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Clinical and Research News
Behavior Strategies First-Line Treatment in Pediatric Insomnia
Psychiatric News
Volume 42 Number 24 page 16-16

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 monitored.

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 in October.

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 participation.

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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 time.

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.

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"[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 insomnia.

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.

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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 at<www.sfn.org/am2007/index.cfm?pagename=call_for_abstracts> by clicking on "Neuroscience Meeting Planner" and then searching for session 61.92.

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