Monday, August 22, 2022

Back to school & back to sleep: melatonin supplementation in children

- Lilian White, MD

As the end of summer approaches, children are making their way back to into the classroom. With this transition and possible changes in sleep-wake schedules, sleep disorders in children and adolescents may become more apparent. Parents may ask about the use of melatonin to treat insomnia during this transitional period.

Normal sleep duration and sleep patterns change as children age. Children 5 to 12 years old usually require 9-12 hours of sleep, and only 5 in 100 need daytime naps. Adolescents typically need 8-10 hours of nighttime sleep. Daytime napping in adolescents suggests insufficient sleep at night or a potential sleep disorder. Most high school students do not get enough sleep. This lack of sleep is associated with an increased risk of obesity, diabetes mellitus, injuries, poor mental health and attention/behavioral problems.

About 10-30% of children struggle with insomnia. Children may have difficulty initiating or maintaining sleep. They may be diagnosed with an insomnia disorder if this occurs at least 3 times per week for at least 3 months. Childhood insomnias are characterized as difficulty with sleep-association (e.g., require caregiver to be present to fall asleep) or limit-setting (e.g., absence of a regular bedtime routine). Behavioral interventions are considered first line treatment. In the Choosing Wisely campaign, the American Academy of Sleep Medicine recommends not prescribing medications to treat behavioral childhood insomnia.

Adolescents are more commonly affected by delayed sleep phase syndrome, a subtype of circadian sleep rhythm disorder. The prevalence is estimated to be 7-16%. Sleep onset and awakening are delayed by more than 2 hours for at least 3 months. A sleep diary may be helpful in making this clinical diagnosis. The most powerful influence on the circadian rhythm is light. Decreased morning light exposure and/or increased evening light exposure may worsen symptoms. Treatment of delayed sleep phase syndrome includes regular sleep-wake schedules, avoiding bright or blue light prior to bedtime, bright light therapy within the first 1-2 hours of awakening, and melatonin.

Melatonin helps the onset of sleep in the circadian rhythm. Melatonin is typically recommended at a dose of 0.3 to 5 mg taken 1.5 to 6.5 hours before bed for a short duration (i.e. days). Ideally, melatonin moves sleep onset earlier. However, if taken later – such as the middle of the night or at bedtime – it may move sleep onset later. Melatonin may be particularly helpful in children with neurodevelopmental conditions such as attention-deficit/hyperactivity disorder and autism if behavioral approaches are insufficient to improve insomnia.

Melatonin is generally well-tolerated. Adverse effects most commonly include headache, daytime sleepiness, dizziness, and nausea. The effects of long-term melatonin use in children are not well established; low-quality evidence suggests that it may affect the timing of puberty through potential downstream effects on sex hormones. More research is needed to explore this relationship.

Although melatonin may be purchased over the counter in the United States, it may be harmful if ingested at unintended high doses. Over the past few years, physicians have seen an increase in melatonin given to children, with one study noting a 7x increase. Poison control centers have reported an 530% increase in calls regarding melatonin ingestion (94% of which were unintentional). Melatonin is available in many child-friendly forms such as gummies or chewables. If melatonin use is recommended, physicians should caution parents to store melatonin in a safe place away from children.

While melatonin may present a helpful option to treat certain sleep disorders in children, behavioral interventions are still considered the most effective and first-line treatment. Additional tips for behavioral management of insomnia can be found in a recent AFP article on Common Sleep Disorders in Children and related patient education.