Sleep disorders in pediatric patients require thorough examination, careful
diagnosis, trials of behavioral interventions, and motivation and cooperation
from parents and patients themselves. Medications should be used with caution
after weighing risks, and benefits and treatment should be closely
This was some of the advice presented to a full house of attendees at the
American Academy of Child and Adolescent Psychiatry annual meeting in Boston
All presenters at the session emphasized that no prescription sleep aids on
the market have been approved by the Food and Drug Administration for use in
pediatric patients and that clinical-trial data are very limited regarding
safety and efficacy in this population. They urged clinicians to perform
thorough assessments and enlist the help of parents to identify contributing
factors to the etiology of a child's sleep problems, which can be complex. For
instance, comorbidities such as attention-deficit/hyperactivity disorder
(ADHD) and bipolar disorder, concomitant medications like amphetamine and
methylphenidate, daytime anxiety, and excessive stimulation in the evening can
contribute to insomnia or disturbed sleep.
The presenters suggested that clinicians ask questions such as: Is the
child having trouble falling asleep? Does he or she sleep enough hours at
night and still doze off during the day (fragmented sleep or poor sleep
quality)? Or does the child stay up late to play video games and sleep in on
weekends, thus having trouble adjusting to the normal school schedule during
weekdays (circadian rhythm disorder)? A sleep journal, kept by a parent or the
young patient to record the child's sleep pattern, habits, and symptoms, is a
good tool to help the psychiatrist pinpoint the cause of the insomnia.
Behavioral interventions and good sleep hygiene should be the first-line
treatment before prescribing sleep aids, the presenters agreed. To change bad
habits that interfere with optimum sleep takes time and effort, but it is
essential for a long-term solution to the problem and may reduce or eliminate
the need for drug therapy. Psychiatrists are more likely to succeed through
educating both patients and parents and enlisting their full
For infants and small children with disturbed sleep patterns, Anna
Ivanenko, M.D., Ph.D., an assistant professor of clinical psychiatry and
behavioral sciences at Northwestern University, recommended that clinicians
teach parents strategies to establish good sleep hygiene with their children.
The "faded bedtime" technique, for example, can work for children
as well as adults with difficulty falling asleep. "A child's bedtime is
temporarily delayed by typically 30-minute increments," she said,"
so that the child is sleepier when he goes to bed and falls asleep in
much less time. The bedtime is then gradually advanced to 30 minutes
earlier." Meanwhile, the parent should maintain and enforce the wake-up
She advised having parents keep a sleep diary, including the timing of the
child's naps and activities around bedtime, to track patterns and target
problem areas. A positive bedtime routine, like scheduling relaxing activities
before bedtime and avoiding overstimulation, can help develop good sleep
hygiene for life. "Combined with rewards with something the child really
likes, [the behavioral interventions] can work very well for little
kids," she said.
The importance of behavioral interventions was echoed by other presenters."
In general, medications should rarely be the first choice and certainly
not the full treatment in children," said Judith Owens, M.D., M.P.H., of
Brown University. "If you haven't worked on the behavioral aspects, once
you stop the medication, the insomnia comes right back." Both Ivanenko
and Owens noted that today the setup of many children's bedrooms is
counterproductive for a healthy sleep routine. Computers, television, and
other electronic gadgets can multiply in the bedroom and erode the time and
quality of sleep. "Use common sense," both presenters said.
"[Drug therapy] selection should be based on the clinical judgment of
the best match between the clinical situation and individual property of the
drug," said Owens. "It is very important to set specific treatment
goals that are measurable and realistic," she suggested, and"
negotiate with the family in terms of their expectations."
Combined with behavioral interventions, medications should be used at the
lowest dosage and for the shortest duration possible.
Selection of appropriate medication is dependent on specific symptoms,
Owens stressed. To treat sleep-onset problems, use the shortest acting drugs
possible. For early awakening, choose longer-acting drugs that don't cause
morning hangover. Psychiatrists should consider comorbidities, such as ADHD
and mood disorders, and concomitant medications as underlying causes of
secondary insomnia. Teenagers should be questioned in detail about their use
of over-the-counter remedies, caffeine-laden beverages, or alcohol, which may
interfere with sleep. Alcohol and substance use must be ruled out before a
treatment is chosen.
Owens reviewed the medications commonly prescribed off-label to treat
pediatric patients with insomnia, including alpha agonists (for example,
clonidine, guanfacine), trazodone, benzodiazepines, and newer
sedatives/hypnotics such as zolpidem (Ambien), eszopiclone (Lunesta), and
ramelteon (Rozerem). Each carries a unique risk-and-benefit profile and
requires careful monitoring.
Clonidine, for example, has been used to treat insomnia in children with
comorbid hyperactivity and irritability. It has a rapid onset and short half
life, but the drug has a narrow therapeutic window and a high risk for
cardiovascular toxicity. Zolpidem has been linked to sleep walking and sleep
eating, with potentially dangerous consequences. Benzodiazepines, less
frequently used now, carry the risks of physical dependence and rebound
Patients can obtain sedating antihistamines without a prescription and may
consider them to be safer, but their efficacy in pediatric patients is
questionable, according to Owens. Diphenhydramine is known to cause
paradoxical excitation in younger children.
Delayed sleep-phase syndrome is a type of circadian rhythm sleep disorder
most often seen in adolescents. Patients' sleep time becomes later and later
at night, which results in difficulty waking up in the morning and staying
awake in classes, according to Kyle Johnson, M.D., an assistant professor of
psychiatry in the Division of Child and Adolescent Psychiatry at Oregon Health
and Science University. He is also the associate director of the Sleep
Medicine Program at the university.
"Circadian disorders can occur as a part of normal child development
or as a result of irregular inconsistent sleep schedule or can be associated
with developmental disorders, disabilities, or other medical
conditions," said Johnson. He too emphasized the value of taking a
thorough history and examination before prescribing treatment.
Johnson noted that behavioral therapy aimed at habit changes, with the
cooperation of parents and the adolescent patient, can effectively readjust
distorted sleep rhythm. He stressed the importance of maintaining a strict and
consistent wake-up protocol on weekends. Staying up late and sleeping in on
weekend mornings can sabotage the sleep routine established during the week
and create a vicious cycle.
Johnson also pointed out that light therapy in the morning can help the
body retune its sleep-wake cycle to the natural day-night rhythm.
Both Johnson and Owens recommended using low-dose (0.5 mg) melatonin, taken
orally five to six hours before bedtime, to normalize the circadian rhythm."
There have been some studies, typically in special-needs populations,
[that] seem to suggest that melatonin is effective and well tolerated, and may
result in some improvement in daytime functioning," said Owens. She
cautioned that "there really isn't a lot of long-term data on
safety." The higher dose of 2 mg or 3 mg, a formulation commonly sold as
tablets, induces sleep through its sedative effect and should be taken 30
minutes before bedtime.
Ramelteon, a selective melatonin receptor agonist, is believed to act
similarly to melatonin to normalize the sleep-wake cycle.
Researchers from Vanderbilt University recently linked the natural
production of melatonin and sleep. Children with autism spectrum disorders,
who typically have sleep disturbances, had lower levels of a melatonin
byproduct in urine than children with more deep sleep. This study, led by Beth
Malow, M.D., director of the Vanderbilt Sleep Disorders Center, was presented
as a poster at the annual meeting of the Society for Neuroscience in November
in San Diego.
An abstract of "Nocturnal Urine 6-Sulfatoxymelatonin Levels
Are Related to Sleep Parameters in Children With Autism" can be accessed
by clicking on "Neuroscience Meeting Planner" and then searching
for session 61.92. ▪