How does melatonin affect children with psychiatric (psych) comorbidities?

Melatonin for Children with Psychiatric Comorbidities

For children with delayed sleep-wake phase disorder (DSWPD) and psychiatric comorbidities, strategically timed fast-release melatonin at dosages of 3-5 mg (3 mg if <40 kg; 5 mg if >40 kg) taken at 18:00-19:00 is effective and recommended. 1

Efficacy in Children with Psychiatric Comorbidities

• Melatonin advances circadian phase (DLMO) by nearly 1 hour compared to placebo in children with ADHD 1
• Actigraphically assessed sleep-onset time advances by approximately 37 minutes in children with psychiatric comorbidities 1
• Significant decrease in initial sleep latency (approximately 19 minutes) has been observed in children with ADHD taking melatonin 1
• Melatonin is effective for improving sleep duration, latency, and reducing night wakings in children with autism spectrum disorders 1

Dosing Recommendations

• For children with psychiatric comorbidities, fast-release melatonin at 3-5 mg is recommended 1, 2
• Weight-based approach: 3 mg if <40 kg and 5 mg if >40 kg has shown effectiveness 1, 2
• Timing: Administration at 18:00-19:00 for optimal effect 1
• Treatment duration of 4 weeks is recommended to evaluate effectiveness 1, 3
• Lower doses may be more effective than higher doses due to potential receptor desensitization with higher doses 2

Safety Profile

• No serious adverse reactions have been documented in relation to melatonin use in children with psychiatric comorbidities 1, 2
• Melatonin is well-tolerated in children with ADHD who developed sleep problems after methylphenidate treatment 4
• Long-term safety data in children is limited, but available evidence is reassuring 2
• Potential concerns about effects on reproductive development have not been substantiated in follow-up studies 2

Specific Psychiatric Comorbidities

• In ADHD: Melatonin (mean dosage 1.85 mg/day) is effective for sleep onset delay that develops after methylphenidate treatment 4
• In autism spectrum disorders: Melatonin improves sleep duration, latency, and reduces night wakings 1
• Effectiveness appears consistent regardless of specific psychiatric comorbidity (ADHD, mood disorders, anxiety disorders, or learning disabilities) 4
• Melatonin can be useful as an adjuvant treatment during acute phases of psychiatric disorders when insomnia symptoms are present 5

Important Precautions and Drug Interactions

• Use with caution in patients taking warfarin due to potential interactions 2, 6
• Caution advised in patients with epilepsy based on case reports 2, 6
• Melatonin has been associated with impaired glucose tolerance in some individuals 6
• Monitor for enhanced sedation when using melatonin with other sedating medications 6
• Choose United States Pharmacopeial Convention Verified formulations for more reliable dosing and purity 2, 6

Clinical Algorithm for Use in Children with Psychiatric Comorbidities

1. Confirm diagnosis of DSWPD and psychiatric comorbidity 1
2. Determine appropriate dose based on weight (3 mg if <40 kg; 5 mg if >40 kg) 1, 2
3. Administer fast-release melatonin at 18:00-19:00 1
4. Continue treatment for at least 4 weeks to evaluate effectiveness 1, 3
5. Monitor for improvements in sleep onset time, sleep latency, and total sleep time 1, 2
6. Reassess periodically due to limited long-term safety data 2, 6

Common Pitfalls and How to Avoid Them

• Avoid excessive dosing - higher doses may cause receptor desensitization and be less effective 2
• Morning grogginess and "hangover" effects are more common with higher doses 2, 3
• Melatonin is regulated as a dietary supplement, raising concerns about purity and reliability of stated doses 2, 3
• Do not expect significant improvement in night wakings, as melatonin primarily affects sleep onset 1
• Consider that optimal timing of administration (18:00-19:00) is critical for effectiveness in this population 1