Sleep is often overlooked in mental health but should be considered the “5th vital sign,” especially in children. While adults have more complex problems, prioritizing healthy sleep in children is crucial and manageable with the right approach. Some strategies to improve sleep with kids, in addition to considering over-the-counter options:
- Limit Time on Electronic Devices: No screens after dinner to limit stimulation and get the body prepared for rest. Encourage calming activities like reading, organizing, drawing , etc. Push back on excuses and establish a consistent regimen.
- Monitor Fluids: Avoid sugary or caffeinated drinks before bedtime, as they can disrupt sleep.. Limit nighttime fluids to reduce trips to the bathroom or bedwetting.
- Dietary Considerations: Avoid spicy, sugary, dairy, or acidic foods that may cause gastrointestinal discomfort or produce more mucus. Stick to bland or simple meals in the evenings.
- Create a Sleep-Only Environment: The bedroom should be quiet, dark, room temp or lower, and free of pets or distractions. A cluttered, noisy, or dirty space can interfere with rest and be a fall or fire risk.
The focus should remain on building sustainable habits. Medications can be considered as a last resort after foundational steps have been tried, consistent, and optimized. For the follow-ups, continue to focus on building healthy habits.
Nightmares and Terrors/Sleepwalking
It’s important to address nightmares in children and adults, particular because people would avoid sleep if the dreams are distressing. If nightmares are linked to trauma (e.g., PTSD), treatment should focus on mood/anxiety and sleep. For nightmares unrelated to trauma, the focus is on improving sleep or reducing the nightmares. The medications below describes the mood, the sedation to target the nightmares or meds that can tackle both in ABC order. Sidebar: nothing is FDA approved for kids or nightmares so it’s all off-label.
- Clonidine: helps with anxiety, agitation, and nightmares, caution for significant sedation, low blood pressure risks -but it’s temporary. Also caution for NOSEBLEEDS that cause a discontinuation.
- Guanfacine: helps with anxiety, agitation, and nightmares, doesn’t cause as much sedation as with clonidine.
- Hydroxyzine: helps with anxiety and nightmares, no major issues with blood pressure.
- Melatonin: it may not help with sleep but it can improve the quality of the sleep structure over time, however dreams can also be more vivid.
- Olanzapine: helps with agitation, hallucinations, it’s my go-to if the child is “seeing things” and you can micro dose it but caution due to metabolic s/e. If you have to keep increasing the dose, you may need to switch meds to avoid the metabolic issues. I usually consider switching if 2-5mg is not helping but continue to assess for hallucinations, the patient may need to continue the medication.
- Quetiapine: helps with agitation and nightmares but can cause RLS, weight gain, etc. so sometimes I avoid using this with adults. Sedation and nightmare treatment may be dose-related.
Other Medications
- Mirtazapine: this is a great option if the patient is small, substance abuse, or elderly (it stimulates appetite), sedation may be dose-related. Mirtazapine doesn’t cause bad dreams but I’m not sure if it prevents them so if they’re still occurring, I’ll probably switch the medication if sleep or the nightmares aren’t improving.
- Prazosin: I have many patients that say it doesn’t help but usually the dose has to be gradually higher, starting with 1mg QHS to 6mg/QHS. Prazosin is not the same as clonidine and doesn’t cause as much sedation or blood pressure issues so it can be dosed in the day, for example, PTSD 2mg BID and 5mg QHS for hypervigilance. Also, similar a med, doxazosin, is longer-acting and also helps with PTSD, but less side-effects than clonidine or prazosin so it can be in the day.
- Topiramate: starting at 25mg to 75mg, it shouldn’t cause drowsiness but it can help with nightmares and is a good option if the patient has an elevated BMI.
- Trazodone: I rarely use trazodone with males but with substance disorders and girls -it’s a great option for sleep and nightmares but probably based on the dose.
Sidebar: if the patient already has bizarre, PTSD, vivid dreams do not use varenicline (Chantix). I have patients ask about it, but I treat it like a contraindication and let them know it’s best to avoid it. FDA did have a black box warning for SI and depression but removed it and said ‘take precautions’, not sure why -but it shouldn’t be prescribe to pilots for example -so use precautions, weigh the pros and cons…
My Kid Still Can’t Sleep
With the above medications, you can combine and/or increase dosages but here are some extra things to consider:
- To be on the safe side, people generally have no genetic markers with hydroxyzine, guanfacine, or clonidine (according to the latest genetic research) so you can start with those medications with no major issues but as usual start low and titrate up/increase slowly.
- If I’m concerned about weight or metabolic s/e, I’ll avoid olanzapine and quetiapine. I do have parents and kids that insist on olanzapine, but try to counter it with topiramate, stimulants, increase the dosages of weight-neutral medications i.e. clonidine. I normally don’t put kids or adults on metformin, because I’ll rather switch the medication and it may not be covered by insurance.
- If the child still can’t calm down, I’ll consider a mood stabilizer. I’m not targeting sleep but the overall hyper behaviors, which can help the child finally calm down and get a normal sleep pattern. I have a few kids doing well on lithium and can low dose for another medication to target sleep.
- If the child or adult STILL is struggling to sleep then I would consider a sleep study, this usually isn’t done at first because of the lack of coverage and can be too time-consuming. Some sleep studies take months to get scheduled, if they even treat children… but in the meantime, you can still target sleep while waiting for additional interventions.
- Lastly, doxepin has been working great for my adults but I don’t put kids on it. Imipramine and clomipramine can help with bedwetting, but it’s dosed differently. I also read that doxepin can help with sleepwalking/talking. Again take precautions with unconventional treatment. I simply avoid meds that aren’t usually used with kids or a high-risk, but collaborate or refer to a sleep specialist, especially if things are getting worse… TCAs (doxepin) can be fatal in an overdose and will worry if the family gets confused and start doubling doses, etc. Other mentions; tizanidine, tamsulosin (Flomax), baclofen again additional risks but they have been used for sleep and nightmares, but not approved for children.
Additional Help with Sleep (Adults)
- About Sleep: the basics about sleep, the stages, mechanisms, and parts of the brain involved.
- Sleep Assessments: more ramblings about sleep habits, any breathing issue -get a sleep study before targeting sleep, and DSM.
- OTC Treatment: home remedies, supplements, and items available at any local store that help with sleep.
- Prescribed Sleep Medications: what’s FDA for insomnia, pharmacotherapies from organizations, and meds that affect sleep.
