Pediatric insomnia

Even if pharmacological therapy is considered for pediatric insomnia, the importance of sleep hygiene education is critical in any discussion and should be considered paramount in treating children with sleep problems. Behavioral approaches to bedtime struggles and night waking in children have been systematically studied and are the foundation of treatment [18, 19]. Detailed descriptions of behavioral approaches for pediatric insomnia are available [1, 18, 19]. 

First, despite the widespread use of medications for pediatric sleep problems in clinical settings for both normal and developmentally delayed children, there are no medications approved by the Food and Drug Administration (FDA) for the treatment of difficulty initiating and/or maintaining sleep in the pediatric population. The sleep specialist should choose a treatment option that is matched to the patient s clinical situation, and is diagnostically driven rather than aimed at simply resolving the symptom. Examples of indications and contra-indications for use of hypnotics in pediatric insomnia are provided in the consensus statement [1],... 

Special considerations for pharmacological treatment of pediatric insomnia in children with children with special needs... 

Despite the lack of an ideal pediatric sedative/hypnotic medication, pharmacological agents are widely used for sleep problems in pediatrics. A summary of pharmacological and clinical properties of medications currently most commonly used in the treatment of pediatric insomnia are discussed below (Tables 1 and 2). Although many different classes of medications have sedating properties, only those used in clinical practice for treatment of insomnia are reviewed. 

Table 1. Pharmacology of selected medications used for pediatric insomnia [56]... 

Zaleplon (Sonata) is a non-benzodiazepine medication that binds to the benzodiazepine receptor. It has a very short half-life, making it useful for sleep onset insomnia. Effects on sleep architecture appear minimal, although it may increase SWS. It has been shown to be safe in recent studies [39], The most common side effect reported in adults is headaches. Use of zaleplon has not been studied in children, except in one study where it was used for sedation purposes. Therefore, its potential role in the clinical treatment of pediatric insomnia is not known. 

Other classes of medications that may be used for pediatric insomnia include mood stabilizers/anticonvulsants (depakote), other classes of antidepressants (mir-tazapine), atypical antipsychotics (risperidone), and chloral hydrate, as well as herbal... 

Owens JA, Babcock D, Blumer J, Chervin R, Ferber R, Goetting M, Glaze D, Ivanenko A, Mindell J, Rappley M, Rosen C, Sheldon S (2005) The use of pharmacotherapy in the treatment of pediatric insomnia in primary care Rational Approaches. A Consensus Meeting Summary. J Clin Sleep Med 1 49-59... 

Owens J, Rosen C, Mindell J (2003) Medication use in the treatment of pediatric insomnia Results of a survey of community-based pediatricians. Pediatrics 111 e628-e635... 

Adverse reactions occurring in at least 3% of pediatric patients include abnormal gait, aggressive reaction, anorexia, ataxia, confusion, constipation, difficulty with concentration/attention, difficulty with memory, dizziness, epistaxis, fatigue, gastroenteritis, hyperkinesia, increased saliva, injury, insomnia, nausea, nervousness, personality disorder (behavior problems), pneumonia, psychomotor slowing, purpura, skin disorder, somnolence, speech disorders/related speech problems, urinary incontinence, viral infection, weight decrease. 

Adverse reactions include nausea, nervousness, headache, insomnia, anxiety. Sexual dysfunction with loss of libido is a common complaint. Insomnia can be a problem. Urticaria and rashes have been described. Venlafaxine may significantly increase the risk of suicide and is therefore not recommended as a first line treatment of depression. The view that also fluoxetine and other SSRIs can lead to suicide is under debate for quite some time now. In most countries SSRIs are not approved for use in pediatric populations. In the UK and in the USA only fluoxetine can be prescribed for children. 

Antihistamines have been used for several decades in the treatment of anxiety in children (Tader, 1988). Prescription data show that antihistamines are widely used in pediatric psychiatric practices (Zito et ah, 2000). Diphenhydramine and hydroxyzine have been reported to modify anxiety symptoms in children with various psychiatric disorders. They are mainly used as a sedative in patients with insomnia. Occasionally they are used for mild acute agitation (AACAP, 1997). 

The following symptoms, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, and mania, have been reported in adult and pediatric patients being treated with antidepressants for major depressive disorder as well as for other indications, both psychiatric and nonpsychiatric. 

Nervous system stimulation is less frequent than nervous system depression, but when it occurs it causes insomnia, irritability, and tremor nightmares, and hallucinations. In overt intoxication, these effects may be related to anticholinergic effects. In an analysis of 113 200 admissions to a pediatric hospital there were only two patients with excitation, insomnia, visual hallucinations, and seizures, followed by coma (71). 

Silver, WI1971. Insomnia, tachycardia and cola drink Pediatrics 47 635. 

Anbar RD, Slothower MP (2006) Hypnosis for treatment of insomnia in school-age children A retrospective chart survey. BMC Pediatr 6 23... 

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