Melatonin Treatment for Pediatric Patients with Insomnia: Is There a Place for It?

Prescription Trends of Medications Used to Treat Sleep Disturbances in School-Aged Children: An Interrupted Time-Series Analysis in France, 2016-2023

OBJECTIVE

To assess rates and trends of hypnotic medication prescriptions for children and adolescents.

STUDY DESIGN

Cross-sectional study of national dispensing data between January 1, 2016, and December 31, 2023, in France. Prescriptions of hypnotic medications (hydroxyzine, alimemazine, melatonin, and Z-drugs) dispensed to children aged 6-17 years were analyzed. Monthly rates of hypnotic prescriptions per 1000 children were modeled before and after the pandemic onset (March 2020) to assess rate and trend changes. Rate ratios (RRs) were calculated between estimated and expected prescription rates.

RESULTS

Overall, 2 675 142 prescriptions were dispensed to an average yearly population of 9 963 497 children. In January 2016, prescription rate of hypnotic medications was estimated at 1.9 per 1000 and at 6.8 per 1000 in December 2023, with postpandemic onset rates exceeding the expected by 131% (RR: 2.31, 95% CI: 2.08; 2.54). Prescription trends increased for all medications from -0.1% (95% CI: -0.2; 0.1%) per month prepandemic to +1.4% (95% CI: 1.2; 1.6%) after the pandemic onset for hydroxyzine; +0.1% (95% CI: 0.0; 0.2%) to +0.9% (95% CI: 0.7; 1.0%) for alimemazine; +2.2% (95% CI: 2.0; 2.3%) to +4.4% (95% CI: 3.9; 4.9%) for melatonin; and -3.2% (95% CI: -3.6;-2.8%) to +1.8% (95% CI: 1.4; 2.2%) for Z-drugs. Monthly prescription rates exceeded the expected by 38% (RR: 1.38, 95% CI: 1.31; 1.46) for hydroxyzine; 19% (RR: 1.19, 95% CI: 1.15; 1.22) for alimemazine; 344% (RR: 4.44, 95% CI: 4.07; 4.80) for melatonin; and 419% (RR: 5.19, 95% CI: 4.24; 6.14) for Z-drugs.

CONCLUSIONS

Recent substantial increases in hypnotic medication prescribing for children are possibly related to their persistently deteriorating mental health, changes in prescribing strategies, and/or unmet pre-existing needs.

Melatonin use in the pediatric population: an evolving global concern

BACKGROUND

The impact of melatonin on pediatric populations has not yet been widely researched. This narrative review is intended to summarize the current literature regarding the efficacy and safety of melatonin for children and potential pitfalls in its clinical use, in order to assist pediatric practitioners in making evidence-based recommendations that serve the best interests of their patients and families.

DATA SOURCES

A literature review of melatonin in the pediatric population was conducted using PubMed search terms: melatonin, pediatrics, child/adolescent.

RESULTS

Melatonin use in the pediatric population world-wide has increased significantly over the past several decades. While a number of studies, largely in children with neurodevelopmental disorders with insomnia, have suggested that melatonin is generally safe and well-tolerated, a similar body of evidence is overall lacking for typically developing children and prospective studies regarding long-term adverse events are lacking. In addition, recent studies have raised concerns regarding the variable content of melatonin in over-the-counter products, as well as safety issues relating to accidental ingestions.

CONCLUSIONS

Due to a number of concerns regarding inappropriate use, lack of efficacy and safety data across pediatric populations and variability in actual content, melatonin should be used with caution in children and only under medical supervision.

Melatonin use in managing insomnia in typically developing (TD) children: A technical report

Although melatonin is widely used globally for the management of insomnia in children and adolescents, there are few clinical guidelines available for healthcare practitioners, particularly in typically developing (TD) children. Because existing data are either sparse or inconclusive, a task force comprised of pediatric sleep researchers and clinicians was established by the International Pediatric Sleep Association (IPSA) to first examine the available literature and to develop a set of evidence-based (when possible) and consensus-based recommendations to guide practitioners in decision-making regarding melatonin use in pediatric insomnia. A summary of the evidence pertaining to melatonin's use in pediatric clinical settings, and efficacy and safety in TD children is presented below as a companion to an accompanying list of specific recommendations.

Melatonin use in infants and toddlers

Background Melatonin use in the pediatric population is on the rise in the United States, where it is available as an over-the-counter and online supplement. There are no data regarding the safety and efficacy of melatonin in children less than 2 years old. The aim of this study was to examine various aspects of melatonin use by caregivers of infants and toddlers in the US. Methods Caregiver users of the Nanit baby monitoring system with a child aged 0-36 months were invited to complete an online survey regarding melatonin use, sources of information/recommendations about melatonin, formulations used and reasons for administering melatonin to their child. Participants also completed the Brief Infant Sleep Questionnaire-Revised (BISQ-R). Results A total of 3063 caregivers (1.93%) responded to the survey, of whom 1.7% had ever used melatonin for their child. About half of those caregivers had received a recommendation for melatonin from a source other than a healthcare professional. Caregiver perception of 'sleep as a problem' as assessed by the BISQ-R was not significantly different between those who had or had not used melatonin for their child, and reasons for use included non-supported indications such as sleeping later or promoting "more restful and better sleep". Conclusions The results of this study support mounting concerns regarding the widespread use of melatonin in the US pediatric population, especially given the lack of regulatory oversight and the documented inaccuracy of label claims versus actual melatonin content.

An online survey among general pediatricians on melatonin use in children with chronic insomnia

OBJECTIVES

Although melatonin (MLT) is the molecule most used by pediatricians for sleep problems, scarce evidence exists on its use in healthy pediatric population. The objective of this study was to describe MLT use by Italian pediatricians in healthy children with chronic insomnia.

STUDY DESIGN

A cross-sectional open survey was administered to Italian pediatricians, between June and November 2022, collecting information about their use of MLT in healthy children: age range of patients, dosages used, time of administration, duration of treatment, association with other treatments, perceived efficacy, and side effects. Data were reported as frequencies with their respective 95% confidence intervals. Chi-square statistics assessed significant differences between pediatricians who had training in pediatric sleep and those who did not.

RESULTS

Among 428 respondents, 97.4% of pediatricians used MLT; 87.3% of them prescribed MLT in children aged 1-2 years, 62.1% in 2-5 years and 42.5% in 10-18 years. 84.9% of them suggested to take MLT 30 min before bedtime. 37.9% indicated to continue treatment for one month, 30.2% for 2-3 months. 74.1% of pediatricians usually prescribed MLT 1 mg/day. The most frequent treatment associated with MLT was sleep hygiene (85.4%). Almost all pediatricians found MLT effective in reducing difficulties falling asleep. Only 3.2% of them reported mild side effects.

CONCLUSIONS

MLT is widely prescribed by Italian pediatricians, but no consensus exists about its use in typically developing children. There is a need for clear guidelines to optimize the use of MLT in healthy children.

Management of sleep disorders in autism spectrum disorder with co-occurring attention-deficit hyperactivity disorder: update for clinicians

AIMS

To update and examine available literature germane to the recognition, assessment and treatment of comorbid autism spectrum disorder (ASD), attention-deficit hyperactivity disorder (ADHD) and sleep disruption, with a predominant focus on children, adolescents and emerging adults.

BACKGROUND

Considerable overlaps exist among ASD, ADHD and sleep disruption. Literature and guidance for clinicians, administrators, policy makers and families have been limited, as such deliberations were rarely considered until 2013.

METHOD

This narrative review of the literature addressing sleep disruption issues among those with ASD, ADHD and comorbid ASD and ADHD involved searching multiple databases and use of reverse citations up to the end of September 2022. Emphasis is placed on secondary sources and relevant data for clinical practice.

RESULTS

Complex clinical presentations of ASD/ADHD/sleep disruption are frequently encountered in clinical practice. Prior to 2013, prevalence, clinical presentation, pathophysiology, prognosis, other sleep-related factors and interventions were determined separately for each disorder, often with overlapping objective and subjective methods employed in the process. High percentages of ADHD and ASD patients have both disorders and sleep disruption. Here, the extant literature is integrated to provide a multidimensional understanding of the relevant issues and insights, allowing enhanced awareness and better care of this complex clinical population. Database limitations are considered.

CONCLUSIONS

Assessment of ASD symptomatology in youth with ADHD, and the reverse, in cases with disrupted sleep is critical to address the special challenges for case formulation and treatment. Evidence-based approaches to treatment planning and multi-treatment modalities should consider combining psychosocial and biological interventions to address the complexities of each case.

Melatonin: Facts, Extrapolations and Clinical Trials

Melatonin is a fascinating molecule that has captured the imagination of many scientists since its discovery in 1958. In recent times, the focus has changed from investigating its natural role as a transducer of biological time for physiological systems to hypothesized roles in virtually all clinical conditions. This goes along with the appearance of extensive literature claiming the (generally) positive benefits of high doses of melatonin in animal models and various clinical situations that would not be receptor-mediated. Based on the assumption that melatonin is safe, high doses have been administered to patients, including the elderly and children, in clinical trials. In this review, we critically review the corresponding literature, including the hypotheses that melatonin acts as a scavenger molecule, in particular in mitochondria, by trying not only to contextualize these interests but also by attempting to separate the wheat from the chaff (or the wishful thinking from the facts). We conclude that most claims remain hypotheses and that the experimental evidence used to promote them is limited and sometimes flawed. Our review will hopefully encourage clinical researchers to reflect on what melatonin can and cannot do and help move the field forward on a solid basis.