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Insomnia in children: when are hypnotics indicated?
Mohammed Younus1, Michael J Labellarte
1Division of Child and Adolescent Psychiatry, Johns Hopkins Medical Institutions, Baltimore, Maryland 21287-3325, USA.
Insights
Pediatric insomnia, a common childhood symptom, requires careful assessment. Behavioral therapies and limited medication options offer short-term relief, but long-term solutions need further research.
Area of Science:
- Pediatrics
- Sleep Medicine
- Child Psychiatry
Background:
- Pediatric insomnia presents as a nonspecific symptom with diverse potential causes, including developmental, psychosocial, and medical factors.
- Accurate diagnosis of childhood insomnia necessitates thorough clinical evaluation, potentially involving symptom scales and laboratory tests.
Observation:
- Controlled studies on pediatric insomnia treatments are scarce, with fewer than ten published on psychosocial and/or psychopharmacological interventions.
- Directive parent education and behavior modification techniques show efficacy in the short-term management of insomnia in young children.
- Certain medications like benzodiazepines, antihistamines, and phenothiazines have demonstrated short-term effectiveness but lack FDA approval for pediatric insomnia.
Findings:
- Behavioral interventions are effective for short-term insomnia relief and as adjunctive treatments.
- Short-acting benzodiazepines may be useful for specific short-term pediatric insomnia cases linked to anxiety or mood disorders.
- Long-term benzodiazepine use is cautioned against due to tolerance and misuse risks.
Implications:
- Further research is needed to develop and validate effective long-term treatments for pediatric insomnia.
- Newer hypnotics, combined with psychosocial approaches, may offer future therapeutic options for childhood insomnia.
- Intrinsic pediatric insomnia might benefit from chronotherapy or specific medical management strategies.
Abstract:
Insomnia in children is a nonspecific impairing symptom that may be the result of normal developmental changes, psychosocial duress, a sleep disorder, a psychiatric disorder, other medical disorders, substance misuse, or an adverse effect of medication. Careful clinical assessment of insomnia in children may include the use of symptom rating scales, laboratory testing, or other medical assessment. Short- and long-term treatment of insomnia in children involves management of etiological factors and associated syndromes. Controlled treatment studies of pediatric insomnia are limited to <10 published studies of psychosocial and/or psychopharmacological treatment in young children. Directive parent education and behavior modification techniques have been effective in short-term treatment of insomnia in young children, and may be the preferred treatment of extrinsic insomnia, as well as an important adjunctive treatment of any insomnia symptoms. Two benzodiazepines [flurazepam and delorazepam (chlordesmethyldiazepam)], one antihistamine (niaprazine) and one phenothiazine [alimemazine (trimeprazine)] have been shown to be effective in the short-term treatment of insomnia in young children, although none of these agents have US Food and Drug Administration approval for pediatric insomnia. Short-acting benzodiazepines may have a role in the brief treatment of pediatric insomnia associated with an anxiety or mood disorder, psychosis, aggression, medication- induced activation, or anticipatory anxiety associated with a medical procedure. However, tachyphylaxis and risk of misuse preclude the long-term use of benzodiazepines for the treatment of insomnia in children. Newer hypnotics, which appear better tolerated than the benzodiazepines in studies of adults, may have a role when combined with psychosocial treatments of pediatric insomnia. Treatment of intrinsic pediatric insomnia may additionally involve chronotherapy or medical management.