Commonly used PRNs for Pediatric Patients

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As needed medications (or PRNs) are often used in pediatric patients. What do we know about the evidence base for two common as needed medications?

Hydroxyzine

Hydroxyzine is an antihistamine that is sometimes used as needed for kids and teens with anxiety and/or sleep difficulties.

• Hydroxyzine has an FDA approval “for symptomatic relief of anxiety and tension associated with psychoneurosis” and “as an adjunct in organic disease states in which anxiety is manifested” in adults and children. It also has indications for pruritus and as a sedative before and after general anesthesia. It does not have an approved indication for insomnia in children.

Dosing:

• For children under 6 years old: 50mg daily in divided doses

• For children 7 years old +: 50 to 100mg daily in divided doses

Some possible side effects: 

• As is commonly seen with psychiatric medications – we do not have systematic reviews or randomized control trial evidence on the anxiolytic effects of hydroxyzine in children and adolescents.

• Common side effects include dry mouth and drowsiness.

Caution:

• Tolerance can develop over time, necessitating higher doses. Some kids can experience paradoxical reactions including excitability/hyperactivity. Secondary anticholinergic effects.

Best practice: Hydroxyzine may provide quick acting, short term relief for anxiety on an as needed basis. May be used for occasional or short-term situational use for sleep, particularly in those with comorbid atopic disease. It is not recommended for frequent or long-term use for anxiety or sleep.

Melatonin

• Melatonin is a common supplement used by pediatric patients to help with sleep.

• There is little evidence about efficacy and safety in typically developing children for insomnia.

• Data supports use in patients with circadian phase delay and supports use for sleep-onset insomnia in children with neurodevelopmental disorders including Autism Spectrum Disorder (ASD).

Dosing:

• Depends on clinical use – see this link.

• Lowest effective dose – typically 0.3-3mg in children, sometimes used up to 5mg.

Some possible side effects:

• Rebound wakefulness when wears off, vivid dreams, and rebound insomnia when discontinued.

• Generally well tolerated, however, we are lacking longer term prospective studies on health effects like impact on immunologic, metabolic and reproductive functions in typically developing children.

Caution:

• Rise of melatonin overdoses in pediatric patients the U.S., store safely in locked containers.

• Reliability of over-the-counter preparation variable – third party verification seal may provider more reliable preparation.

Best practice:

• Behavioral treatment and comprehensive sleep assessment are always recommended first.

• Most benefit for sleep-onset insomnia in children with neurodevelopmental disorders.

• Can consider low doses for shortest amount of time possible in typically developing children with insomnia, should not be used in healthy children without sleep problems to “promote restful sleep.”