Pharmacological Guidelines

There is relatively little information available on the pharmacological management of sleep disorders in children. Most pharmacological guidelines were developed for sleep disorders in adults and must be empirically extrapolated to children. The medications are typically neither Food and Drug Administration (FDA)-approved for the specific sleep disorder nor for the pediatric age range. The physician is often forced to prescribe medications as an "off label" indication. This may result in frustrating insurance reimbursement delays or denials for the family (28). These reimbursement problems may affect the availability of a specific medication, the family's adherence with the medication or force the physician to prescribe a less desirable alternative medication (29). The medication may not be available commercially in an easily administered format. Very young children may not be able to swallow pills, and may require the pharmacist to compound the medication into a suspension. In addition, due to the natural aversion among both parents and physicians to use medications for pediatric sleep disorders, medications are usually prescribed as a last resort or in the most refractory situations. Fortunately, this situation may be changing as the FDA is requesting more pediatric data from newly approved drugs and we may expect more pediatric clinical drug trials in the future (30).

At times, a decision to use medication in a child may be made not necessarily to assist the child as much as to help the parents or other family members sleep better. It is not unusual that parents may finally seek help for a child's long-standing sleep problem when the parents feel they can no longer put up with interruptions to their own sleep. Further complicating the pharmacological treatment of sleep disorders in children is the general lack of specialized training in sleep disorders available to the healthcare providers who are working with these children. Failure to consider or properly apply nondrug treatments as part of the comprehensive management of the child may also lead to unsatisfactory results. These factors may result in children that are not properly managed due to either underdosing or overdosing of medication, or incorrect medication selection.

There may be an over-reliance on the effects of the medication by both the parents and healthcare provider without adequate application of behavioral techniques to help improve the child's sleep. A common scenario in clinical practice is parents' complaint of a child's paradoxical reaction to a hypnotic medication. "It made it worse" or "he became hyper" may be the parents' complaint. This may occur because the timing or the dose provided was incorrect. The parents may expect that once a medication has been finally prescribed to help their child sleep that it will "knockout" the child. It is important that the healthcare provider advising this family take into account the circadian modulation of alertness. Humans will typically experience an enhanced alertness in the evening. If a hypnotic is given during this circadian time window, the medication may not work or the child may be frightened by hypnagogic hallucinations. If a medication has been previously shown to shorten sleep latency by only 20 or 30 minutes, giving this medication two or three hours prior to the usual falling asleep time could elicit this common scenario. This same medication given at a more appropriate circadian time could be effective. Children may also be given a medication and then be allowed to play or watch television until the medication "kicks in." This may also result in frightening hypnagogic hallucinatory phenomenon.

This lack of proper management of the sleep problem may be particularly common among children with neurological or psychiatric disabilities (31-34). If the child cannot communicate what they feel is causing the sleep difficulty incorrect assumptions may be made by the family and/or healthcare provider. In cases of insomnia, this can result in an escalating cycle of progressively more sedating agents with increasing likelihood of adverse effects. Concomitant daytime sedation may occur which may interfere with the child's therapeutic program and exacerbate the child's disabilities. In some situations, the fear of putative addiction may limit the physician or the family from using pharmacotherapy adequately to improve the child's sleep.

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Sleeping Solace

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