What medications, aside from antihistamines and nasal decongestants, can cause hallucinations in children?

Medications That Can Cause Hallucinations in Children

In addition to antihistamines and nasal decongestants, several commonly used medications in children can cause hallucinations, including stimulants for ADHD, benzodiazepines, montelukast, beta-agonist inhalers, and certain antipsychotics. 1

Antihistamines and Decongestants (For Context)

First-generation antihistamines and decongestants are well-documented causes of hallucinations in children:

• Oral decongestants (pseudoephedrine, phenylephrine):

  • Can cause agitated psychosis, ataxia, and hallucinations, especially in infants and young children 1
  • Even at recommended doses, can cause stimulatory effects including hallucinations 1, 2
  • Particularly dangerous in children under 6 years 1

• Topical decongestants (oxymetazoline, xylometazoline):

  • Can also cause systemic effects including hallucinations when absorbed 1, 3

• First-generation antihistamines (diphenhydramine, chlorpheniramine):

  • Associated with significant CNS effects including hallucinations 1
  • FDA has raised concerns about their safety in young children 4

Other Medications That Can Cause Hallucinations in Children

1. Stimulant Medications for ADHD

• Methylphenidate, amphetamine derivatives
  • Can cause hallucinations, especially at higher doses
  • Risk increases when combined with decongestants 1
  • Visual hallucinations are more common than auditory

2. Benzodiazepines

• Can cause paradoxical reactions including:
  • Hallucinations
  • Agitation
  • Aggressive behavior
  • Increased anxiety
  • These reactions are more common in children and elderly 5

3. Montelukast (Leukotriene Receptor Antagonist)

• Used for asthma treatment
• Can cause neuropsychiatric effects including visual hallucinations
• Hallucinations typically resolve within 48 hours of discontinuation 6

4. Beta-Agonist Inhalers

• Albuterol and other beta-agonists
  • Can cause hallucinations, especially with excessive use
  • Both the medication itself and fluorocarbon propellants in MDIs may contribute 7
  • Switching to powder formulations may reduce risk

5. Antipsychotics

• Paradoxically can cause hallucinations, especially during withdrawal
• Haloperidol and other typical antipsychotics may cause visual hallucinations in some children 1

6. Corticosteroids

• Both systemic and high-dose inhaled steroids
• Can cause psychosis and hallucinations, especially with prolonged use
• Risk increases with higher doses

Clinical Considerations

Risk Factors for Medication-Induced Hallucinations

• Young age (especially under 6 years)
• Overdose or supratherapeutic dosing
• Polypharmacy (especially combinations of CNS-active medications)
• Renal or hepatic impairment affecting drug clearance
• Genetic variations in drug metabolism

Management Approach

1. Immediate discontinuation of the suspected medication
2. Supportive care and reassurance
3. Monitor vital signs and mental status
4. Consider activated charcoal if recent ingestion/overdose
5. Symptoms typically resolve within 24-48 hours of medication discontinuation

Prevention Strategies

• Avoid combination products containing multiple active ingredients
• Use weight-based dosing for all pediatric medications
• Consider alternative medications in children with prior adverse reactions
• Educate caregivers about proper dosing and potential side effects
• Use second-generation antihistamines which have better safety profiles 1

Key Pitfalls to Avoid

• Misdiagnosing medication-induced hallucinations as primary psychiatric disorders
• Continuing the offending medication or adding psychotropic medications to treat the hallucinations
• Overlooking the possibility of accidental ingestion or overdose
• Failing to recognize that even OTC medications can cause serious neuropsychiatric effects

Remember that children are more susceptible to medication-induced hallucinations due to their developing blood-brain barrier, immature drug metabolism, and different receptor sensitivities compared to adults.