Ranitidine for pruritus management in an infant

Chronic pruritus is defined as a sensation driving the urge to scratch persisting longer than 6 weeks [1]. Pruritus is typically treated through antagonism of histamine receptors, with H1, H3 and H4 receptors having a dominant role [2].

A 4‐month‐old boy presented to a tertiary care paediatric facility with a left arm segmental haemangioma. Multiple ulcerations extended from the lateral arm, forearm and inner wrist fold. On presentation, the infantile haemangioma was treated with propranolol and regular dressing changes, but irritability remained a predominant symptom.

Simple analgesics and oxycodone (0.1 mg.kg⁻¹) as required were used to manage pain, with controlled release morphine (0.1 mg.kg⁻¹) initiated once daily and titrated to 0.5 mg.kg^‐1 twice daily in conjunction with gabapentin (10 mg.kg⁻¹) at night. Three months later, there were increased reports of “arm rubbing” and “arm banging” following dressing changes. Opioids were initially increased, then weaned with no significant improvement in symptomology. Subsequently, gabapentin was increased to twice daily dosing, but symptoms intensified and oxycodone (0.1 mg.kg⁻¹) and controlled release morphine (0.4 mg.kg⁻¹) at night were re‐introduced.

Following consultation with specialists at Westmead Children’s Hospital, Sydney, ranitidine (2 mg.kg⁻¹) was initiated once daily for pruritus management. The patient's irritability decreased within 24 h. Following the introduction of daily ranitidine; opioids and gabapentin were gradually weaned and then ceased, with no evidence of irritability at 2‐month follow up. An attempt to cease ranitidine resulted in a return of irritability and “arm rubbing” so ranitidine was re‐introduced.

This is a case in which ranitidine caused a significant improvement in an infant’s comfort in the context of an ulcerated haemangioma. Managing infants and pre‐verbal children with pruritus is challenging. A randomised double‐blind study (n = 45) found combination antihistamine therapies (terfenadine/ranitidine) led to a reduction in itch when compared with a single antihistamine [3] and ranitidine has been demonstrated to suppress itch in response to skin prick testing in atopic adults [4].

There is currently limited evidence regarding the efficacy of ranitidine in infants and young children. In this case, monotherapy with ranitidine was a useful alternative to manage pruritus when other therapies had failed. Further research to explore the efficacy of ranitidine would be beneficial to inform practice in the management of paediatric pruritus.