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Managing behavioural sleep problems and using melatonin
Matt Dwyer: Hi, I’m Matt Dwyer and welcome to sleep where professor Harriet Hiscock and associate professor Emma Sciberras from the Murdoch Children’s Research Institute help you identify sleeping problems in your children from infancy through to secondary school and give you easy to understand steps to improve their sleep cycles and overall health.
Sometimes we just can’t get to sleep. One of the few things that can help us is melatonin, but what actually is melatonin and how does it help us sleep?
Professor Harriet Hiscock: Melatonin is a hormone that’s secreted by a little gland in our brain called the pineal gland and it helps us get off to sleep. It doesn’t help us stay asleep.
That’s a really important thing for parents to know because often they’ll use it and it works to get their child off to sleep at the start of the night but their child may still wake overnight. We know that when it becomes dark, melatonin starts to get switched on in our brain and that can be even in babies, you find melatonin being excreted in the urine and in their saliva.
So it’s there and playing a part in starting our sleep schedules right from the beginning of life. So a lot of children we see, we’ll try the behavioral strategies that we’ve talked about first for insomnia or delayed sleep, but sometimes they just don’t work and you’ve given it a really good go for two or three weeks.
If that’s the case, that’s when we would recommend starting some melatonin for them.
Matt Dwyer: So when we do start them on melatonin, when is the best time to take it?
Professor Harriet Hiscock: It can be used in a couple of different ways. So one is to try and reset that body clock to make you sleepier early. If you’re going to use it that way, you actually try and give it about four or six hours before your desired sleep onset, it’s quite a lot earlier. The most, common one isthat it’s used as a sort of a hypnotic effect to get kids or adults off to sleep. That’s when you give it about an hour before the desired bedtime. So the actual dose, we don’t have really good information and good data on this, but in a primary school aged child, you might use between one to three milligrams an hour before bedtime. In secondary school, for an adolescent child, you might use up to six milligrams for bedtime but going much beyond six milligrams is unlikely to have any additive effect at all.
Matt Dwyer: Another buzz word that is always thrown around with melatonin is serotonin. Can you explain what that is?
Professor Harriet Hiscock: Yes, serotonin is a precursor to melatonin. So melatonin, as I said before, is a hormone that the brain makes. It makes it using something called tryptofan, which is an amino acid that gets converted into serotonin. Then serotonin, in turn, gets converted into melatonin and secreted by the pineal gland in the brain. They’re sort of related, but on a pathway of manufacturer, if you like,
Matt Dwyer: Can you overdose on melatonin?
Professor Harriet Hiscock: No, you can’t. If you take too much melatonin, your body will probably just excrete it, so wee it out. Some of the side effects, again it’s thought to be really very safe, in animal models it has shown to affect puberty but in the longer term, follow-up studies of humans that hasn’t been shown to be the case. Having said that, the long term, follow-up studies really only go out to about 14 months.
So it’s not been studied in the really long term just yet . There are some studies that have said, ‘maybe does it increase seizure activity in children known to have seizures?’ but again, it’s not really clear cut. By and large, it’s really very safe to use. We tend to recommend using it for a period of months rather than weeks.
There’s no point in just using it for a week or so and then stopping it. The child tends to go back to having insomnia and problems sleeping again. It’s something we might use for three months or so and then start to reduce it by reducing the amount you give to your child every night and then starting to give it every second night, every third night, et cetera, but it really is a second line therapy once you’ve tried the other behavioral strategies and made sure you’ve gotten those healthy sleep habits already set up at the start of the night.
Matt Dwyer: Does age affect melatonin levels and how much we should be giving?
Professor Harriet Hiscock: Yeah it does. Most dosing of medication in children is all about body weight; if you weigh less you give less of the medication and it’s the same for melatonin. So certainly in the primary school age, one to three milligrams, adolescents three to six milligrams, but there are higher dosage formulations available for adults, but really there’s not a lot of evidence that you need to take more than that. You might get up to nine milligrams, I’ve seen that in adults.
Matt Dwyer: On getting to sleep easier and staying in that deep sleep, can we oversleep?
Professor Harriet Hiscock: Not normally with melatonin because it just helps you get off to sleep at the start of the night. It doesn’t seem to have any hangover effect in the morning ,so you should hopefully wake refreshed and ready to start your day and your children should as well. It’s also used a lot by people when they’re adjusting to jet lag as well because it has an effect of the start of your sleep onset, but it doesn’t carry on to the morning at all.
Matt Dwyer: What foods are best for sleep?
Professor Harriet Hiscock: Well, there’s not a lot of evidence around this but there’s a lot in the popular media. People will talk about tryptophan and serotonin-containing “feel good” foods, those market buzz words. I think it’s anything from milk, chicken, eggs, salmon, those sorts of things. So there’s lots of buzzwords around that but not a lot of evidence for it. Really, I think the main thing still is avoiding caffeine in your diet or your child’s diet after 3:00 PM if you want help to get off to sleep.
Matt Dwyer: Is it bad to eat just before bed?
Professor Harriet Hiscock: It’s bad in terms of going to bed on a full stomach, which makes you feel uncomfortable. There are recommendations to have a small meal at nighttime and to have breakfast and lunch be the bigger meals of the day.
Matt Dwyer: Should you only really take melatonin after seeing a specialist?
Professor Harriet Hiscock: Yes, because really you should be trying the behavioral strategies first and if they are going to work, they’re going to be a much more enduring solution.
It’s also nice, then, that you don’t have to take something, even though melatonin is a naturally occurring hormone, which we think is safe. It’s always better to go with the behavioral strategies first. One of the issues a lot of parents will ask me about is, “where do I get melatonin?” In Australia, it’s not available over the counter, you have to get it on a prescription. There are two sorts of prescriptions. One is on our ‘PBS’ or, pharmaceutical benefits scheme, and that’s for something called Circadin. That’s a long-acting, slow release form of melatonin, but it’s not licensed for children. It’s really licensed for older adults with insomnia. That’s available on PBS and that’s a two milligram formulation. Mostly for children we end up going through our compounding pharmacists who will make up drops or tablets for children, which might be one milligram, two milligram, or three milligrams. There are a number of online melatonin pharmacies because if you traveled to the US or Europe, you can just buy it over the counter in a pharmacy or even in a supermarket without any script. I do tell my families if they’ve got someone going overseas to stock up because it’s cheaper. Otherwise, if they’re going to go online, to make sure that they are getting the dose that the doctor has prescribed and to avoid any homeopathic, naturopathic formulations where they just say ‘melatonin’, but they don’t actually say how much is in it.
I think that’s important when you go to the health food shops who also can sell melatonin. They often don’t say how much has he in that formulation. Avoid that, and make sure you know exactly how many milligrams you’re getting on your prescription.
Matt Dwyer: As an adult taking melatonin, are there signs when you should start to taper it off?
Professor Harriet Hiscock: Well I think, again, if you’re finally getting to sleep really easily after a few weeks-minimum do it for a few weeks so that your body clock gets into that rhythm-of that earlier bedtime, after a few weeks you might start to taper the dose off as an adult. I’ve certainly had adolescents start to taper it off and stop it and then they just can’t get to sleep so we restart it again. I do have some kids, and I don’t know if it’s a placebo effect or an actual effect, who have come off it and there’ll be the odd night they just can’t sleep. They go to the bathroom, take their melatonin out of the bathroom cabinet, and 20 minutes later they go to sleep.
I don’t know if that’s placebo or not, but the occasional use like that is probably okay as well. Generally you’re on it for a few months before you start weaning off it again. Again, there’s good information on the Sleep Health Foundation. Their tip sheets about melatonin are useful for families as well.
Matt Dwyer: Would you take melatonin for smaller naps?
Professor Harriet Hiscock: No, absolutely not. It’s really about sleep onset for the nighttime and not for smaller nap times for many reasons. We don’t want to take away that drive to go to sleep. So one of the traps that adults and kids with insomnia can get into is thinking they’ll just have a nap during the day but that takes the edge off their drive to go to sleep at night. It’s definitely not recommended.
Matt Dwyer: Are there any harms for longterm usage?
Professor Harriet Hiscock: In longterm, we don’t have a lot of data beyond about 14 months of use of melatonin for children. Generally what’s shown is that seems to be fine for these kids. There were concerns about it interfering with puberty but that doesn’t seem to be borne out in the literature to date.
Generally I think weighing up the pros and cons, it’s better to get a good night’s sleep with melatonin then to go without melatonin and get a poor night’s sleep.
Matt Dwyer: What sort of other medications are there besides melatonin?
Professor Harriet Hiscock: Parents will come and ask about the use of Vallergan or Phenergan, which are common anti-histamines.
Number one, they are not recommended and not to be used in a baby under the age of one year. That’s because of concerns about SIDS or sudden infant death syndrome so we don’t use it. Very occasionally we’ll use it in preschool children where they are particularly oppositional and feisty and the parents have tried a behavioral intervention and the child has just been so upset or angry that they’ve cried for hurs and it just hasn’t worked.
Sometimes in consultation with a doctor, such as myself, I’ll recommend that they use Vallergan or Phenergan for a short period of time, and that means a week. We start off at a relatively high dose and we reduce it over each night and that needs to be done in conjunction with the behavioral strategies.
If you just use the Phenergan or Vallergan, as soon as you stop that, then the child will go back to their bad sleeping habits. It’s just a bandaid effect. If you use the two together you can take the edge off the child protesting at the start of the night, and that can work really nicely, but that’s gotta be done in conjunction with your pediatrician or your GP if they feel confident knowing what to do.
So they’re the most common medicines that I might use. A lot of people still use something called Clonidine, which is actually a blood pressure medication, but has a side effect of making you sleepy. That can be used at nightalthough, again, it does have side effects.
This is one that I would try and leave as a last resort. The main side effects being that it can cause rebound high blood pressure and children have been known to overdose on it as well. It’s gotta be something that is locked away, high up in a cupboard, and obviously only given under medical supervision.
Associate Professor Emma Sciberras: Harriet, with those examples of when you’d use those medications, would you try melatonin first or in what situations would you skip straight to these kinds of medications?
Professor Harriet Hiscock: Yeah that’s a really good question. I think if I had a toddler who was very oppositional and defiant and we were using, for example, the checking method, then I would actually start with Phenergan or Vallergan first, because I know we’ve got just got a short acting period of time, so a week, that we’re going to be doing this.
If the issue is more insomnia and a primary school or secondary school child, then I’d start with melatonin first because. The Vallergan or Phenergan is just to take the edge off the child refusing or resisting the behavioral strategy, whereas melatonin is more for a kid who is trying to get to sleep, they just can’t get to sleep despite the relaxation or mindfulness or bedtime fading. Potentially, they’re just not producing enough melatonin in their brains and that’s what we need to use to help them get to sleep.
Associate Professor Emma Sciberras: I think it’s interesting, I went to the international pediatric sleep conference last year and somebody was presenting on a big study where they went into family homes and made the environment consistent. They blacked out all of the windows from a certain time in the night so that they were controlling the amount of light that the children received. Then, they measured the melatonin onset that was naturally occurring in their brains. The amount of variation that was found in that study, even though the kids were in a really similar environment, was just startling.
For some kids it was starting at around 5:30 in the afternoon and for other kids, the onset wasn’t until 10:30 at night. It was just such a huge variation.
Professor Harriet Hiscock: I think that’s, in some ways, reassuring because I see a lot of kids who are not frightened of anything, not anxious about anything, not worried about anything at school but they just can’t get to sleep. I think these are the kids who are not producing enough melatonin, or they’re producing it at 10:30 at night when they actually need to be asleep at 8:30 PM. That’s when it’s great to be able to give them melatonin to help them get enough sleep.
Matt Dwyer: Can you become addicted to it?
Professor Harriet Hiscock: You can’t become addicted to melatonin but I think, psychologically, some children do become quite reliant on it. So what I’ve done in those cases is slowly wean them off the melatonin after some months and use a herbal preparation called Valerian instead which is readily available. You can speak to the health food store people or your pharmacist about that.
We’ve taken them off melatonin and put them onto this instead, and then slowly wean them off that as well. That’s just anecdotal. There’s no scientific evidence behind that being the right pathway.
Matt Dwyer: You mentioned that melatonin isn’t addictive or it’s not bad for children. What about normal, regular sleeping tablets?
Professor Harriet Hiscock: So the benzodiazepines are a big no, no generally in children and adolescents. So whilst adults might use them short-term, if they’re having issues or they’re adjusting to jet lag, they’re certainly not preferred in kids. They do have the potential to become addictive and that’s a real issue then to get them off those medications.
So melatonin would trump any of the regular sleeping tablets in children and adolescents.
Matt Dwyer: Sleep was presented by Harriet Hiscock and Emma Sciberras and produced by me, Matt Dwyer. Audio production done by Darcy Thompson and our executive producer is Jen Govern. For more apps, go to podcast.one.com or download the podcast one app and listen for free.
If this series resonated with you, you might also be interested in the concussion podcast. It’s hosted by neuro-psychologist and concussion expert at the Murdoch Children’s Research Institute, Vicki Anderson. AIn it, she explains to me what really happens during a concussion, the physical and mental effects concussions can have on children and how to tell if that knock on the head could have caused a concussion. Just search “concussion podcast” to start listening.