View this email in your browser

BHIPP Bulletin

Volume 1, Issue 5
March, 2016
Sleep concerns are one of the most frequent consultation questions we receive, whether this is the presenting problem or part of another area of concern. This is the final article of a three-part series discussing the assessment of and treatment of pediatric sleep disorders. This month, BHIPP Consultants Dr. Rheanna Platt and Dr. Joyce Harrison discuss pharmacologic treatments of sleep problems in children.


Assessment and Treatment of Sleep Disorders, Part Three


     If behavioral strategies are ineffective, or if sleep troubles are significantly worsening an existing medical or psychiatric disorder, medication can be considered. Though the medications discussed in this issue have been studied in pediatric populations, most of the data on sleep medications is extrapolated from adult studies. Prior to starting medication, an “exit strategy,” criteria for tapering or discontinuing medication, should be discussed.

     Over the counter medications include melatonin and antihistamines. Melatonin is typically secreted by the pineal gland during darkness. It has both hypnotic (sleep-inducing) and chronobiotic (clock-altering) properties. When used as a chronobiotic i.e. to “advance the clock” of an adolescent who may tend to fall asleep very late, low doses such as 100mcg can be used, 4-5 hours before desired sleep onset. It has minimal effect on sleep architecture. As a hypnotic, typical doses would be 2.5-3mg for school age children and 5mg for adolescents. Studies in 6-12 year old children with idiopathic insomnia have shown that melatonin can decrease in sleep latency by approximately 30 minutes, and advance sleep set by about an hour. Children with ADHD and ASD may have alterations in melatonin and doses of 1-6mg have been studied in these populations. Of note, while melatonin tends to be well-tolerated, side effects can include hypotention, bradycardia, possible lowering of the seizure threshold, and inhibition of GnRH secretion. Melatonin has a short half-life so is most appropriate for difficulties with sleep onset/initiation rather than sleep
maintenance (i.e. middle of the night awakenings).

     Antihistamines such as diphenhydramine and doxylamine have also been studied in children. They have also been shown to decrease sleep latency and marginally increase sleep duration. Potential benefits of this class of medications include their rapid onset of action, low cost, and availability in liquid formulations. Side effects include paradoxical excitation (more common in younger children) and anticholinergic side effects (including dry mouth, constipation, urinary retention, and blurred vision). Tolerance to sedation is common, so these are best used for short-term treatment, particularly in the case of comorbid atopic disease.

     The most commonly used prescription medications for pediatric insomnia are the alpha agonists clonidine and guanfacine. These medications tend to be rapidly absorbed, have quick onset of action and can be particularly appropriate in cases with co-existing ADHD. It should be noted that immediate release clonidine has a short half life and can be associated with middle-of-the-night awakening (conversely, due to its short half life it can also be used in the setting of middle of the night wakening). Dose range for clonidine is 0.05-0.3mg at night. Side effects include hypotension (and rebound hypertension), and dysphoria. Alpha agonists may also alter sleep architecture (increasing slow-wave sleep and decreasing REM sleep). Alpha agonists are best considered in the setting of comorbid ADHD. Benzodiazepines, while commonly used for adults, are not typically recommended in the pediatric population due to increased risk of disinhibition and abuse potential. Also commonly used in adults, Zolpidem has minimal evidence for use in the pediatric population, with a single controlled study failing to demonstrate evidence of improvement in sleep latency or other objective measures of sleep quality.

 
Resources

Howard, Barbara J., and Joyce Wong. "Sleep disorders." Pediatrics in review/American Academy of Pediatrics 22.10 (2001): 327-342.


Pelayo, Rafael, and Michael Dubik. "Pediatric sleep pharmacology." Seminars in pediatric neurology.
Vol. 15. No. 2. WB Saunders, 2008.
Printer Friendly PDF
Meet the BHIPP Team
Dr. Rheanna Platt is a clinical consultant with the BHIPP team and has worked with the program since 2013. She earned a bachelor’s degree in biology from Brown University and worked at a health advocacy organization in Boston before attending medical school at Mayo Medical School.  During medical school, she completed a Master of Public Health degree at Johns Hopkins. She completed pediatric residency at Johns Hopkins, and went on to train in adult psychiatry at Columbia University/New York State Psychiatric Institute and a child psychiatry fellowship at the NYU Child Study Center.  She joined the faculty at Hopkins in 2013 and is based at the Bayview campus, where she works with the Latino Family Clinic and is also working to increase collaboration and communication between pediatrics and child psychiatry.  Her interests include detection of family mental health problems, Latino mental health, and integration of mental health care into pediatrics. In her work with BHIPP, she loves being able to support callers in taking care of the "whole patient."

Resources and Information

Mark your calendars! Children's Mental Health Awareness Week 2016 is May 1-7. 

Join the campaign and become a 2016 Partner! 

Only through partnership with organizations like yours can the campaign reach a diverse audience of families, caregivers, educators, and providers through many different channels.

Visit the campaign's Partners page for more information and ideas to share the importance of children's mental health in your community.
 
In February, the AAP released an updated Mental Health Chapter Action Kit. The Action Kit includes six core action areas that provide strategies to AAP Chapters for improving children's mental health programs and services. 

The core action areas include:
  • Strategies to Partner with Families
  • Strategies to Assess the Service Environment
  • Strategies to Collaborate with Mental Health Professionals
  • Strategies to Education Chapter Members
  • Strategies to Partner with Child-Service Agencies
  • Strategies to Maximize Benefits and Financing
Access more information about the AAP's mental health initiatives and Chapter Action Kit on their website. 
 
Copyright © 2016 Maryland Behavioral Health Integration in Pediatric Primary Care (BHIPP), All rights reserved.


Want to change how you receive these emails?
You can update your preferences or unsubscribe from this list

Email Marketing Powered by Mailchimp