Insomnia is a common issue in children and adolescents in primary care settings. Given the difficulties associated with poor sleep, parents often ask providers for rapid solutions. As a result, one of the most prescribed medications is the antihistamine hydroxyzine. Yet randomized control data in children is lacking. There is no clinical efficacy, safety, or expert guidance to use this medication, nor is it recommended in peer reviewed journals (sleep organizations, AACAP, AAP). The most common adverse reaction to antihistamines at therapeutic doses is impaired consciousness. With overdose, adverse effects are predominately anticholinergic. Tolerance to antihistaminergic agents can develop quickly and some children can experience dramatic and paradoxical overarousal. Given the lack of data supporting its use and relatively poor tolerability, what is a clinician to do?For sleep disturbance, it is always best to identify and treat the underlying cause of insomnia, optimize lifestyle changes to promote natural sleep, and limit the use of sleep agents to a short increment of time. The Illinois DocAssist website has a free webinar on identifying and treating pediatric sleep issues. Below are guidelines for assessing and treating pediatric insomnia.
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Determine if the sleep problem is chronic, sudden, or occurs intermittently. Visit the screening tools section on the DocAssist website to access links to tools that assist in determining sleep related issues in children and adolescents.
- Ask about other problems associated with the sleep disturbance such as snoring, restless legs, or periodic limb movements.
- Look for medical and medication causes of sleep interference such as enlarged tonsils, asthma, nasal congestion, or use of corticosteroids, stimulants, albuterol, and drug-drug interactions.
- Consider environmental factors interfering with sleep such as a noise, nocturnal use of electronics, overcrowding, daytime napping, and poor sleep hygiene. Screen time has been found to impact sleep, help families institute a media plan to ensure good sleep hygiene.
- Assess for psychosocial stressors that effect well-being such as family chaos, loss of a relationship, academic pressure, and interpersonal conflicts
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- Obtain a substance misuse history. Learn how to ask youth about substance use in this free webinar on pediatric substance misuse featuring DocAssist Medical Director, Diane Misch, MD.
- Many pediatric mental health issues impact sleep, and it is beneficial to identify the specific disorder, determine any comorbidities and provide first line treatment. Screening tools, treatment guidelines and specific topics are available on the Illinois DocAssist website.
- Educate families about the limited usefulness of sleep agents, importance of lifestyle changes such as regular exercise, consistent sleep habits, healthy diet, weight loss, and the need to treat underlying causes of insomnia. The American Academy of Pediatrics Health Children provides childhood sleep guidelines.
- Help families develop realistic expectations and interventions. Recommend use of a sleep diary to track patterns and progress.
- Call Illinois DocAssist for assistance in assessing and planning next steps in caring for your patients with sleep disturbances.
Sources:
Strawn JR, Dobson ET, Giles LL. Primary Care Psychopharmacology: Focus on Medications for ADHD, Depression, and Anxiety. Curr Probl Pediatr Adolesc Health Care. 2017 Jan;47(1):3-14.
Schnoes, Kuhn, Workman, & Ellis. Pediatric prescribing practices for clonidine and other pharmacologic agents for children with sleep disturbance. Clin Pediatr (Phila.) 2006 Apr; 45(3):229-38
Bushnell, Compton, Dusetzina, Gaynes, Brookhart, Walkup, Rynn, Stürmer. Treating pediatric anxiety: Initial use of SSRIs and other antianxiety prescription medications. J Clin Psychiatry. 2018 Jan-Feb; 79(1): 16m11415.
Klein, Woo, Panther, Odom-Maryon, & Daratha. Somnolence-Producing Agents: A 5-Year Study of Prescribing for Medicaid-Insured Children With Attention Deficit Hyperactivity Disorder . J Pediatr Health Care, 2019 May-Jun; 33(3):e1-e8.
Bruni, Angriman, Calisti, Comandini, Esposito, Cortese, & Raffaele Ferri. Practitioner Review: Treatment of chronic insomnia in children and adolescents with neurodevelopmental disabilities. Journal of Child Psychology and Psychiatry 2018 59:5:489–508
