NEW YORK -- Medication should almost never be the first line of treatment for children and adolescents with insomnia, Dr. Judith Owens said at a psychopharmacology update that was sponsored by the American Academy of Child and Adolescent Psychiatrists.
Instead, proven behavioral strategies should be used; caffeine alcohol, and nicotine intake controlled; and good sleep hygiene practices such as regular sleep-wake times and limited late-night stimulation should be optimized.
'Combining pharmacologic treatment with behavioral therapy really is the key here,' said Dr. Owens in the pediatrics department at Brown University and director of the Pediatric Sleep Disorders Clinic at the Hasbro Children's Hospital, both in Providence, R.I.
This general principle is supported in a recent consensus statement on the pharmacologic management of pediatric insomnia (Pediatrics 2006;117:e1223-32), developed by the National Sleep Foundation in collaboration with Best Practice Project Management Inc. The expert panel behind the statement unanimously agreed there is a need for pharmacotherapy for insomnia, but also for clinical safety and efficacy trials to fill in 'important knowledge gaps' about current pharmacotherapies such as sedatives and hypnotics.
'We don't have a lot of empirical data, but a lot of us are using these drugs in practice, anyway,' Dr. Owens said.
The first-ever practice parameters for the behavioral treatment of bedtime problems and night wakings in infants and young children, also published last year, indicate that behavioral treatment produces reliable and durable changes in most (80%) children (Sleep 2006;29:1263-76).
Treatment of pediatric insomnia is complicated by the paucity of pediatric data, but also because the definition of pediatric insomnia is complicated, Dr. Owens said. Unlike insomnia in adults, pediatric insomnia is often dependent on parental recognition and definitions; occurs in an evolving developmental context; and can be the result of multiple etiologies, including medical, behavioral, environmental, psychiatric, and psychosocial.
'If you have [children not] failing asleep, it could be that they're drinking a six-pack of Mountain Dew a night; it could be restless legs syndrome; it could be a limit-setting issue, or a sleep-on-set associated-type of behavioral insomnia; and each of those has a distinctly different treatment approach,' Dr. Owens said. 'That's why it's so important to understand what the etiology is.'
Other general pharmacologic management principles highlighted by Dr. Owens include: Select appropriate medications: short-acting medications for sleep onset and longer-acting ones for sleep maintenance.
* Screen adolescents for alcohol, drug use, and pregnancy.
* Screen patients for the use of over-the-counter sleep medications and herbal remedies to avoid combined effects with prescribed medications.
* Review side effects with family.
* Monitor efficacy and side effects frequently.
* Avoid abrupt discontinuation of medications to minimize withdrawal or rebound effects.
Medication use is contraindicated if insomnia occurs in the presence of untreated sleep-disordered breathing; if it is attributable to developmentally based normal sleep behavior or a self-limited condition; if there is a potential for drug interactions; or if there is limited ability to monitor the medication, Dr. Owens said.
BY PATRICE WENDLING
Chicago Bureau
