Autonomic instability in a dehydrated child on guanfacine: Case report and literature review.

An 8-year-old girl on guanfacine extended-release (GXR) for attention-deficit/hyperactivity disorder presented with somnolence, bradycardia and hypotension during a heat wave. No overdose was suspected. She was admitted to the intensive care unit for monitoring and ongoing fluid resuscitation for hypotension. Electrocardiogram showed intermittent atrioventricular dissociation. Upon restarting the drug post-discharge, blood pressures were normal, and follow-up electrocardiograms documented asymptomatic bradycardia but no dissociation. GXR is used as monotherapy or adjunct therapy in the treatment of inattention and hyperactivity in children. No published paediatric or adult study has documented atrioventricular dissociation, bradycardia or hypotension significant enough to warrant hospital admission. This case suggests that GXR can pose a hemodynamic risk to children in the context of elevated environmental temperatures and dehydration. Clinicians should be aware of this potential complication and should counsel patients about signs and symptoms of hypotension, bradycardia, bradypnea and somnolence.

Altered activation and functional asymmetry of exner's area but not the visual word form area in a child with sudden-onset, persistent mirror writing.

Mirror writing is often produced by healthy children during early acquisition of literacy, and has been observed in adults following neurological disorders or insults. The neural mechanisms responsible for involuntary mirror writing remain debated, but in healthy children, it is typically attributed to the delayed development of a process of overcoming mirror invariance while learning to read and write. We present an unusual case of sudden-onset, persistent mirror writing in a previously typical seven-year-old girl. Using her dominant right hand only, she copied and spontaneously produced all letters, words and sentences, as well as some numbers and objects, in mirror image. Additionally, she frequently misidentified letter orientations in perceptual assessments. Clinical, neuropsychological, and functional neuroimaging studies were carried out over sixteen months. Neurologic and ophthalmologic examinations and a standard clinical MRI scan of the head were normal. Neuropsychological testing revealed average scores on most tests of intellectual function, language function, verbal learning and memory. Visual perception and visual reasoning were average, with the exception of below average form constancy, and mild difficulties on some visual memory tests. Activation and functional connectivity of the reading and writing network was assessed with fMRI. During a reading task, the VWFA showed a strong response to words in mirror but not in normal letter orientation - similar to what has been observed in typically developing children previously - but activation was atypically reduced in right primary visual cortex and Exner's Area. Resting-state connectivity within the reading and writing network was similar to that of age-matched controls, but hemispheric asymmetry between the balance of motor-to-visual input was found for Exner's Area. In summary, this unusual case suggests that a disruption to visual-motor integration rather than to the VWFA can contribute to sudden-onset, persistent mirror writing in the absence of clinically detectable neurological insult.

Sleep-promoting medications in children: physician prescribing habits in Southwestern Ontario, Canada.

BACKGROUND: Research indicates that physicians may frequently use pharmacotherapy to treat pediatric insomnia despite minimal safety data and very limited indications. Canadian data on the subject are lacking. This study aimed to determine physicians' views on and prescribing habits for sleep-promoting over-the-counter medication (OTCM) and prescription (RXM) medications for children. METHODS: A modified 26-item version of the 'Pediatric Sleep Medication Survey', originally developed by Judith Owens and colleagues, was sent to 100 pediatricians and a random sample of 421 family physicians in Southwestern Ontario, Canada. RESULTS: A total of 67 returned surveys were sufficiently complete for analysis. Sixty-one respondents indicated their specialty (28 pediatricians, 33 family physicians). In a typical 6-month period, 89% and 66% of respondents have recommended OTCM and RXM, respectively, for children with sleep problems. Only 20% have received any formal training on pediatric sleep disorders. The most common circumstances and sleep problems for which OTCM or RXM were recommended were mood disorders, developmental delay and attention deficit hyperactivity disorder (ADHD) (56, 40, and 39%, respectively), and insomnia, bedtime struggles/delayed sleep onset and circadian rhythm disorders (52, 48, and 28%, respectively). A total of 30% recommended OTCM or RXM to otherwise healthy children with sleep problems. Melatonin (73%), OTC antihistamines (41%), antidepressants (37%), and benzodiazepines (29%) were the most commonly recommended OTCM and RXM, respectively. CONCLUSIONS: Respondents in our sample frequently use pharmacotherapy to treat pediatric sleep problems; few have received any training in this area. Our findings indicate the need for evidence-based guidelines and regular physician training in the management of pediatric sleep disorders.