The goal of this post is to review pharmacologic strategies in children, both on and off label, and some common issues each may have.
Sleep hygiene seems to be mentioned often, but rarely enforced by parents. This practice includes the implementation of standard bedtimes, absence of caffeine, a relaxed bedroom and primarily the removal of screens. While this article does not go in depth into these practices, it is important for any primary care provider to familiarize themselves with screening and education on sleep hygiene. Additionally, screening for sleep apnea in any child with attentional issues is important as well.
The ever present melatonin has become so commonplace that it now occupies an entire section in most pharmacies. In children, it is FDA approved and there is clear evidence it improves sleep initiation, duration and quality; however the risks remain unknown. As melatonin is a hormone, long term use appears to disrupt endogenous production, especially when used at high doses. There appears to be evidence that 0.5mg is appropriate, while higher doses are used most often when chasing waning benefit. It is recommended to only be used short term or as needed. Most parents report loss of effectiveness in their children after regular use. At times, subsequent insomnia may occur as well. It can be helpful both to initiate sleep and to promote a healthier circadian rhythm. For patient centered information consider the mayo clinic website: https://www.mayoclinic.org/healthy-lifestyle/adult-health/expert-answers/melatonin-side-effects/faq-20057874
Clonidine is also commonly used in children for sleep initiation. Often 0.1-0.2 mg given at bedtime promotes rapid sleep initiation. This can often help benefit sleep when rebound hyperactivity occurs as a stimulant wears off. While it does not carry FDA approval, it does meet community standard for care and is generally quite safe. One drawback is that it wears off after 4-6 hours, potentially not benefiting those with middle insomnia or early waking. However, given the short half-life, a second dose can be used. Please note that overdoses can be lethal due to respiratory depression. This medication must be locked away from small children.
Trazodone is so sedating that it often cannot be prescribed when needed as an anti-depressant. On the other hand, it is inexpensive and benefits middle waking due to long duration of action. Given this, it has found a place as a commonly used sleep aid. Community standard initial dosing is commonly 25 mg, though at times patients may find up to 150 mg beneficial. Notably, in patients under 25yo, a reminder that it is an anti-depressant and carries the black box warning regarding increased suicidal ideation is important. It is certainly a serotonergic agent. A reminder to discuss serotonin syndrome in patients on additional serotonergic meds including but not limited to SSRI’s, SNRI’s and Triptans. Additionally, in males there is a rare but present risk of priapism. It is necessary to discuss with the patient and their parents before prescribing. Finally, trazodone can cause vivid dreams. In patients with nightmares this can be unpleasant if not unbearable. If prescribing trazodone is commonplace in your practice, consider reviewing this short Healthline article to review its side effects: https://www.healthline.com/health/sleep/trazodone-for-sleep#risks
In certain depressed patients, initiation of Remeron, especially at low doses, may complement their primary treatment. Its boost of appetite and benefit to sleep initiation and maintenance is strikingly beneficial. The rapid onset of these side effects are due to histamine 1 antagonism. Often its long term use is not tolerated due to weight gain, but in the short term, can jump start treatment. Common starting dose of 7.5 mg to 15 mg is appropriate. A reminder that, similar to trazodone, this medication carries the black box warning related to increased suicidal ideation in persons younger than 25 years old.
Benadryl, Atarax, Hydroxyzine, Doxylamine Succinate are off label anti-histamines often used in children to promote sleep. Commonly these are used as needed rather than on a regular basis. While sleep latency greatly improves, there is question if the sleep is in fact restorative, with numerous studies noting a decrease in REM time when used. Often there is AM grogginess related to this class that may undermine daytime learning, especially in the morning. Given this concern there is a greater consideration to use only as needed rather than on a regular basis. Doses 25 mg or less often avoid frustrating side effects related to anti-histamine use. Approximately ten percent of the childhood population has a paradoxical energizing. It would be best to test dose prior to any long distance overnight flights.
In adults, the use of benzodiazepines and its sibling medications Zolpidem, lunesta etc have found a place in daily dosing and as needed. Currently, there is not an FDA indication in children under age 18. There are often only rare cases where these medications are considered. Notably, there is street value with these medications and if prescribed, please review DEA considerations with the patient.
Finally, Seroquel and other atypical anti-psychotics clearly can be sedating, and at times are prescribed as standalone sleep aids. This practice should be avoided due to risks of weight gain, odd/abnormal movements, pre-diabetes and lipid derangement. However, if a child requires an atypical antipsychotic due to a primary mental health condition, such as ASD agitation, it may be appropriate to consider Seroquel due to its sedating nature if insomnia is present. As always, the lowest effective dose should be considered.
This list is clearly not exhaustive but hopefully offers some guidance regarding initial steps in the treatment of insomnia in children and teens. A second stanza of the previously mentioned River Riddle is “what runs but never walks?” Perhaps use this as a reminder that if a child is running bedtime and refusing to turn off screens, the most potent, safe and necessary treatment is family therapy rather than any of the meds listed above.
Joshua Stein MD
For further information: https://link.springer.com/article/10.1007/s40675-016-0036-1#Sec3