Confession: I have blocked people on The Book of Faces just for bragging about how their newborns sleep 30 hours a day. Even when Little Miss has been sleeping well I live in fear of “those nights.” (I am not the most rational person in the nighttime—bad decisions have been made.) So it goes without saying (well obviously not without saying) that I have a lot of empathy for the parents wandering the pharmacy aisles looking for something to help their children sleep. For a long time I was hesitant to recommend anything due to a lack of good evidence but…that has changed! Are you excited?!?
The majority of these recommendations also apply for adults but insomnia treatment in adults includes a lot more treatment options (mostly prescription medications) that are better evaluated on a case by case basis.
The majority of these recommendations also apply for adults but insomnia treatment in adults includes a lot more treatment options (mostly prescription medications) that are better evaluated on a case by case basis.
Let’s start with what I DON’T recommend:
Diphenhydramine (Benadryl ®) or doxylamine (Unisom®) are both NOT a good idea. There isn’t any evidence that they improve sleep and (if you’re really lucky) they can actually make children MORE awake. This is one of the few places my recommendations differ for adults—these options are fine for adults to use occasionally for sleep. I would place them as a third-line option after behavior changes (discussed below) and melatonin.
What I DO recommend:
As always, I am a fan of behavioral modifications first and foremost. Things like:
· Consistent bedtimes (and naptimes, if applicable)
· Avoiding caffeine and bright screens (TV, tablet, phones, etc.) around bedtime
· Create a relaxing bedtime routine
Adults can also try removing their clocks, getting daily exercise/outdoors time and avoiding/limiting alcohol and nicotine.
If your children are taking stimulant medications (e.g. Adderall®, Ritalin®), you will probably have additional sleep concerns. On top of these basic behavioral modifications, kids on stimulants will also benefit from consultation with their prescriber and/or pharmacist to adjust the timing or duration of the stimulant medication to help make bedtime easier.
If you have given all of these things a good solid effort and you are still struggling with bedtime, I would start considering melatonin. The beginning dose would be 3 mg 30 to 60 minutes before bedtime but you can adjust the dose anywhere from 0.5 mg to 6 mg (aiming for the smallest effective dose). WARNING: This is not like the prescription sleep medications that will knock you out even if you decide you need to stay awake. If you are not ready for relaxation and bedtime as soon as you take melatonin you can negate its effectiveness.
My favorite thing about melatonin is that it is the same thing your body is already designed to use to set your sleep-wake cycle. (Your brain releases melatonin in response to the decrease in light at evening-time.) The fact that melatonin is supposed to be floating around in your body helps limit the side effects and makes it difficult, if not impossible, to become dependent on or resistant to melatonin’s sleep benefits. As far as side effects go, most people only experience a mild headache or slight morning drowsiness. This is even more impressive if you have ever enjoyed the hangover of the traditional over-the-counter and prescription sleep medications or if you have ever heard from people who sleep-eat or sleep-drive while taking prescription sleep medications.
I would like to add a side-note here for Su who asked about melatonin causing weird dreams. In all the data I sifted through I could not find any specific mention of melatonin causing weird dreams but, that said, it wouldn’t surprise me (especially for someone already prone to weird dreams). Unfortunately, I would expect any other effective sleep medication to cause the same issue (and the prescription ones might be worse) and I doubt the dreams would go away with continued use. This would be a case of choosing between a rock and a hard spot. Just what you wanted to hear.
This also seems like a good time to bring up drug holidays. Parents with children on prescription stimulants may already be familiar with the concept but, for the rest of you, this basically means not giving a medication for a few days or weeks. The thought behind this being that it allows you to assess where the child is without the medication, avoids the rut of thinking the child can’t live without the medication and somewhat addresses the concern of whether these medications are affecting the child’s long-term development. I would recommend planning on giving kids a drug holiday from melatonin on weekends (for kids in school) or more often if you can.
BONUS: I didn’t realize until I started researching this post that melatonin is being investigated for several special populations of children, especially those with autism-spectrum or other developmental disorders. These children have higher rates of insomnia (along with all the other issues they have to face) and melatonin appears to be helpful on more than one level.
As always, since melatonin is a natural product it is not subject to the regulation of the other over-the-counter medications and you will want to look for USP Verification on the label to guarantee you are getting what you paid for.
Main References:
Advances in the Research of Melatonin in Autism Spectrum Disorders: Literature Review and New Perspectives International Journal of Molecular Sciences 2013, 14, 20508-20542
A Practice Pathway for the Identification, Evaluation, and Management of Insomnia in Children and Adolescents with Autism Spectrum Disorders Pediatrics 2012, 130, S106-S127
Meta-Analysis: Melatonin for the Treatment of Primary Sleep Disorders PLoS ONE 2013, 8, 5, e63773
Diphenhydramine (Benadryl ®) or doxylamine (Unisom®) are both NOT a good idea. There isn’t any evidence that they improve sleep and (if you’re really lucky) they can actually make children MORE awake. This is one of the few places my recommendations differ for adults—these options are fine for adults to use occasionally for sleep. I would place them as a third-line option after behavior changes (discussed below) and melatonin.
What I DO recommend:
As always, I am a fan of behavioral modifications first and foremost. Things like:
· Consistent bedtimes (and naptimes, if applicable)
· Avoiding caffeine and bright screens (TV, tablet, phones, etc.) around bedtime
· Create a relaxing bedtime routine
Adults can also try removing their clocks, getting daily exercise/outdoors time and avoiding/limiting alcohol and nicotine.
If your children are taking stimulant medications (e.g. Adderall®, Ritalin®), you will probably have additional sleep concerns. On top of these basic behavioral modifications, kids on stimulants will also benefit from consultation with their prescriber and/or pharmacist to adjust the timing or duration of the stimulant medication to help make bedtime easier.
If you have given all of these things a good solid effort and you are still struggling with bedtime, I would start considering melatonin. The beginning dose would be 3 mg 30 to 60 minutes before bedtime but you can adjust the dose anywhere from 0.5 mg to 6 mg (aiming for the smallest effective dose). WARNING: This is not like the prescription sleep medications that will knock you out even if you decide you need to stay awake. If you are not ready for relaxation and bedtime as soon as you take melatonin you can negate its effectiveness.
My favorite thing about melatonin is that it is the same thing your body is already designed to use to set your sleep-wake cycle. (Your brain releases melatonin in response to the decrease in light at evening-time.) The fact that melatonin is supposed to be floating around in your body helps limit the side effects and makes it difficult, if not impossible, to become dependent on or resistant to melatonin’s sleep benefits. As far as side effects go, most people only experience a mild headache or slight morning drowsiness. This is even more impressive if you have ever enjoyed the hangover of the traditional over-the-counter and prescription sleep medications or if you have ever heard from people who sleep-eat or sleep-drive while taking prescription sleep medications.
I would like to add a side-note here for Su who asked about melatonin causing weird dreams. In all the data I sifted through I could not find any specific mention of melatonin causing weird dreams but, that said, it wouldn’t surprise me (especially for someone already prone to weird dreams). Unfortunately, I would expect any other effective sleep medication to cause the same issue (and the prescription ones might be worse) and I doubt the dreams would go away with continued use. This would be a case of choosing between a rock and a hard spot. Just what you wanted to hear.
This also seems like a good time to bring up drug holidays. Parents with children on prescription stimulants may already be familiar with the concept but, for the rest of you, this basically means not giving a medication for a few days or weeks. The thought behind this being that it allows you to assess where the child is without the medication, avoids the rut of thinking the child can’t live without the medication and somewhat addresses the concern of whether these medications are affecting the child’s long-term development. I would recommend planning on giving kids a drug holiday from melatonin on weekends (for kids in school) or more often if you can.
BONUS: I didn’t realize until I started researching this post that melatonin is being investigated for several special populations of children, especially those with autism-spectrum or other developmental disorders. These children have higher rates of insomnia (along with all the other issues they have to face) and melatonin appears to be helpful on more than one level.
As always, since melatonin is a natural product it is not subject to the regulation of the other over-the-counter medications and you will want to look for USP Verification on the label to guarantee you are getting what you paid for.
Main References:
Advances in the Research of Melatonin in Autism Spectrum Disorders: Literature Review and New Perspectives International Journal of Molecular Sciences 2013, 14, 20508-20542
A Practice Pathway for the Identification, Evaluation, and Management of Insomnia in Children and Adolescents with Autism Spectrum Disorders Pediatrics 2012, 130, S106-S127
Meta-Analysis: Melatonin for the Treatment of Primary Sleep Disorders PLoS ONE 2013, 8, 5, e63773
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