What are you really recommending to your patients?

by: Daniel Wood, PA-C

Karen is the mother of a 7-year-old first grader who is having difficulty sleeping. Karen is inquiring if there are any “natural” supplements that you can recommend to help her son, Noah, sleep. Maybe melatonin?

I often receive this question in my general pediatric clinic, and I always respond with a general discussion about supplements such as melatonin. Many in the general and clinical public are unaware of the details of what they are really buying when they purchase a supplement in their local store. First, I explain to parents there is a difference between a supplement and say, pharmaceutical drugs and infant formula. Pharmaceutical drugs help medical conditions. Infant formula provides nutrition. Both are reviewed by the FDA for effectiveness or safety.

However, a supplement states that it will help “maintain” health, not improve it. And a supplement does not require FDA oversight or approval. Furthermore, independent reviews of supplements have found a wide variation in mg contained in the supplement. For example, the bottle may list 3mg of melatonin, but it actually it can contain as much as 5mg or as little as 1mg. Even scarier, supplements also have been found to contain other unclaimed ingredients such as lead, mercury, cadmium and arsenic. So, what can you do as a provider? I recommend starting with companies that employ an independent agency to analyze their products. United States Pharmacopeia and consumerlab.com, for example, will make sure the product has what it claims to have and doesn’t have all that other stuff you don’t want.

When discussing sleep disorders in a child a provider must remember to address the variety of behavioral and medical problems that can present with childhood insomnia, typically manifested as bedtime resistance, difficulty initiating sleep, night wakings, or combinations of these symptoms. I usually recommend behavioral strategies as the first line treatment. After that, I have a discussion about the two most common over the counter (OTC) supplements recommended for sleep: antihistamines and melatonin.

Antihistamines may be considered for short-term situational or occasional use in younger children with the precautions. Tolerance to antihistamines such as diphenhydramine or hydroxyzine tends to develop, necessitating increasing doses, and should not be used chronically. In addition, they will cross the blood-brain barrier and bind to histamine type 1 (H1) receptors in the brain and can disrupt the sleep architecture. Other potential side effects of antihistamines include daytime drowsiness, anticholinergic effects (such as dry mouth, blurred vision, urinary retention), and paradoxical excitation.

It should be noted that fatal overdoses with Benadryl have been reported in infants.

The second most common sleep aid for children that I often hear mentioned is melatonin. The best-established use of melatonin is for patients with a documented circadian phase delay. Melatonin can help improve sleep onset, especially in children with autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD).

Melatonin is a hormone secreted by the pineal gland in response to decreased light. It should be taken about an hour prior to bedtime. For insomnia secondary to sleep onset, typical doses are 1 mg in infants, 2.5 to 3 mg in older children, and 5 mg in adolescents, given 30 minutes before bedtime. In autistic children, effective doses have been reported as high as 10 mg.

Studies that have looked at melatonin use for durations up to four years have failed to demonstrate significant adverse effects in children. However, a paucity of data exists at this time.

In summary, recommend behavioral techniques first, then Benadryl for short-term use, and then melatonin if a child has a comorbid condition.

 

You can see Daniel Wood, PA-C speak at the GAPA 2019 Summer Conference in Hilton Head Island, SC.

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