What are the recommended treatments for pediatric insomnia?

Treatment of Pediatric Insomnia

Behavioral interventions, specifically consistent bedtime routines with visual schedules and bedtime fading, should be the first-line treatment for all children with insomnia, with melatonin (starting at 1 mg, 30-60 minutes before bedtime) reserved as second-line therapy if behavioral approaches fail after 4 weeks. 1, 2, 3

First-Line: Behavioral Interventions

Core Behavioral Strategies

• Establish consistent bedtime routines with fixed sleep and wake times, which reduces initial insomnia with an effect size of 0.67 in children 1
• Implement bedtime fading by temporarily moving bedtime later to match the child's natural sleep onset time, then gradually shift it earlier in 15-30 minute increments until reaching the desired bedtime 1, 3
• Use visual schedules to help children understand bedtime expectations, particularly effective for those who prefer routine and sameness 1, 2
• Provide hands-on parent education about sleep hygiene, proper sleep-onset associations, and consistent limit-setting, as this is crucial for success 1, 3

Monitoring Progress

• Maintain sleep diaries to objectively track sleep onset, duration, and night wakings 1, 3
• Schedule follow-up within 2-4 weeks after initiating behavioral interventions 1, 2, 3
• Expect improvements within 4 weeks of starting treatment 1, 2, 3

Evidence Strength

The American Academy of Pediatrics strongly recommends behavioral interventions as first-line treatment before considering any pharmacological therapy, supported by moderate-to-low level evidence 2, 4, 5

Second-Line: Pharmacological Treatment

Melatonin as Preferred Agent

If behavioral interventions fail after 4 weeks, melatonin is the safest and most evidence-based pharmacological choice 1, 2, 3, 4

• Start with 1 mg of melatonin administered 30-60 minutes before bedtime in children over 2 years old 1
• Melatonin produces an effect size of 1.7 with a mean reduction in sleep onset latency of 60 minutes 1
• Melatonin can reduce sleep latency by 16-42 minutes and is generally well-tolerated with mild side effects 1
• Melatonin has the strongest evidence base for treating pediatric insomnia, particularly in children with neurodevelopmental disorders 1, 2, 4, 6

Medications to Avoid

• Benzodiazepines are not recommended for chronic insomnia in children due to risk of disinhibition and behavioral side effects 1, 4
• Antihistamines (hydroxyzine, diphenhydramine) are widely prescribed but have limited evidence supporting their use 4
• Tricyclic antidepressants are not recommended in children because of their safety profile 4

Special Considerations for Comorbid Conditions

ADHD and Sleep

• Insomnia must be addressed first before starting ADHD medication, as untreated sleep problems worsen ADHD symptoms, impair cognitive function, and exacerbate behavioral issues 2
• Do not start ADHD medication until sleep is stabilized, as stimulant medications can worsen insomnia 2
• Atomoxetine may be preferred over stimulants in complex cases with persistent insomnia 2

Neurodevelopmental Disorders

• Children with autism spectrum disorder, ADHD, or other neurodevelopmental disabilities have higher rates of insomnia (over 80% in some populations) 6
• Melatonin is particularly effective and safe in this population 1, 2, 4, 6
• Visual supports and schedules enhance effectiveness of behavioral interventions in children with neurodevelopmental disabilities 3

When to Refer to Sleep Specialist

Refer to a sleep specialist if: 1, 2, 3

• Insomnia does not improve with initial behavioral and pharmacological interventions after 4 weeks
• Particularly severe insomnia causing significant daytime impairment or placing the child at risk for harm while awake at night
• Suspected underlying primary sleep disorders (sleep apnea, restless legs syndrome)
• Child is taking multiple medications for sleep when initially assessed

Critical Pitfalls to Avoid

• Do not start with medication when behavioral interventions have strong evidence and avoid medication side effects 1
• Do not implement behavioral strategies without adequate parent education and support, as this leads to failure 1
• Do not prescribe benzodiazepines for chronic pediatric insomnia 1, 4
• 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