Drug safety and dosage is a particularly relevant subject in pediatric patients, because such factors are generally not considered by pharmaceutical companies when drug information is generated. Only recently has the Food and Drug Administration become interested in this area of pharmaceutical marketing and prescribing. Because of developmentally-related metabolic differences, drug absorption and metabolism differs greatly between children and adults, as well as children of different ages.¹ Accordingly, central nervous system (CNS) toxicity associated with the use of therapeutic dosages of any drug in children is potentially possible and physicians should be alert to this at all times.

CNS effects are particularly likely to occur with medications that have an intrinsic neurotropic action as, for example, anticholinergic drugs. Such action may be seen in many pharmacologic agents, including those that are in common use for conditions unrelated to CNS pathology. Agents with anticholinergic activity, such as cyproheptadine (Periactin), can cause an acute CNS syndrome resembling acute psychosis.² Nonetheless, it is uncommon to observe a true toxic reaction to these agents except at high dosage levels. We describe the case of a child who developed central anticholinergic syndrome (CAS) while on therapeutic doses of cyproheptadine for migraine prophylaxis, and review the literature pertaining to similar cases in children.

	CASE REPORT

A 9-year-old boy presented to the Medical College of Virginia (MCV) emergency department with hallucinations and agitation. He had gone to bed without complaints, and at 1 AM he awoke abruptly, talking incessantly about his homework, despite having completed it that evening. As the night progressed he became intermittently agitated, and began experiencing visual hallucinations: he would pick up imaginary objects, and see people who were not present in the room. Around 7:30 AM his mother brought him to the MCV emergency department.

The patient, who was an excellent student, had complained about . . . [Full Text of this Article]