Claritin dosing for children under 2 years of age?

[clachan3]

You know, we just had a script like this 2 weeks ago for a 9 month old. The pharmacist (Im a grad intern right now) stated that she would NOT fill the script as the safety and efficacy for children <2 yoa had not been established. If the doc wanted it to be filled, she had to provide the pharmacist a faxed copy of a study/recommendation that would support its use. The doc said "I do it all the time." The pharmacist said "that doesn't make it right, I'm not filling it." Boy were they Pissed.

Thats cool, we shouldn't have to fill prescriptions that we don't feel comfortable with. Thank goodness I don't work for a busy store now so I don't have to rush and fill these kind of scripts. I haven't gotten Claritin scripts for under 2 years old (I might have at my old job). Claritin is my go to drug if the patients haven't tried anything and for young kids 2 and up.

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[group_theory]

Just adding to the discussion (from my perspective)

I routinely don't recommend any OTC cough or cold medications to children under 6 years of age who have viral illnesses. I tell the parents they don't work (and run the risk of overdoses). Saline nasal spray, bulb suction, and time is what I tell them. Besides, arent most infant OTC cough and cold medications now off the shelves?

Young infants with rashes should be examined by a healthcare provider. While children are known to develop rashes at a drop of a hat, rashes are clues to illnesses and may not necessarily be confined to allergic reactions. If the rash is Fifth Disease instead of an allergic reaction, benadryl (or claritin) will not help. If a parent brings a child with red eyes, fevers, red tongue, and rash, and you miss Kawasaki Disease (or Scarlet Fever), there can be long-term consequences for the child.

In regards to Benadryl, it's a relatively safe drug and used often in kids under the age of 2. A recent survey of primary care pediatricisn showed that roughly half of the participants have recommended Benadryl for sleep issues in kids between the age of 0-2.

The american association of poison control centers published an out of hospital guideline in 2006 for Benadryl overdoses in children and validated in a recently published article (n=305). Kids who ingested less than 7.5mg/kg generally did fine and didn't require any treatment nor were they admitted. I think the current dose of benadryl that most pediatricians use are based on old ancedotal experiences and not any well-studied pharmacokinetics or pharmacodynamic studies.

Incidentally, in 2005 the FDA placed a black box warning on Phenergan, which includes a contraindication in children younger than 2 years old because of continued reports of serious adverse events, such as respiratory depression and central nervous system reactions, including seizures.

In office, I generally tell the parents the child's weight, and then tell them how much Tylenol or Advil to give (both in mg and in amount depending on infant or children version). I also write down the weight (in kg) on a piece of paper for the parents to take, and tell them that if they have questions about dosing, to ask the pharmacist. Hope you guys/gals don't mind


Owens JA, Rosen CL, Mindell JA. Medication use in the treatment of pediatric insomnia: results of a survey of community-based pediatricians. Pediatrics. 2003;111(5, pt 1):e628-e635.

Bebarta VS, Blair HW, Morgan DL, Maddry J, Borys DJ.
Validation of the American Association of Poison Control Centers out of hospital guideline for pediatric diphenhydramine ingestions.
Clin Toxicol (Phila). 2010 Jul;48(6):559-62.


Starke PR, Weaver J, Chowdhury BA. Boxed warning added to promethazine labeling for pediatric use. N Engl J Med. 2005;352:2653

 

[Old Timer]

Just adding to the discussion (from my perspective)

I routinely don't recommend any OTC cough or cold medications to children under 6 years of age who have viral illnesses. I tell the parents they don't work (and run the risk of overdoses). Saline nasal spray, bulb suction, and time is what I tell them. Besides, arent most infant OTC cough and cold medications now off the shelves?

Young infants with rashes should be examined by a healthcare provider. While children are known to develop rashes at a drop of a hat, rashes are clues to illnesses and may not necessarily be confined to allergic reactions. If the rash is Fifth Disease instead of an allergic reaction, benadryl (or claritin) will not help. If a parent brings a child with red eyes, fevers, red tongue, and rash, and you miss Kawasaki Disease (or Scarlet Fever), there can be long-term consequences for the child.

In regards to Benadryl, it's a relatively safe drug and used often in kids under the age of 2. A recent survey of primary care pediatricisn showed that roughly half of the participants have recommended Benadryl for sleep issues in kids between the age of 0-2.

The american association of poison control centers published an out of hospital guideline in 2006 for Benadryl overdoses in children and validated in a recently published article (n=305). Kids who ingested less than 7.5mg/kg generally did fine and didn't require any treatment nor were they admitted. I think the current dose of benadryl that most pediatricians use are based on old ancedotal experiences and not any well-studied pharmacokinetics or pharmacodynamic studies.

Incidentally, in 2005 the FDA placed a black box warning on Phenergan, which includes a contraindication in children younger than 2 years old because of continued reports of serious adverse events, such as respiratory depression and central nervous system reactions, including seizures.

In office, I generally tell the parents the child's weight, and then tell them how much Tylenol or Advil to give (both in mg and in amount depending on infant or children version). I also write down the weight (in kg) on a piece of paper for the parents to take, and tell them that if they have questions about dosing, to ask the pharmacist. Hope you guys/gals don't mind


Owens JA, Rosen CL, Mindell JA. Medication use in the treatment of pediatric insomnia: results of a survey of community-based pediatricians. Pediatrics. 2003;111(5, pt 1):e628-e635.

Bebarta VS, Blair HW, Morgan DL, Maddry J, Borys DJ.
Validation of the American Association of Poison Control Centers out of hospital guideline for pediatric diphenhydramine ingestions.
Clin Toxicol (Phila). 2010 Jul;48(6):559-62.


Starke PR, Weaver J, Chowdhury BA. Boxed warning added to promethazine labeling for pediatric use. N Engl J Med. 2005;352:2653

I hope you read the literature better than you read this thread. Both eyes next time. A sick child with fever and other symptoms of acute infection is not the topic under discussion. Hives will NEVER be mistaken for:

• The first four childhood viral infections
• The Fifth disease
• Scarlett Fever
• Kawasaki Disease
• Roseola Infantum
• Coxsackieviruses and Other Enteroviruses

Also, nobody here is talking about treating the common cold. You will need to use your critical thinking skills or work on your reading comprehension or try a different straw man.

What has actually been discussed:

Should a pharmacist dispense a prescription for Loratadine in children under 2 written by a physician.

Should a pharmacist make an OTC recommendation for a child with seasonal allergies under the age of 2.

Should a pharmacist make an OTC recommendation for a child with hives or an obvious allergic under the age of 2.

We of course welcome your input into items actually under discussion.

 

[group_theory]

Rashes are actually very difficult to identify sometimes (even to trained pediatricians). Even the list of potential causes of rashes that you listed ... they are sometimes are difficult to identify without a thorough history and exam (and sometimes just time for the rash and other symptoms to evolve). If a parent brings an infant with hives to the office, my main concern is why does this child have hives and could this be something else?

And yes, while I understand that the discussion wasn't about colds and treatment of colds, the discussion turned towards whether pharmacists should recommend OTC medications for children under 2. I didn't get the impression that the discussion was limited to Claritin only, since the discussion turned towards hives (and you don't usually treat hives with loratadine). Hence why I made a mention on the use of benadryl by pediatricians for under 2 (no great study on safety for allergies in under 2, but at least half of the pediatricians surveyed feel comfortable recommending benadryl for sleep issues for those under 2)

I just wanted to give a different perspective (since there are some talk about "calling the pediatrician" in this thread)

In regards to seasonal allergies - true hay fever in infants under 2 years old are extremely rare (at least according to 3 pediatric allergists whom I have trained with)

 

[spacecowgirl]

group - thanks for your input. We don't get a lot of peds at our little hospital, but we occasionally have to dose stuff (IV azith pops to mind) that doesn't have clear-cut recommended dosing in little ones. In the outpatient realm, APAP, ibuprofen and diphenhydramine would be the 3 things I would not have a problem recommending for most kids.

If I get a script like the one mentioned in the OP, I wouldn't worry much about it. I see much more concerning scripts for the elderly IMO.

 

[dingerx]

You have failed to convince me I have picked the wrong side of the argument. Are you trying to tell me you work in "regulatory" what ever that means and information easily searched and available on the FDAs website is false? Here is another link for you to read.

http://www.uspharmacist.com/content/c/14137/

I don't want to take the time to go into my credentials because it takes way too long for a forum. Your own link refers to the recom coming from the FDA being focused on APAP. I also work in a peds hospital and we dose anti-histamines every day to almost every pt, even under the age of 2.

 

[dingerx]

group - thanks for your input. We don't get a lot of peds at our little hospital, but we occasionally have to dose stuff (IV azith pops to mind) that doesn't have clear-cut recommended dosing in little ones. In the outpatient realm, APAP, ibuprofen and diphenhydramine would be the 3 things I would not have a problem recommending for most kids.

If I get a script like the one mentioned in the OP, I wouldn't worry much about it. I see much more concerning scripts for the elderly IMO.

How many benzos could a person possibly need? (comes to mind)

 

[xiphoid2010]

On a somewhat related note, I've seen a lot of parents coming in and asking for benadryl for their child under 2. While I always tell them that it's not recommended for children under 2, I always get: "but my doctor said it was ok."

In that case the pharmacist should just counsel and help them, to ensure they pick the right product and dosage. Pediatricians has been using it safely in infants for decades now. In fact, most drugs in infants are off-label use, with little or no clinical trials in that population (is that really a suprise?).

Flat out denying is not in the best interest of the patient, only increase the risk of harm.

 

[MountainPharmD]

I don't want to take the time to go into my credentials because it takes way too long for a forum. Your own link refers to the recom coming from the FDA being focused on APAP. I also work in a peds hospital and we dose anti-histamines every day to almost every pt, even under the age of 2.

That's great and all but what does this have to do with the op's original question or anything else discussed in this thread?

 

[Dr. Tufail Nazir]

http://www.advancedpediatricassociates.com/pedwebarticle6.asp?tCategoryId=62

 

[meister]

Five year thread bump, nicely done.

 

[owlegrad]

At last we finally get an answer!