Sleep is the 5th vital sign in mental health. I feel like I made that up but it could’ve been repeated somewhere in the universe, the point is how SLEEP should be that important in the treatment plan, especially with kids. Adults are more tricky because they got too many problems, but it shouldn’t be rocket science in children.
As my father would say, “just close your eyes!” so he was irritating and didn’t care that sleep just isn’t that easy for everyone. If the child sleeps without assistance God bless, but for many others let’s talk about the worst-case scenario, which is 90% of my ped population:
The child is up till 12am, tosses and turns or wakes up around 3am, wants to eat, walks around, and has to be at school in 3 hours. The super diphenhydramine, melatonin, and all the gummies didn’t help. Now it’s your turn to talk, and you explained to the family that there’s no magical formula or at least give them the face and start by discussing some simple habits that they need to consider:
- NO electronic devices at bedtime: I’ll say after dinner, the child needs to work on calming down. The kid may say “it’s for school!” but NO, don’t get tricked, the device(s) should’ve been used before bedtime. Let them read or draw…anything that’s not going to stimulate them to stay awake like screens.
- Check the Fluids: avoid sweets, sugar, honey, milk, tea, or items that people use to help them “sleep” because fluids and sugar can keep a child UP.
- Improve Bathroom Habits: going back to fluids, if the child is bedwetting or constantly up at night using the bathroom, it will affect sleep so consider limiting fluids at night i.e. <1 cup. Information and help about bedwetting.
- Check the Food: the child may have to avoid spicy hot foods, dairy, acidic…things that can cause a GI upset. Even if the child has a healthy stomach, it can still quickly react to sour things so consider bland/simple foods in the evening.
- Create a Peaceful Environment: maybe Brian shouldn’t be sleeping with the dog, cats, birds, and the bees. I have a family that I think just merged with the forest and lakes. Let the bedroom be just for SLEEP, not wildlife.
The parent may not want to hear any of your advice and want medications effective immediately but nope keep reiterating good habits. Let’s finally talk about meds:
Nightmares and Terrors/SleepWalking
I usually ask about nightmares with kids and adults because people will avoid sleep because of them. If it’s related to trauma i.e. PTSD then treat the mood/anxiety and the sleep but if it’s just nightmares, then target the sleep and/or nightmare. Below describes the mood, the sedation to target the nightmares or meds that can tackle both in ABC order (remember 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, BP, (caution NOSEBLEEDS with children).
- Guanfacine: helps with anxiety, agitation, and nightmares, doesn’t cause as much sedation as with clonidine.
- Hydroxyzine: helps with anxiety and nightmares, no issues with blood pressure (BP).
- Melatonin: with all the medications, I still tell parents to use melatonin to continue to build the sleep structure not necessarily for “sleep” alone and it helps with nightmares but dreams can also be more vivid with melatonin.
- Olanzapine: helps with agitation, hallucinations, it’s my go-to if the child is “seeing things” and you can microdose it but caution due to metabolic s/e. If you have to keep increasing the dose, you may need to switch meds to avoid metabolic issues. I usually consider switching if >5-10mg 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 have major RLS s/e, so sometimes I avoid using this with adults. Sedation and nightmare treatment may be dose-related. Also, caution r/t the side-effects of weight.
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/depression isn’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 BP issues so it can be dosed in the day, for example, PTSD 2mg BID and 5mg QHS for hypervigilance. Also, similar med doxazosin is longer acting, helps more with PTSD, less s/e than clonidine or prazosin so it can be titrated higher to 4mg QHS i.e.
- 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.
Side note: 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.
My Kid Still Can’t Sleep
With the above medications, you can combine and/or increase dosages but what direction to start or go in? hint: use genetic testing but here are some extra things to consider:
- To be on the safe side, people generally have no genetic markers against 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/go slow.
- 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.
- If the child still can’t calm down, I’ll consider a mood stabilizer. I’m not targeting sleep but the overall 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 med 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 first because coverage and situations can become so difficult. Some sleep studies take months to get scheduled… so this is assuming things were addressed in the assessment, but in the meantime, you can still target sleep while waiting for the sleep study.
- Lastly, doxepin has been working great for my adults but I don’t put kids on it. Imipramine and clomipramine help with bedwetting, but it’s dosed differently. I also read that it can help with sleepwalking/talking. Again take precautions with unconventional treatment aka just avoid it and collaborate or refer to a sleep specialist, especially if things are getting worse… TCAs can be fatal and I worry if a kid can’t verbalize side-effects that may be causing serious problems or if the family gets confused and start doubling doses…etc. Other mentions; tizanidine, tamsulosin (Flomax), baclofen again additional risks such as being habit-forming or extra s/e but they have been used for sleep and nightmares.
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.
