Many children, including those with chronic conditions or neurodevelopmental disorders, have trouble falling asleep or staying asleep. The first steps for improving sleep in these patients are to look for the causes of inadequate sleep, ensure that cortisol is kept to a minimum, and adopt consistent routines at bedtime, according to Megan Thomas, MBChB, PhD, associate professor of developmental pediatrics at Dalhousie University in Halifax. These steps should precede melatonin use. Thomas spoke at a virtual pediatric conference held by the University of Toronto and the Hospital for Sick Children in Toronto.

Possible reasons for poor sleep can include sleep disorders such as restless legs syndrome and periodic limb movement disorder, both of which are linked to low ferritin and can be managed through intake of iron-rich foods or iron supplementation.

Similarly, constipation can impair a child’s ability to get to sleep and stay asleep. It can be managed using laxatives, which may have to be taken on a long-term basis, added Thomas. She serves as chair of the Canadian Paediatric Society’s special interest group on sleep and is a member of the board of the International Pediatric Sleep Association.

Screening at Health Encounters

Clinicians should screen for sleep problems at every health visit, keeping in mind that most children and youths with neurodevelopmental or chronic health conditions frequently have problems getting to sleep or staying asleep, Thomas emphasized.

“When we look at [the rate of] children and youth with neurodevelopmental or chronic health conditions, we see that number is up to over 80%,” she said. Children with autism spectrum disorder (ASD) also face challenges in falling asleep. “It’s helpful to provide anticipatory guidance.”

Implementing behavioral interventions such as setting consistent day and nighttime schedules, engaging in calming activities that immediately precede bedtime (such as reading stories), and avoiding caffeine-containing snacks or drinks at least 6 hours before bed are steps to promote healthy sleep, said Thomas.

Cortisol vs Melatonin

It is important for clinicians and parents to recognize that cortisol, which is produced in response to exciting activities, acts against melatonin. “This was a bit of a lightbulb moment for me when I realized that melatonin and cortisol have opposite effects,” said Thomas.

“If activities are too stimulating, cortisol rises with excitement,” she added. “If bath time is wild and wacky and if playtime with a parent is really exciting, let’s not give up on those, but let’s move them to a different time in the day.” Exciting activities should take place earlier, while calmer activities are appropriate “in that buildup to bedtime,” she said.

Although antihistamines may have a sedative effect, they also can trigger excitability and excitation, cautioned Thomas. Decongestants can result in insomnia, beta-blockers can block melatonin, and steroids promote the release of cortisol.

Optimization of Melatonin

A child should be given melatonin 30-60 minutes before his or her desired sleep time because it is expected to decrease sleep latency, said Thomas. “It is likely to improve sleep onset but it might not increase total sleep time.”

A starting dose of 1-2 mg is effective in about 40% of pediatric patients, said Thomas. “This is still a supraphysiological dose,” and minimal benefit accrues with a dose exceeding 6 mg.

Administering melatonin will likely not impact awakening at night, but using extended-release tablets may offer benefit in that regard. Such tablets are now indicated by Health Canada for the treatment of insomnia in children and adolescents aged 2-18 years with ASD or Smith-Magenis syndrome for whom sleep hygiene measures have been insufficient.

Pronounced Challenge With ASD

Patients with ASD have challenges attaining healthy sleep, agreed Elliott K. Lee, MD, director of the Sleep Disorders Clinic at the Royal Ottawa Mental Health Center. Melatonin offers therapeutic value for these patients.

“It’s a challenging group to treat because not only can they have many behavioral issues, but they also frequently have many physiologic factors that introduce challenges to initiating and maintaining sleep,” Lee told Medscape News Canada. “That is a group that can benefit from melatonin.”

The implementation of behavioral interventions often has a more sustained effect on sleep promotion over the long term, he added. “They take more effort on the part of parents and families, but they are usually better in the long run.”

Thomas and Lee reported having no relevant financial relationships.