Do you scale up 2nd generation anti-histamines to 4x daily in acute urticaria in the pediatric population as you do in adults?

Severe urticaria is certainly a therapeutic challenge. Updosing 2nd generation antihistamines in children has been studied, more trials need to be done. For refractory urticaria in children, I will often recommend 2X the recommended dose of a 2nd generation antihistamine in the morning and maximize the dosing of a first-generation antihistamine at night. If this is not effective, a prednisone taper can certainly be used to break the cycle. If the urticaria recurs, cyclosporine may be effective for severe, refractory urticaria.

Manti et al., PMID 30253383

Cuvillo et al., PMID 18225708

I do try to increase the dose of 2nd generation antihistamines in the pediatric population. I start with twice the age-appropriate dose. I have had to increase to 4 times the recommended dose when double dosing did not alleviate their urticaria. This is better tolerated in older children vs the < 3-year-old group. I try to avoid first-generation antihistamines for long-term use due to the behavioral and cognitive side effects associated with them in children. I also try to avoid giving oral corticosteroids because of the rebound urticaria side effect. I have also tried montelukast in the past, but clinically did not note sufficient benefit to warrant its use in this population for urticaria. Parents are also very concerned about the black b...