Is hyoscine (scopolamine) appropriate for use in pediatric patients, and what are the age restrictions and dosing guidelines for motion‑sickness prophylaxis, abdominal cramping, and pre‑operative sedation?

Can Hyoscine Be Given in Children?

Hyoscine (scopolamine) can be used in children, but with significant age-related restrictions and heightened safety concerns, particularly in children under 6 years who face the greatest risk of adverse events including acute psychosis and delirium.

Age-Specific Restrictions and Safety Profile

Transdermal Scopolamine (Motion Sickness)

• Transdermal scopolamine patches are NOT recommended for young children due to documented cases of severe toxicity, including a reported case of acute delirium with psychotic behaviors, hallucinations, and aggressive behavior in a 4-year-old boy 1
• The transdermal formulation delivers 0.5 mg over 72 hours with highly variable plasma concentrations (range 11-240 pg/mL), making dose control particularly problematic in pediatric patients 2
• Systemic anticholinergic toxicity manifests as flushing, bizarre actions, hallucinations, hyperactivity, and incoherent speech in children 1

Hyoscine Butylbromide (Abdominal Cramping)

• Hyoscine butylbromide has a more favorable safety profile for abdominal cramping due to minimal systemic absorption (bioavailability <1%) and inability to cross the blood-brain barrier 3
• This formulation exerts local spasmolytic effects on gastrointestinal smooth muscle without significant CNS penetration 3
• However, specific pediatric dosing guidelines and safety data are lacking in the available evidence

Critical Safety Considerations in Pediatric Sedation Context

High-Risk Age Groups

• Children younger than 6 years, particularly those under 6 months, are at greatest risk of adverse events during any sedation or medication administration 4
• The American Academy of Pediatrics emphasizes that young children are especially vulnerable to respiratory depression, airway obstruction, and loss of protective reflexes 5, 4

Anticholinergic Effects and Monitoring

• Anticholinergic agents like scopolamine produce dose-dependent adverse effects including hallucinations, vertigo, dry mouth, and drowsiness 2
• Drug-induced psychosis should be considered in any child with acute behavioral changes when anticholinergic agents have been administered 1
• The short plasma half-life and first-pass metabolism after oral administration limit predictability in pediatric dosing 2

Practical Clinical Algorithm

When Considering Hyoscine in Children:

For Motion Sickness:

1. Avoid transdermal scopolamine in children under 12 years given documented toxicity cases and lack of pediatric safety data 1
2. Consider alternative antiemetics with established pediatric safety profiles
3. If used in adolescents, monitor continuously for CNS effects including behavioral changes 1, 2

For Abdominal Cramping:

1. Hyoscine butylbromide may be considered due to minimal systemic absorption 3
2. Ensure proper dosing calculations based on weight, recognizing that pediatric patients require individualized pharmacokinetic considerations 6
3. Monitor for rare anticholinergic effects despite low bioavailability 3

For Pre-operative Use:

1. Alternative agents are preferred - the American Academy of Pediatrics recommends pentobarbital (2-6 mg/kg IV) or midazolam (0.2-0.3 mg/kg IV) for procedural sedation with established pediatric safety profiles 4
2. If scopolamine is used for antisialagogue effects, use minimal effective doses with continuous monitoring 5

Common Pitfalls to Avoid

• Failing to recognize that children are not simply "small adults" and require age-specific pharmacokinetic considerations including organ maturity and metabolic capacity 6
• Underestimating the risk of CNS toxicity from transdermal formulations, which can cause severe delirium even in young children 1
• Not having rescue protocols in place - practitioners must be able to manage one level deeper than intended sedation 5, 4
• Inadequate monitoring - continuous physiologic monitoring and presence of personnel not performing the procedure are essential when any sedating medication is used 4

Key Contraindications and Warnings

• Scopolamine crosses the placenta and should be used cautiously in pregnant adolescents 2
• The highly variable pharmacokinetic response to transdermal scopolamine reflects individual differences that are even more pronounced in developing pediatric patients 7, 2
• Symptoms resolve after removal of the patch and conservative management, but recognition of toxicity is critical 1