Hospitals Shift Pediatric Antihistamine Prescribing to Safer Alternatives

Quality improvement measures help displace use of older, more sedating antihistamines in children.

Published on Feb. 13, 2026

Got story updates? Submit your updates here. ›

A study published in Pediatrics found that relatively simple system changes, such as updated order sets and making the safer antihistamine cetirizine more accessible, can substantially reduce the use of older, more sedating first-generation antihistamines like diphenhydramine in pediatric care settings. The interventions, which included clinician education, medication dispensing changes, and updated clinical pathways, led to a drop in first-generation antihistamine prescriptions from 74% to 28% in the pediatric emergency department and from 54% to 36% in inpatient units over a two-year period.

Why it matters

First-generation oral antihistamines like diphenhydramine are associated with concerning side effects in children, including oversedation, coma, seizures, attention-deficit/hyperactivity disorder, and impaired learning. Shifting prescribing patterns toward the safer second-generation antihistamine cetirizine can improve pediatric patient safety and outcomes.

The details

The study, led by Dr. Katelyn Wong at the Yale School of Medicine, implemented a two-phase quality improvement project in a pediatric hospital setting. In the emergency department, clinicians received education on the efficacy and safety of second-generation antihistamines, medication dispensing machines were preloaded with cetirizine, and clinical pathways were updated to make it the preferred antihistamine. When the intervention expanded to inpatient units, the education shifted to a series of 20-minute sessions delivered by resident and pharmacist champions. These changes led to a significant drop in first-generation antihistamine prescriptions, while costs for antihistamine medications increased moderately.

  • The study took place between 2022 and 2024.
  • The emergency department intervention began in 2022.
  • The inpatient unit intervention expanded in 2023.

The players

Katelyn Wong, MD

Assistant professor in the Department of Pediatric Pulmonology, Allergy, Immunology and Sleep Medicine at the Yale School of Medicine in New Haven, Connecticut, and the lead author of the study.

Brian Johnston, MD, MPH

Chief of pediatrics at Harborview Medical Center in Seattle, who was not associated with the study.

Sai Nimmagadda, MD

Attending physician in the Division of Allergy and Immunology at Lurie Children's Hospital in Chicago, and an associate professor of pediatrics at Northwestern University Feinberg School of Medicine, who was not involved with the study.

Got photos? Submit your photos here. ›

What they’re saying

“Health systems should strongly consider the use of quality improvement methodology to reduce the use of first-generation antihistamines in favor of second-generation antihistamines [SGAs].”

— Katelyn Wong, MD, Assistant professor (Pediatrics)

“In addition, if second-generation drugs are not clearly favored in order sets, pathways, and dispensing cabinets, the path of least resistance remains the older medications.”

— Brian Johnston, MD, MPH, Chief of pediatrics (Medscape)

“Diphenhydramine 'would probably not get approved today by the Food and Drug Administration, just due to the sedating effects.' If there are drugs with less side effects, those are the ones we should be prescribing rather than sticking to an old habit.”

— Sai Nimmagadda, MD, Attending physician (Medscape)

What’s next

The study authors plan to further evaluate the long-term sustainability of the interventions and their impact on patient outcomes.

The takeaway

By implementing relatively simple quality improvement measures, healthcare systems can significantly reduce the use of older, more sedating antihistamines in pediatric care and improve patient safety and care through greater adoption of the safer second-generation alternatives.