What medications are used for nocturnal awakenings in infants?

Medications for Nocturnal Awakenings in Infants

Behavioral interventions should be the first-line approach for nocturnal awakenings in infants, with medications reserved for specific conditions or when behavioral strategies have failed.

Behavioral Interventions (First-Line)

Behavioral approaches are the foundation of managing infant night wakings and have strong evidence supporting their effectiveness:

• Consistent bedtime routines - Implementing a regular, calming pre-sleep routine 1
• Sleep training methods:
  • Unmodified extinction (letting infant cry until falling asleep)
  • Extinction with parental presence (staying in room but not intervening)
  • Graduated extinction (progressively increasing time between check-ins)
  • Bedtime fading/positive routines 2
• Environmental modifications:
  • Room-sharing without bed-sharing (reduces SIDS risk while facilitating monitoring)
  • Keeping soft objects and loose bedding away from sleep area
  • Never placing infants on couches or armchairs for sleep 1
• Preventive parent education about sleep-onset associations 3

Medication Options for Specific Conditions

For Atopic Dermatitis-Related Awakenings

1. Antihistamines

   • Often used first-line for sleep disturbance in children with eczema
   • Limited efficacy: improve global sleep assessments in only 26% of children with eczema 1
   • Diphenhydramine may decrease sleep latency but recent evidence shows it may not decrease nighttime awakenings 1
   • Tolerance to sedating effects develops despite continued side effects 1

2. Doxepin

   • High H1 receptor antagonist activity with sedative effects
   • May reduce pruritus and decrease sleep latency
   • Initial dose of 10 mg nightly can be titrated as needed 1

3. Melatonin

   • Small but statistically significant effect on sleep onset, duration, and efficiency
   • Dosing: 1 mg in infants, 2.5-3 mg in older children, 30 minutes before bed 1
   • Particularly effective for children with autism spectrum disorders 1

For Circadian Rhythm Disorders

1. Melatonin
   • Effective for improving sleep onset and duration
   • Dosing for sedating effect: 1 mg in infants, taken 30 minutes before bedtime 1
   • Safe and well-tolerated in children 1

Important Considerations and Cautions

• Avoid benzodiazepines in infants - can disrupt sleep architecture, be addictive, and have not shown efficacy in reducing nocturnal scratching 1

• Antihistamine cautions:

  • Primarily work through sedation rather than treating underlying causes
  • Anticholinergic side effects persist even as tolerance to sedation develops
  • Limited evidence supporting their use for infant sleep problems 1

• Melatonin safety:

  • Generally safe in appropriate doses
  • Should be used cautiously in children with asthma (though recent analyses suggest potential benefits) 1

Algorithm for Management

1. Rule out medical causes of night wakings (reflux, milk protein allergy, atopic dermatitis)
2. Implement behavioral interventions (consistent bedtime routine, appropriate sleep environment)
3. For persistent awakenings with specific conditions:
   • Atopic dermatitis: Consider antihistamines (limited efficacy) or melatonin
   • Circadian rhythm disorders: Consider melatonin at appropriate dosing
4. Monitor response and adjust approach as needed

Common Pitfalls to Avoid

• Relying on medications before trying behavioral interventions
• Using adult sleep medications in infants without evidence
• Ignoring the importance of consistent sleep routines and environments
• Bed-sharing, which increases SIDS risk and is associated with more frequent night wakings 1
• Using medications long-term without periodic reassessment

Remember that most infant sleep problems respond well to behavioral interventions, and medications should be reserved for specific conditions or when behavioral approaches have failed.