propranolol. 2, 8
- Using in undiagnosed asthma: Always auscultate lungs and ask about exercise-induced wheezing before prescribing. 6, 1
- Abrupt discontinuation: Taper over 1–3 weeks to prevent rebound symptoms. 6, 7
Alternative Considerations
- For children with asthma or diabetes, propranolol is contraindicated; consider cognitive-behavioral therapy or SSRIs (sertraline, fluoxetine) as first-line alternatives. 6, 1
- For situational anxiety without somatic symptoms, propranolol is unlikely to be effective; psychological interventions are preferred. 3, 4