Hydroxyzine for Pediatric Insomnia
Hydroxyzine is not recommended as a treatment for insomnia in children due to limited evidence supporting its use, and behavioral interventions followed by melatonin should be prioritized instead.
Treatment Algorithm for Pediatric Insomnia
First-Line: Behavioral Interventions (Always Start Here)
- Establish consistent bedtime routines with fixed sleep and wake times, which can reduce initial insomnia with an effect size of 0.67 in children 1
- Implement visual schedules to help children understand bedtime expectations, particularly effective for those who prefer routine and sameness 2
- Use bedtime fading by temporarily moving bedtime later to match natural sleep onset, then gradually shift earlier in 15-30 minute increments 2
- Provide hands-on parent education about sleep hygiene, proper sleep-onset associations, and consistent limit-setting 2
- Maintain sleep diaries to objectively track sleep onset, duration, and night wakings 1
Second-Line: Melatonin (If Behavioral Interventions Fail After 2-4 Weeks)
- Melatonin has the strongest evidence base for treating pediatric insomnia and is the safest pharmacological choice for children with neurodevelopmental disorders 3, 1
- Start with 1 mg administered 30-60 minutes before bedtime in children over 2 years old 1, 4
- Titrate by 1 mg every 2 weeks if ineffective, up to a maximum of 5-6 mg 1
- Melatonin produces an effect size of 1.7 with a mean reduction in sleep onset latency of 60 minutes 1
- Can reduce sleep latency by 16-42 minutes and is generally well-tolerated with mild side effects 1
Why Hydroxyzine Is Not Recommended
- Antihistamine agents such as hydroxyzine are the most widely prescribed sedatives in pediatric practice, but evidence supporting their use is still limited 5
- No medications are approved by the US Food and Drug Administration for pediatric insomnia 3
- The evidence base for antihistamines in treating childhood insomnia remains insufficient compared to melatonin 5, 6
Follow-Up and Monitoring
- Schedule follow-up within 2-4 weeks after initiating any intervention 1, 2
- Expect to see benefits and improvements within 4 weeks 3
- Monitor for treatment-emergent daytime sleepiness, which can impair school performance and requires dose adjustment 1
- Reassess diagnosis and consider alternative approaches if no benefit is seen within 4 weeks 1
When to Refer to Sleep Specialist
- Insomnia not improving with initial interventions 3, 2
- Particularly severe insomnia causing significant daytime impairment or placing the child at risk for harm while awake at night 3
- Suspected underlying primary sleep disorders (sleep apnea, restless legs syndrome, periodic limb movements, parasomnias) 3, 2
- Children taking multiple medications for sleep when initially assessed 3
Critical Pitfalls to Avoid
- Do not start with medication when behavioral interventions have strong evidence and avoid medication side effects 2
- Do not implement behavioral strategies without adequate parent education and support, as success depends on proper implementation 2
- Benzodiazepines are not recommended for chronic insomnia in children due to risk of disinhibition and behavioral side effects 2