Anticholinergic burden in children: what the evidence does and does not show

The pediatric question needs its own evidence

An adult anticholinergic warning can be a reason to ask a careful question about a child’s medication, but it is not a pediatric outcome study. Children differ in age, developmental context, conditions treated, formulations, and treatment duration. A responsible evidence summary must therefore identify which pediatric question was actually studied rather than import an adult risk label wholesale.

This article is a narrative review of the cited pediatric cognition and symptom literature. It does not claim a new systematic search or create a pediatric burden score. The aim is to explain why apparently different findings may answer different questions and why neither broad reassurance nor blanket alarm follows from a single source.

Cognitive evidence is not the same as all adverse effects

Ghezzi and colleagues’ 2021 meta-analysis did not find an overall association with poorer cognitive performance in the studied pediatric exposures. That finding should remain bounded by the included medicines, populations, outcomes, and durations. It is not proof of safety for every long-term pediatric regimen. Ghezzi et al., 2021

A cognitive outcome cannot stand in for constipation, dry mouth, urinary symptoms, school participation, or every other relevant experience. Conversely, a report of one of those symptoms does not establish cognitive impairment. Evidence should be organized by outcome so a result in one domain is not used to answer a different question without support.

Symptom studies address another part of the problem

Feinstein and colleagues examined medication exposure and parent-reported anticholinergic symptoms in children with severe neurological impairment. The study provides population-specific symptom evidence rather than a universal pediatric cognitive validation. Feinstein et al., 2023

That distinction matters because caregiver observations and objective cognitive tests have different strengths and limitations. A child may not be able to describe an experience in the same way as an adult, while an observed change may have several explanations. The source of the report and the clinical context therefore belong in the evidence statement.

Exposure studies do not automatically establish harm

Research can describe how often children receive medications classified by an adult scale. Such studies are useful for understanding prescribing patterns, but prevalence is not itself an estimate of adverse effects. A classification applied to a prescription record also does not necessarily establish actual use or validate a clinical threshold.

The Slovenian nationwide database study, for example, analyzed outpatient prescription claims and described anticholinergic exposure across age groups. Its design illustrates a medication-use question that differs from measuring a child’s clinical response. Čebron Lipovec et al., 2020 These kinds of studies should complement outcome research, not be relabeled as proof of individual harm.

What a source scale can contribute now

An original source observation can identify a medicine for further review and show where sources agree or differ. The observation should keep its source name, version, and population context. If it was not validated for the child’s age or outcome, the article should state that limit rather than change the category to make it seem pediatric-specific.

Missing observations need the same discipline. An unlisted medicine is not assigned zero, and absent pediatric validation does not mean an adult source observation should be deleted. The correct display can show the source evidence while clearly marking that its clinical applicability in a child remains uncertain.

The product and treatment purpose are essential

Pediatric use often raises practical questions about the exact preparation, concentration, route, and administration history. These details should be verified from the current product and clinical record. They should not be inferred from a generic ingredient name or from a formulation used in a different study.

The medicine’s purpose also matters. A review should record the intended benefit and the concern prompting assessment. A medication may address an important symptom while creating another issue worth discussing. The directory cannot decide that tradeoff from a source category, and this article does not provide medication-change instructions.

How to communicate a bounded conclusion

A useful conclusion states the evidence type, population, and outcome. For example: the cited pediatric study assessed a defined cognitive outcome under particular exposure conditions; it did not establish a universal safety threshold. Or: a symptom association was observed in a medically complex group and requires caution when generalized to other children.

That wording is more informative than saying “safe in children” or “dangerous in children.” It also gives a family or clinician a clear next question: whether the child’s actual product, use pattern, and concern resemble the context for which evidence exists.

A useful reading order begins with the study’s question rather than the medicine’s category. First identify whether the publication measured exposure prevalence, a reported symptom, a cognitive test, or the result of treatment. Then identify the children represented, the observation period, and how medication use was established. Only after those details are clear should the result be brought into a discussion about a particular child. This order helps prevent a familiar medicine name from making unrelated evidence seem directly applicable.

The comparator is equally important. A study of a treated condition may compare groups that differ in why treatment was needed or in other supports they receive. An observed difference can therefore require more explanation than “the anticholinergic medicine caused it.” Conversely, a null cognitive comparison cannot answer whether one child’s new dry mouth or constipation is related to treatment. Those concerns require their own evidence and clinical assessment.

The practical output can be modest but specific: a correct product record, a named source observation, an accurately bounded research finding, and a clear unanswered question. Those are useful advances even when no pediatric risk threshold can be justified. They also identify what a future study would need to measure, instead of using lack of certainty as a reason to import an adult rule.

Evidence gaps and priorities

Important unresolved questions include longer exposure histories, complex combinations, developmental subgroups, route-specific products, and outcomes that matter to children and families. A future study should define those questions explicitly rather than simply reuse an adult threshold and call the result pediatric validation.

The current evidence supports careful medication review and honest uncertainty. It does not authorize synthetic pediatric scores, extrapolated dementia risk, or treatment decisions based solely on a badge. The next useful step is a precise clinical or research question matched to the evidence that can actually answer it.

References

1. Feinstein JA, et al. Anticholinergic Medications and Parent-Reported Anticholinergic Symptoms in Neurologically Impaired Children. J Pain Symptom Manage. 2023;65(2):e109-e114. Source
2. Vennard O, Stewart C, Tolia M, Soiza RL, Myint PK. Anticholinergic Medication Burden Scales: A Systematic Review. J Am Geriatr Soc. 2026;74(6):1771-1784. Source
3. Hong IS, Bishop JR. Anticholinergic use in children and adolescents after initiation of antipsychotic therapy. Ann Pharmacother. 2010;44(7-8):1171-1180. Source
4. Ghezzi E, Chan M, Kalisch Ellett LM, et al. The effects of anticholinergic medications on cognition in children: a systematic review and meta-analysis. Sci Rep. 2021;11:219. Source
5. Čebron Lipovec N, Jazbar J, Kos M. Anticholinergic Burden in Children, Adults and Older Adults in Slovenia: A Nationwide Database Study. Sci Rep. 2020;10:9337. Source

Disclosure

Funding: None. Conflict of interest: None declared for the UnifiedACB educational project.

Educational evidence summary. This content does not provide patient-specific medical advice and does not replace clinical judgment, medication reconciliation, or prescribing guidance.