Sleep Medications
Overview
Pearls & Alerts
Many pediatric sleep medications are used “off-label.” They have not been studied extensively in children and are associated with a number of concerning adverse effects and medication interactions.
Strongly consider specialist consultation prior to initiating long-term sleep medications or high-risk/high-side effect medications like antipsychotics. Pediatric sleep specialists include specially trained pulmonologists and psychiatrists. For children with seizures and/or spasticity, a neurologist or physiatrist can also provide expert guidance. For sleep apnea, direct referral to ear, nose, and throat (ENT) services can be considered.
Of the selective serotonin reuptake inhibitors (SSRIs), citalopram and fluvoxamine can cause mild sedation and, therefore, may be considered for treatment of anxiety-related sleep problems.
Children with insomnia and gastrointestinal problems may find treatment with gabapentin or amitriptyline can help both concerns.
Over-the-Counter
-
Short-acting melatonin: instant-release
- Special considerations: Not recommended for treatment for night awakenings. Can cause daytime drowsiness or increase seizure frequency. [Blackmer: 2016] Can give 30-60 minutes before bedtime to aid sleep onset or 3-6 hrs before bed if managing phase-shifting. There is little evidence for dosing higher than 5 mg.
- Formulations: Liquid, tablet, chewable tablet or gummy, capsule, oral disintegrating tablet, sublingual liquid and spray
-
Pediatric dosing:
- 6 mos – 14 years: Typically 2-5 mg, although doses as low as 0.3 mg may be just as effective
- >14 yrs: 5 mg, although doses as low as 0.3 mg may be just as effective
- Alternate dosing: Lower doses (0.3-0.5 mg) have been effective for treatment of jet lag and 0.5 mg doses for sleep/wake disorders associated with blindness.
-
Long-acting melatonin: slow-release, sustained-release,
controlled-release, time-release
- Special considerations: Little pediatric research on its use. Perceived to have slower onset and longer duration of action than short-acting melatonin. Some formulations contain both short- and long-acting components.
- Formulations: Tablets, capsules, oral dissolving tablets, chewable tablets, sublingual spray
- Pediatric dosing: The same as short-acting melatonin, above
- Special considerations: Milk, antacids, H2-receptor blockers, and proton-pump inhibitors can inhibit absorption of iron. Constipation can occur. Poor palatability is a common reason for discontinuation of iron.
- Formulations: Liquid, tablet
-
Pediatric dosing:
- Initial: 1-2 mg/kg/day of elemental iron in divided doses
- Titrate as needed to increase ferritin to at least 50 ng/mL
- Maximum dose: Typically 6 mg of elemental iron/kg/day
- Special considerations: Daytime sleepiness may be a problem. It is likely to lose effectiveness when used chronically. Some children may react paradoxically with irritability and agitation. An overdose results in anticholinergic effects and impaired consciousness.
- Formulations: Liquid, tablet, chewable tablet, capsule, oral strip (melts in mouth)
- Pediatric dosing: 0.5-1 mg/kg up to 25 mg [Bruni: 2018]
- Special considerations: Supplements are not FDA regulated, so quality may vary.
- Formulations: Tablet, capsule, powder
- Pediatric dosing: 2-5 mg [Bruni: 2018]
- Special considerations: Supplements are not FDA regulated, so quality may vary. See Calcium and Vitamin D.
- Formulations: Liquid, tablet, capsules, also included in various chewable and gummy multivitamins
-
Pediatric dosing:
- Initial: 1000-2000 IU/day (25-50 mcg/day) x 6 weeks
- Maintenance: 400-800 IU/day (10-20 mcg/day)
Antihypertensives
- Special considerations: Withdrawal is more likely in children routinely taking high doses (e.g., >0.2 mg) or receiving daytime doses as well. Be aware of the use of both milligrams (mg) and micrograms (ug) below.
- Formulations: Tablet (weekly patch, epidural available for round-the-clock dosing)
-
Pediatric dosing:
- Initial: 0.025-0.05 mg at bedtime (or ~2-3 micrograms/kg/dose for younger children)
- Titrate by 0.025 mg increments (~5-10 micrograms/kg/day) every 1-2 weeks as tolerated
- Maximum dose: By weight: 27-40.5 kg = 0.2 mg/day, 40.5-45 kg = 0.3 mg/day, >45 kg = 0.4 mg/day; however, usual max is 0.2 mg
- Alternative dosing: Weight-based max = 10 micrograms/kg/day [Blackmer: 2016]
- Special considerations: This is not a first-line treatment for insomnia in adults or pediatric patients. Can cause priapism. Monitor for drug-drug interactions. Wean over 1 to 2 weeks to avoid rebound hypertension and other withdrawal symptoms.
- Formulations: Oral capsule
-
Pediatric dosing:
- Initial: 1 mg at night
- Titrate: Increase by 1 mg every 3-5 days up to 2-4 mg
- Maximum dose: 4 mg/night
Anticonvulsants
- Special considerations: Risk of neuropsychiatric adverse reactions in children 3 to 12 years of age. Can cause weight gain, activation, or behavioral problems in children. Be cautious if used with other central nervous system depressants. Do not use with magnesium or aluminum-containing antacids. Do not discontinue suddenly.
- Formulations: Capsules, extended-release tablets, oral solution, compounded solution
-
Pediatric dosing for ages 3 and older: [Bruni: 2018]
- Initial: 3-5 mg/kg before bedtime
- Titrate by 3-5 mg/kg every 3-7 days as tolerated
- Maximum dose: 15 mg/kg
Antidepressants
- Special considerations: Avoid use in children 0-3 yrs old or if there is history of hypotension. Can increase suicidal thinking in pediatric patients.
- Formulations: Tablets
-
Pediatric dosing:
- Initial: 1-2 mg/kg/dose at bedtime
- Titrate by 12.5-25 mg increments every 2 wks as tolerated [Blackmer: 2016]
- Max dose: age 3-5 years = 100 mg, >5 yrs = 200 mg
- Alternate dosing: Start at 12.5 mg (quarter tablet) for smaller children, 25 mg (half tablet) for larger children
- Special considerations: Can increase suicidal thinking in pediatric patients
- Formulations: Tablet, oral disintegrating tablet
- Pediatric dosing: 3.75 – 15 mg
- Special considerations: Cardiac rhythm disturbances can be caused by tricyclic antidepressants, and a baseline EKG may be indicated. Parents should know that an overdose can be life-threatening; keep medication safely out of reach of all children in the household. It can increase suicidal thinking in pediatric patients.
- Formulations: Tablet
- Pediatric dosing: 5-25 mg [Bruni: 2018]
Antihistamines
- Special considerations: Daytime sleepiness may be a problem. It is likely to lose effectiveness when used chronically. Some children may react paradoxically with irritability and agitation. An overdose results in anticholinergic effects and impaired consciousness.
- Formulations: Liquid, tablet, capsule
- Pediatric dosing: 0.5-1 mg/kg [Bruni: 2018]
Atypical Antipsychotics
- Special considerations: Consultation with psychiatry is advised before use.
- Formulations: Tablet, solution, oral dissolving tablet
- Pediatric dosing: 25 - 50 mg
- Special considerations: Consultation with psychiatry is advised before use.
- Formulations: Tablet, solution, oral dissolving tablet
- Pediatric dosing: 0.5 – 2 mg [Bruni: 2018]
- Special considerations: Consultation with psychiatry is advised before use.
- Formulations: Tablet, solution, oral dissolving tablet, intramuscular injection
- Pediatric dosing: 1-5 mg [Bruni: 2018]
Sedatives/Hypnotics
Benzodiazepines Sedatives/Hypnotics
- Special considerations: Typically used for specific seizure disorders or adult panic attacks, it can be useful for off-label treatment of anxiety-related sleep problems in kids (e.g., children with brain disorders who have severe irritability and sleep problems). The half-life is 8-10 hours, so the effect usually lasts all night.
- Formulations: Tablet, oral disintegrating tablet
-
Pediatric dosing:
- Initial: 0.01-0.03 mg/kg/dose (0.1-0.25 mg) at bedtime, max initial dose 0.25 mg.
- Titrate by 0.01-0.03 mg/kg weekly as tolerated. Do not exceed 0.2 mg/kg/dose or 1 mg total.
- Alternate dosing: 0.25 mg at bedtime
Diazepam (Valium): Indicated for treatment of short-term anxiety, acute alcohol withdrawal, skeletal muscle spasms, and as an adjunct in convulsive disorders.
- Special considerations: While more commonly used as a short-term anxiolytic, diazepam can also help when muscle spasms or spasticity impairs sleep onset. Onset is within 30-60 minutes. Avoid use in babies <6 months or those with sleep apnea. Strongly consider consulting with a specialist prior to prescribing sedative/hypnotic medications for pediatric sleep problems.
- Formulations: Tablet, liquid, rectal gel
-
Pediatric dosing:
- Initial: 0.01-0.03 mg/kg/dose (0.1-0.25 mg) at bedtime, max initial dose 0.25 mg
- Titrate by 0.01-0.03 mg/kg weekly as tolerated. Do not exceed 0.2 mg/kg/dose or 1 mg total
- 1-2.5 mg (start at lowest dose) at bedtime
- Pediatric dosing: 1-2.5 mg (start at lowest dose) at bedtime
- Special considerations: A long-acting benzo typically used for prophylaxis of pediatric partial seizures, this medication can also be useful for treating spasticity interfering with sleep. Consult with pediatric physical medicine and rehabilitation physician (Physiatrist). Avoid use in children <9 years.
- Formulations: tablet
Non-Benzodiazepine Sedative-Hypnotics (“Z drugs”)
Resources
Information & Support
For Parents and Patients
Five Things Parents Should Know About Melatonin (Dr. Craig Canapari)
A 5-minute video about things parents should know about melatonin by a Yale sleep physician.
Practice Guidelines
Allen RP, Picchietti DL, Auerbach M, Cho YW, Connor JR, Earley CJ, Garcia-Borreguero D, Kotagal S, Manconi M, Ondo W, Ulfberg
J, Winkelman JW.
Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease
in adults and children: an IRLSSG task force report.
Sleep Med.
2018;41:27-44.
PubMed abstract
Tools
Sleep Medications (UACAP) ( 401 KB)
One-page algorithm for medical management of pediatric insomnia; Utah Academy of Child & Adolescent Psychiatry.
Services for Patients & Families in Utah (UT)
Service Categories | # of providers* in: | UT | NW | Other states (4) (show) | | NM | NV | OH | RI |
---|---|---|---|---|---|---|---|---|---|
Pediatric Pulmonology | 5 | 4 | 4 | 8 | |||||
Sleep Disorders | 4 | 2 |
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Helpful Articles
Bruni O, Angriman M, Calisti F, Comandini A, Esposito G, Cortese S, Ferri R.
Practitioner Review: Treatment of chronic insomnia in children and adolescents with neurodevelopmental disabilities.
J Child Psychol Psychiatry.
2018;59(5):489-508.
PubMed abstract
Blackmer AB, Feinstein JA.
Management of Sleep Disorders in Children With Neurodevelopmental Disorders: A Review.
Pharmacotherapy.
2016;36(1):84-98.
PubMed abstract
Page Bibliography
Allen RP, Picchietti DL, Auerbach M, Cho YW, Connor JR, Earley CJ, Garcia-Borreguero D, Kotagal S, Manconi M, Ondo W, Ulfberg
J, Winkelman JW.
Evidence-based and consensus clinical practice guidelines for the iron treatment of restless legs syndrome/Willis-Ekbom disease
in adults and children: an IRLSSG task force report.
Sleep Med.
2018;41:27-44.
PubMed abstract
Anderson L.
Melatonin.
Drugs.com; (2019)
https://www.drugs.com/melatonin.html. Accessed on 9/11/2019.
Barrett JR, Tracy DK, Giaroli G.
To sleep or not to sleep: a systematic review of the literature of pharmacological treatments of insomnia in children and
adolescents with attention-deficit/hyperactivity disorder.
J Child Adolesc Psychopharmacol.
2013;23(10):640-7.
PubMed abstract / Full Text
Blackmer AB, Feinstein JA.
Management of Sleep Disorders in Children With Neurodevelopmental Disorders: A Review.
Pharmacotherapy.
2016;36(1):84-98.
PubMed abstract
Blumer JL, Findling RL, Shih WJ, Soubrane C, Reed MD.
Controlled clinical trial of zolpidem for the treatment of insomnia associated with attention-deficit/ hyperactivity disorder
in children 6 to 17 years of age.
Pediatrics.
2009;123(5):e770-6.
PubMed abstract
Bruni O, Angriman M, Calisti F, Comandini A, Esposito G, Cortese S, Ferri R.
Practitioner Review: Treatment of chronic insomnia in children and adolescents with neurodevelopmental disabilities.
J Child Psychol Psychiatry.
2018;59(5):489-508.
PubMed abstract
Felt BT, Chervin RD.
Medications for sleep disturbances in children.
Neurol Clin Pract.
2014;4(1):82-87.
PubMed abstract / Full Text
Sangal RB, Blumer JL, Lankford DA, Grinnell TA, Huang H.
Eszopiclone for insomnia associated with attention-deficit/hyperactivity disorder.
Pediatrics.
2014;134(4):e1095-103.
PubMed abstract