Melatonin for Kids and Babies. The Ultimate Guide.

Last Updated on 3 August 2022 by Dott. Sandro Cantoni

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Another rough night. Your child can’t fall asleep. Or only does so very late. In the morning there is school and work for you. And waking up is not easy. Can melatonin be the solution? In this article, you will find a complete guide on everything you need to know about melatonin.

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In 1958, a group of researchers led by Aaron Lerner isolated melatonin in a small gland in the brain. It has so many effects besides regulating sleep. It works as a hormone and also as an antioxidant. In fact, all living organisms (bacteria, mollusks, fish, plants, animals), produce melatonin.  Since I have often prescribed melatonin in my 30 years as a pediatrician, it is a substance I know very well.  And it is also very important for you to know it better, especially if you plan to use it for your child.

What is melatonin and how is it produced by our body?

At the base of our brain, we have a small structure called the pineal gland. This gland, starting at 3 months of age, produces melatonin, a natural hormone. The melatonin then goes into the bloodstream and returns to the brain where it takes effect. It also reaches all the other organs in the body. 

Other organs produce melatonin, especially the retina and intestines, but in smaller amounts. Melatonin is an important hormone in regulating the daily wake-sleep cycle. In fact, the greatest production of melatonin occurs at night, with the highest concentration from 2 to 4 a.m. 

During the day, exposure of the eyes to light blocks the production of this hormone.  Light stimulates retinal cells. These cells send a signal to certain parts of the brain, which block the production of melatonin. The same thing happens if the eyes are exposed to light from a screen during the evening or night hours. In this case, the brain interrupts the production of melatonin.

What are the other effects of natural melatonin?

Melatonin has an important antioxidant effect, it protects us from free radicals.  Other effects are due to its interaction with many organs, through receptors. These are like keys to getting into cells.  These receptors are present everywhere. In the kidneys, pancreas, liver, bones, skin, genital system, heart, and many others. 

Metabolism and glucose and insulin system.

This hormone intervenes in the metabolism of insulin and glucose. As well as metabolism in general. For example, during the night there is reduced production of melatonin. And this contributes to the reduced secretion of insulin and the release of glucose from the liver reserves, to keep blood sugar at a good level. This is one of the reasons why an excessive dose of melatonin can cause an increase in blood glucose. And thus is contraindicated in diabetic patients.

Blood pressure.

Melatonin is important for the cardiovascular system, particularly blood pressure. This hormone regulates the daily blood pressure cycle and then causes it to drop at night.

Brain.

This hormone is important in many functions of the central nervous system. For example, the connection between various neurons. Has a protective antioxidant, and reparative effect. In fact,  there is a decrease in melatonin production in many diseases of the central nervous system. Such as Parkinson’s, Alzheimer’s, autism, ADHD, depression, and many others.  This hormone is useful in the therapy of sleep disturbances in patients with these diseases.

How do melatonin supplements work?

The aim of the treatment is to increase the concentration of the natural hormone. To promote sleep, or to adjust the moment of falling asleep. A large dose, say 1 to 5 mg, has a sedative, sleep-inducing effect after about half an hour. Several studies have shown some efficacy in reducing the time to fall asleep. Both in healthy children and in children with diseases like autism or hyperactivity. 

Effect on the daily sleep-wake cycle. 

Melatonin is a drug that can synchronize and reset the sleep-wake rhythm. It has an effect called chronobiotic. This is useful, for example, to regulate an altered sleep-wake cycle, as in blind patients.  A small dose, for example, 0.3 – 0.5 mg, can regulate this cycle. Some children have an altered sleep-wake rhythm cycle and fall asleep very late. If they take melatonin 5-6 hours earlier, they can anticipate bedtime. 

When does melatonin start working, and how long does its effect last?

It depends on the type of melatonin and its use. The fast-acting melatonin, at a normal dosage of 1 to 3 mg in children, begins to work after about half an hour. It has its greatest effect one hour after administration. With a lower dose, 0.5 mg, the onset of effect occurs after several hours.

There is also extended-release melatonin, which begins to act after about three hours. It lasts for several hours. This is very rarely used in children, due to the lack of clinical studies. And also because there is only the tablet or capsule formulation.

Does melatonin really work?

In both adults and children, melatonin has been shown to be of some effectiveness in improving sleep problems. In some specific conditions. A systematic review done by the Agency for Healthcare Research and Quality (AHRQ) showed that melatonin can work. In both the sleep disorders of healthy children and in kids who have ADHD or autism. 

Efficacy of melatonin in children with autism and hyperactivity

In most children with autism, the administration of melatonin leads to improved sleep.  Children with hyperactivity often have sleep problems. Especially those who take a stimulant medication, such as methylphenidate (e.g., Ritalin).  In these children with ADHD, and Autism, melatonin shortens the time it takes to fall asleep. It also prolongs the total duration of sleep.

Efficacy of melatonin in children who have difficulty falling asleep (sleep-onset insomnia)

Difficulty falling asleep is a very frequent disorder in children and adolescents. In this condition, there is reduced sleep time and tiredness in the morning. It often causes problems in school and behavior. For this reason, it is important to try to intervene to help children and their families. Good sleep hygiene and other interventions are essential. If these do not work, drug therapy is often used.
A recent study evaluated several published studies on the efficacy and safety of melatonin in this disorder.  The conclusion was that melatonin, used for short periods, appears safe and effective. 

So, what can I do? will melatonin help my child sleep?

If sleep hygiene and all behavioral measures have had no effect, then you can give melatonin a try. Talk to your pediatrician about it.   For a short time, a few weeks.

There are no clear guidelines about dosing in children. The Canadian Pediatric Society recommends 1 mg of melatonin in young children. 2.5 to 3 mg in older children, and 5 mg in adolescents. Melatonin should be taken 30 to 60 minutes before falling asleep. 

Melatonin is beneficial only if the child has difficulty falling asleep. It is not useful if the child falls asleep well and wakes up at night.  This is because its action lasts two or three hours, no more. There are products with delayed action, but they are rarely used in children. Except in cases of major conditions such as autism.

Before using melatonin, contact your pediatrician

There are many causes of insomnia in children. It is critical to make an accurate diagnosis before starting treatment. Also, the pediatrician must guide the therapy, with dosages appropriate for the child’s age and condition.

Melatonin should never be used alone.

Melatonin supplementation should always be accompanied by sleep hygiene and behavioral measures. For example, melatonin is useless in a child or youth who watches television or another electronic device before bedtime. This is because these screens suppress the natural production of melatonin. 

Because melatonin is a natural substance, the parent thinks it has no major side effects. And that it is quite safe. That’s not the case. For most children, melatonin is a safe substance for a few weeks of treatment. But as with other natural hormones, melatonin can have side effects. Especially if used inappropriately and for a long time. For these reasons, it is not advisable to give it without medical supervision.

Melatonin side effects in kids. 

If melatonin is used for a short time, for example, a few weeks, the unwanted effects are few. In this case, it can be said that it is a fairly safe substance.  

Several studies conducted on newborns and children with various conditions indicate that melatonin is a fairly safe medication.

But the long-term effects are not known. If melatonin is taken for a long time.

Unwanted effects are more common if high doses of melatonin are used. For example, 5 mg or more. Or if melatonin is given at the wrong times. 

These melatonin side effects are as follows:

headaches

dizziness, nausea.

tiredness and drowsiness during the day

mood swings

difficulty concentrating at school

decrease in body temperature

agitation, nightmares

nocturnal enuresis

constipation or diarrhea

Very high doses in adults, such as 10 mg, can also give other effects. Such as hypertension, hepatitis.

Other side effects. 

Immunologic effects.

Melatonin affects the immune system. It should be used with caution in children who are taking immunosuppressive drugs. For example corticosteroids. Or who have an immune system disorder. 

Inflammatory effects and asthma. 

Melatonin increases the concentration of substances that cause inflammation. For example, the “interleukins”. And this effect can worsen diseases in which inflammation is important. Such as bronchial asthma. 

Hormonal effects. 

In patients with delayed puberty, melatonin production is increased. Because of this, it is thought to block pubertal development. Then, when melatonin is discontinued, the appearance of precocious puberty is possible. Moreover, melatonin tends to change the level of some puberty hormones. For this reason, it should be used with caution in pre-pubertal children. 

But one study showed that there were no alterations in pubertal development. Melatonin was administered for an average duration of 3 years and at dosages up to 10 mg per day.

Epilepsy. Seizures.

Some researches have indicated that melatonin lowers the epileptic threshold. In children with neurological problems. That is, it is easier to have seizures of the epileptic type. 

Central Nervous System. 

Discontinuation of melatonin, after prolonged administration, can cause a symptom called “dyskinesia.” This is a sort of tics. the person has random, involuntary movements of the arms, legs, face. This suggests a suppression of the production of natural melatonin.  

Precautions to be taken and contraindications.

The use of melatonin is not recommended without medical supervision. It’s best to avoid melatonin in certain conditions. 

Diabetes

Hormonal problems

Epilepsy or seizures

Liver or kidney disease

Cerebral palsy

Depression

Migraine

Hypertension

Therapy with drugs that depress the immune system, such as corticosteroids.

Variability of Melatonin Content in commercial products.

In several nations, melatonin is found for free sale in pharmacies. And in different forms. (rapid dissolve tablets, flavored liquids, capsules, etc…). In the USA melatonin is not controlled by the FDA. So there are no guarantees of its purity. 

Research has shown that often the concentration is not the one on the label. In several products, the concentration ranged from – 80% to + 400% of that indicated. And even for different lots of the same product. 

So you believe you are giving a certain dose, and instead you give a much higher or lower dose. This is one of the biggest problems with over-the-counter melatonin supplements. 

Take home message

For short-term treatment, melatonin is quite safe. But it can still have side effects that should not be underestimated. For this reason, it is always best to use it only when prescribed by your doctor and under his or her supervision.

Some parents of children who are taking melatonin ask me this. Can a child have a melatonin overdose? A poisoning? Can a toddler overdose on melatonin? Yes. Overdose is possible.

What happens if a kid eats too much melatonin?

It can happen that a child takes too much melatonin. Either accidentally or because parents inadvertently give a too-high dose. The Texas Poison Center found about 770 cases of intoxication, over a 5-year period. 

Symptoms of overdose are usually as follows: 

drowsiness or lethargic state

difficulty speaking

confusion, dizziness

stomach ache 

nausea, vomiting 

agitation, irritability

tremors

headaches 

Can a baby die from melatonin? 

The Texas Poison Control Center has not observed any deaths. 

But an article published in 2019 describes a case of possible intoxication and death. After the administration of very high doses of melatonin in a three-month-old baby. An autopsy found no other cause of death. 

What to do when a kid eats too much melatonin? 

Do not give anything to drink or eat. Do not try to make the child vomit.

Call the Poison Control Center right away. Specialists will tell you exactly what to do. 

Summary

Melatonin is not a risk-free supplement. Always keep the product out of the reach of children. Be very careful with the dosage. Contact the poison control center if you suspect an overdose. Or if your child has the symptoms described above.

Pediatricians like me often prescribe melatonin for various sleep problems in children. Official recommendations regarding melatonin use in children and adolescents are not easy to find.  Two of the best are those of the Canadian Paediatric Society, and the European pediatric neurology Group:

Cummings C; Canadian Paediatric Society, Community Paediatrics Committee. Melatonin for the management of sleep disorders in children and adolescents. Paediatr Child Health. 2012;17(6):331-336. Revised in 2018

Bruni O, Alonso-Alconada D, Besag F, et al. Current role of melatonin in pediatric neurology: clinical recommendations. Eur J Paediatr Neurol. 2015;19(2):122-133. )

In this chapter, you can read their recommendations.

When to take melatonin? For which types of sleep problems is it useful?

Your child may have different types of sleep problems. Melatonin is not always helpful.

If the child falls asleep well but has night-time awakenings, melatonin is useless.  

(There is an International Classification of Sleep Disorders.

Transient sleep disorders that last a few weeks are common. For example, after an illness, a trip, or other stressful events. Melatonin is not used in these cases. 

Instead, your child may have a chronic sleep disorder, with sleep problems at least three times a week. That last at least three months. 

The most common chronic sleep disorders in children are these. The chronic insomnia disorder and the delayed sleep-wake phase disorder. Melatonin may be helpful in these two conditions. 

Chronic insomnia disorder

There are several types of chronic insomnia. The most common type in children is behavioral insomnia in childhood. The child has delayed sleep onset, bedtime refusal, and sleep resistance. This disorder is most common from 4 months to 5 years of age. 

Delayed sleep-wake phase disorder

This is a specific disorder of the sleep-wake circadian rhythm. It occurs mostly in older children and adolescents.

The daily sleep cycle is not synchronized with the normal environmental light/dark cycle. 

So the child can’t fall asleep at an acceptable hour. He is really not sleepy. For example, he falls asleep at 11 o’clock or later. In the morning he has to wake up for school. As a result, there is a significant reduction in the amount of time he sleeps at night. The child is sleepy during the day, or hyperactive, with reduced school performance. During the weekend he partially catches up on lost sleep. And he wakes up late. 

Sleep problems in special populations. 

Sleep problems are frequent in children with autism spectrum disorder and ADHD. Melatonin can help improve sleep for these children. And it’s quite safe.   

Sleep Hygiene

Before trying melatonin, it is crucial to establish good sleep hygiene. 

For example: 

The environment where the child sleeps should be quiet, silent. With temperature not too high (20 degrees).

The child should always sleep in the same room.

Establish a clear bedtime routine. For example, relaxing activities at the same time every night before bedtime.

Never use a tablet or other electronic device after dinner.

Do not give too much food or water before bedtime.

You can find more information in another article. 

At what age can babies and kids take melatonin?

Melatonin is fairly safe when used for a short period, a few months. But there is no research to support its use under 2 years of age. 

The European Neurology Group reduces this limit to 6 months of age.  

Their recommendation is this: 

(“No studies reported the minimum age for administering melatonin. Since it has been used in high dosage in infants to prevent neuronal injuries without side effects, we can expect that melatonin administration after 6 months of age could be quite safe”.)

In any case, the pediatrician should always be contacted before administering melatonin in babies. 

How and When to take melatonin

If the child has difficulty falling asleep, give melatonin 30-60 minutes before bedtime. 

In delayed sleep-wake phase disorder, administer melatonin 3-4 hours before the bedtime. For example, if your child usually falls asleep at midnight, you should administer melatonin at 8 or 9 pm.  

Melatonin dosage for kids.

If used to induce sleep, in children who are experiencing difficulty falling asleep, the initial dosage is 1 to 3 mg. Melatonin should be administered 30-60 minutes before bedtime. 

In delayed sleep-wake phase disorder, lower dosages work well. You start with 0.2 to 0.5 mg 3-4 hours before actual bedtime. Each week you can increase the dose by 0.2-0.5 mg until the desired effect. The greatest dose is 3 mg (5 mg in adolescents)

How long is it necessary to continue melatonin?

The duration of therapy should be tailored on the child and the diagnosis. But normally, melatonin is continued for at least one month. 

Children with Delayed sleep-wake phase disorder require prolonged treatment to achieve a normal sleep cycle. Then, a one-week suspension of therapy may be tried.

Can babies take melatonin for sleep problems? Never before six months and only following pediatric advice after six months of age. I see in the clinic several parents who try it if their child, for example, 7-8 months old, has difficulty sleeping. They have not experienced benefits and in some cases, the situation has worsened.  There is no research on the effectiveness and safety of melatonin in children. So talk to your pediatrician before administering it.

Is there melatonin for babies?

No. There are several types of melatonin on the market. In liquid form, tablets, capsules, gummies. But there is no specific product for babies. 

Can you give a baby melatonin? 

You should never give melatonin if your child is less than 6 months old. It is not helpful and can cause side effects. Even if your baby is older than 6 months, it is best to avoid it. Except in some particular situations if other remedies fail. In these cases, melatonin must be prescribed by the pediatrician and under his supervision.

It should never be forgotten that there is no research attesting to its safety under two years of age. Also, it is not known the long-term side effects. Also because melatonin has many other effects. 

As reported by Dr. David J Kennaway in a 2015 article:

“ Melatonin: (i) it is not registered for use in children anywhere in the world (except for children with autism in Europe); (ii) it has not undergone the formal safety testing expected for a new drug, especially long-term safety in children; (iii) it is known to have profound effects on the reproductive systems of rodents, sheep and primates, as well as effects on the cardiovascular, immune and metabolic systems; and (iv) there is the potential for important interactions with drugs sometimes prescribed for children.”

Why melatonin is not good for babies, especially those less than 6 months old.

In the first 3-4 months of life, the sleep cycle is not controlled by melatonin. Thankfully. Because the baby needs to eat during the night. The baby starts producing melatonin around the third or fourth month of life. 

After the sixth month of age, your doctor may prescribe melatonin. It is considered quite safe by the European Neurology Group. But it’s appropriate to give it only in some special conditions, for example, in children with neurological diseases. After a specific diagnosis of the sleep disorder and if all other remedies have not worked.

It should not be forgotten that sleep problems in children from 6 to 12 months of age are mainly behavioral. For example, the child sleeps poorly or is late because he may have developed associations. He falls asleep only in the arms of his parents or wakes up at night to drink milk and others. 

In these situations, behavioral strategies to remove these associations are effective. These techniques are called sleep training. Melatonin works poorly. And it is useless for reducing nighttime awakenings, because of its short duration of action.  

Variability of Melatonin Content in commercial products.

In several nations, melatonin is found for free sale in pharmacies. And in different forms. (rapid dissolve tablets, flavored liquids, capsules, etc…). In the USA melatonin is not controlled by the FDA. So there are no guarantees of its purity. 

Research has shown that often the concentration is not the one on the label. In several products, the concentration ranged from – 80% to + 400% of that indicated. And even for different lots of the same product.  

So you believe you are giving a certain dose, and instead you give a much higher or lower dose. This is one of the biggest problems with over-the-counter melatonin supplements.

What are the side effects of melatonin in babies?

In babies older than 6 months, if melatonin is used for a short time, for example, a few weeks, it is probably a fairly safe substance.  

But the long-term effects are not known. If melatonin is taken for a long time.

Unwanted effects are more common if high doses of melatonin are used. Or if melatonin is given at the wrong times. 

The side effects in babies are the following:

tiredness and drowsiness during the day

mood swings

crying

decrease in body temperature

agitation, 

nocturnal enuresis

constipation or diarrhea

What other sleep remedies you can adopt for your baby?

It is crucial to establish good sleep hygiene. 

For example: 

The environment where the baby sleeps should be quiet, silent. With temperature not too high (20 degrees).

The baby should always sleep in the same room.

Establish a clear bedtime routine. For example, relaxing activities at the same time every night before bedtime.

Do not give too much food or water before bedtime.

Then contact your pediatrician for a diagnosis ad eventually a personalized sleep training program.

Summary. 

Never use melatonin in young children, under 6 months of age. If your baby is older and you plan to use it for his or her sleep problems, talk to your pediatrician first.

Can you give a kid melatonin? Yes, it’s quite safe. But it can have side effects if not used correctly and for a good reason.

You should never forget that there is no research attesting to its safety under two years of age. Also, it is not known the long-term side effects. Also because melatonin has many other effects. 

As reported by Dr. David J Kennaway.

“ Melatonin: (i) it is not registered for use in children anywhere in the world (except for children with autism in Europe); (ii) it has not undergone the formal safety testing expected for a new drug, especially long-term safety in children; (iii) it is known to have profound effects on the reproductive systems of rodents, sheep and primates, as well as effects on the cardiovascular, immune and metabolic systems; and (iv) there is the potential for important interactions with drugs sometimes prescribed for children.”

Can kids take melatonin? 

The European Neurology Group. consider melatonin quite safe after 6 months of life. 

But, especially in toddlers younger than 2 years, you must be careful. Give melatonin only on pediatric advice. With a specific diagnosis of the sleep disorder and if all other remedies have not worked.

It should not be forgotten that sleep problems in toddlers are mainly behavioral. For example, the child sleeps poorly or is late because he may have developed associations. He falls asleep only in the arms of his parents or wakes up at night to drink milk and others. 

In these situations, behavioral strategies to remove these associations are effective. These techniques are called sleep training. You can use melatonin only if these strategies don’t work. Also, melatonin is useless for reducing nighttime awakenings, because of its short duration of action.  

A review study indicates that melatonin is a tolerable drug in the short-term treatment of sleep-onset insomnia in children (older than 6 years).

Variability of Melatonin Content in commercial products.

In several nations, melatonin is found for free sale in pharmacies. And in different forms. (rapid dissolve tablets, flavored liquids, capsules, etc…). In the USA melatonin is not controlled by the FDA. So there are no guarantees of its purity. 

Research has shown that often the concentration of melatonin is not the one written on the label. In several products, the concentration ranged from – 80% to + 400% of that indicated. And even for different lots of the same product.  

So you believe you are giving a certain dose, and instead you give a much higher or lower dose. This is one of the biggest problems with over-the-counter melatonin supplements.

What are the side effects of melatonin in kids?

If melatonin is used for a short time, for example, a few weeks, the unwanted effects are few. In this case, it can be said that it is a fairly safe substance.  

But the long-term effects are not known. If melatonin is taken for a long time.

Unwanted effects are more common if high doses of melatonin are used. For example, 5 mg or more. Or if melatonin is given at the wrong times. 

The most frequent melatonin side effects are:

headaches

dizziness, nausea.

tiredness and drowsiness during the day

mood swings

difficulty concentrating at school

decrease in body temperature

agitation, nightmares

nocturnal enuresis

constipation or diarrhea

What other sleep remedies you can adopt for your kid?

It is crucial to establish good sleep hygiene. 

For example: 

The environment where the kid sleeps should be quiet, silent. With temperature not too high (20 degrees).

The kid should always sleep in the same room.

Establish a clear bedtime routine. For example, relaxing activities at the same time every night evening.

Do not give too much food or water before bedtime.

Avoid screen activities (television, tablet, smartphone, pc) at least one hour before going to sleep.

Then contact your pediatrician for a diagnosis ad eventually a personalized sleep training program.

Summary. 

Melatonin is quite safe for children. But it can have important side effects and is often not useful. It’s always best to see your doctor before giving melatonin to your child.

The two most common chronic sleep disorders in children are the following. Behavioral insomnia and the delayed sleep-wake phase disorder. Is melatonin indicated in these problems?

Your child may have different types of sleep problems. Transient sleep disorders that last a few weeks are common. For example, after an illness, a trip, or other stressful events. Melatonin is not very useful in these situations.

Sleep problems in children from 3 to 18 months of age are mainly behavioral. For example, the child sleeps poorly or is late because he may have developed associations. He falls asleep only in the arms of his parents or wakes up at night to drink milk and others. 

In these situations, behavioral strategies to remove these associations are effective. These techniques are called sleep training. Melatonin works poorly. And it is useless for reducing nighttime awakenings, because of its short duration of action.

Instead, your child may have a chronic sleep disorder, with sleep problems at least three times a week. That last at least three months. Melatonin may be helpful in these two conditions.

The two most common chronic sleep disorders in children are these. Behavioral insomnia and the delayed sleep-wake phase disorder. 

In the first condition, melatonin is often ineffective. It can be tried, with the supervision of the pediatrician, if sleep hygiene measures and sleep training have failed. 

Melatonin can be useful in the second condition. Always in conjunction with optimal sleep hygiene and behavioral techniques.

Behavioral insomnia

There are several types of chronic insomnia. The most common type in babies and kids is behavioral insomnia in childhood. The child has often delayed sleep onset, bedtime refusal, and sleep resistance. This disorder is most common from 3 months to 5 years of age. 

There are also frequent nocturnal awakenings, requiring parental intervention. This sleep disorder, if prolonged, decreases the quality of life for the child and family. It can cause mood and behavioral disorders, health problems, and learning difficulties. 

It is perfectly normal that at certain times the child has trouble falling asleep, insomnia, and night waking. To be defined as a true sleep disorder, the problem must be chronic. In other words, it must be present at least three times a week for a duration of at least three months. In addition, it must significantly disrupt the child’s and/or family’s quality of life. 

Some parents have told me that their baby wakes up briefly around 4 am when their father leaves for work. After a brief cuddle then he goes right back to sleep. The family and the child have no problems or consequences on their quality of life. No therapy is needed in this case.  

There are two types of Behavioral insomnia. Insomnia related to sleep-onset association and insomnia related to limit-setting problems. Often these two situations are in combination.

Young children develop the ability to sleep through the night from 3 to 6 months. So the diagnosis of a particular sleep disorder cannot be made before 6 months.  

Sleep-onset association type 

The child has difficulty falling asleep, often with frequent nighttime wakings. The child has learned to fall asleep and maintain sleep only if there is a certain condition, called association. Which requires the intervention of the parent. For example, the child falls asleep only if he is rocked, or with a parent lying next to him. Or only if he is breast or bottle-fed.

The problem is also present during the night. All children awaken briefly at the end of their 90-minute sleep cycles, then fall asleep on their own. The child who has insomnia related to sleep-onset association is unable to. He needs the parent’s intervention to fall asleep. The mother or father must pick him up and rock him or lay down beside him, or nurse him. When the baby wakes up he signals this need by crying. Or, if the baby is older, going directly to the parents’ room. 

Does melatonin help in this situation?

It is of little help. Because the problem is behavioral. The best thing to do is to try to remove the associations. With sleep training for at least 4-5 weeks. If this does not work, or if the problem is really important, with an irritable child and exhausted parents, you can try melatonin, always with sleep training. Melatonin is useful if the moment of falling asleep is delayed, it is of no use for nocturnal wakings.

If possible, best to avoid it under two years of age. Melatonin must be prescribed by and under the supervision of a physician. 

Usually, the pediatrician prescribes a low starting dose, such as 1 mg. He then adjusts the dose based on response after a few weeks. 

Limit-setting type

This disorder is most common in preschoolers. The child is sleepy, but protests that he or she does not want to go to bed. Or does not want to stay in bed (bedtime refusal). Or tries to delay bedtime as long as possible (bedtime stalling). And for this reason it can adopt different strategies. For example, he wants to play some more. Or he keeps making requests of his parents. Like something to drink. Or a few more pages from a picture book. 

In this way it often happens that the moment of sleep is delayed. Especially if there are intense disputes with parents with screaming and crying. 

One of the causes of this problem is that parents fail to impose constant rules and limits at the bedtime. For example, they allow the child to go to bed when he wants, or to fall asleep in front of the television. 

But you need to be sure there is not a medical problem that is making it difficult to fall asleep. Such as asthma, a chronic cough, adenoid hypertrophy. Itching in case of atopic dermatitis also makes it difficult to fall asleep. 

Excessive time in bed. 

The opposite can also happen. The parent imposes excessive bedtime rules and limits on the child. 

For example, a parent wants his 4-year-old to sleep 13 hours a night, when his personal need is 10 hours. Then the parent demands that the child go to bed at, say, 7 p.m. with an 8 a.m. wake-up time. The child is not sleepy at 7 p.m., so he fidgets in bed. Then he falls asleep but has night wakings. And wakes up in the morning at 6.

Does melatonin work in the limit-setting type and excessive time in bed? 

No. The best way to solve the problem is the behavioral strategy. With a consistent bedtime routine and limit setting. 

Delayed sleep-wake phase disorder

This is a specific disorder of the sleep-wake circadian rhythm. It occurs mostly in older children and adolescents.

The baby does not need help to sleep and does not wake up at night. But the daily sleep-wake cycle is shifted forward. That is, the child is not sleepy at the normal time, but 1 or 2 hours later. In the morning, if there are no activities like school, he wakes up well 1 or 2 hours later. 

The daily sleep cycle is not synchronized with the normal environmental light/dark cycle. 

So the child can’t fall asleep at an acceptable clock time. He is really not sleepy. For example, he falls asleep at 11 o’clock or later. In the morning he has to wake up for school. As a result there is a significant reduction in the amount of time he sleeps at night. The child is sleepy during the day, or hyperactive, with reduced school performance. During the weekend he partially catches up on lost sleep. And he wakes up late. 

Not all the causes of this disorder are well known, although some habits can maintain it. For example, the exposure, before bedtime, to the light of screens (television, tablets, smartphones).

Does melatonin work in delayed sleep-wake phase disorder?

As with other sleep disorders, behavioral modifications must be adopted before medication. One must first adjust habits that may help or worsen the disorder. Example avoid daytime naps. And removing screens a few hours before bedtime. You can also apply strategies to advance the time of falling asleep. 

If these measures don’t work you can try melatonin. 

One of the most important functions of melatonin is to regulate the sleep-wake rhythm.  That’s why several researches show that it works quite well in this disorder. But the diagnosis must be accurate. And melatonin must always be accompanied by behavioral modifications. 

Regarding the dose of melatonin, low doses can be used to regulate the sleep-wake cycle. In my experience and also according to the recommendations of the European Society of Pediatric Neurology, one can start with a dose of 0.5 mg, administered 3-4 hours before the current bedtime. If unsuccessful, the dosage is increased by 0.5 mg each week to a maximum of 3 mg (5 mg in adolescents). Other pediatricians and the Canadian Pediatric Society recommend higher doses, 2.5 to 3 mg, 30 to 60 minutes before the desired bedtime. 

Summary

The two most common chronic sleep disorders in children are the following. The behavioral insomnia and the delayed sleep-wake phase disorder. 

The first thing to do is to adopt good sleep hygiene and behavioral strategy or sleep training. 

If these do not work, melatonin can be tried in older children and always under the supervision of the pediatrician.

How much melatonin for children? It depends on the sleep problem they have. Melatonin doses and the time of administration are different. That’s why it’s always best to consult your pediatrician before starting therapy.

Behavioral interventions are the mainstays of treatment 

Behavioral interventions are the first thing to do if your child has sleep problems. These are proper sleep hygiene, a consistent bedtime routine, and sleep training. The techniques are different depending on the child’s specific sleep disorder.

Melatonin therapy should be used if behavioral strategies fail. And always in combination with these. 

According to European and Canadian recommendations, melatonin should never be administered before six months of age. 

And there is no research to support its use under 2 years of age.

Start with the lowest effective dose and for a short time  

There are no standard doses of melatonin based on weight, such as an antibiotic. 

The dose changes depending on the specific sleep disorder. But in general, it is always best to start with the lowest effective dose. Then, with your doctor, adjust the dose based on the results. 

If possible, it is best to use melatonin for a short time, 4-5 weeks. The side effects of chronic use are not well known. 

When you decide to discontinue melatonin, it is best to do so gradually. Decreasing the dosage.

What time do you have to administer melatonin? 

Depending on the type of sleep problem of the child, the time of administration of melatonin and the dosage changes. That’s why it is not convenient to give it on your own initiative, without a precise diagnosis from the pediatrician. 

Melatonin can be used as a hypnotic or as a regulator of the daily sleep-wake cycle. The dose and the time of administration are different.

Time of administration and melatonin dosage 

The first thing to do is to determine the child’s sleep problem. Whether he has sleep-onset association insomnia, with difficult and prolonged falling asleep and nocturnal awakenings, or a true Delayed sleep-wake phase disorder. In the latter situation, there are no problems sleeping, but the child falls asleep, and wakes up in the morning, much later. 

The daily sleep cycle is not synchronized with the normal environmental light/dark cycle.  

Melatonin dose for kids with sleep-onset association insomnia

In sleep-onset association with insomnia, melatonin is given as a hypnotic. That is, the goal is to help the child fall asleep in a shorter time. Melatonin must be administered 30-60 minutes before bedtime. 

Start with a low dose: 1 mg every day. If you don’t get the desired result, you can gradually augment it. For example, you increase the dose to 0.5 mg every 1-2 weeks. It is best not to exceed 3 mg. 

Melatonin dose for kids with delayed sleep-wake phase disorder.

In this situation, melatonin must regulate the daily sleep-wake cycle. To work it must be administered several hours before the current sleep onset. Usually 4-5 hours earlier. For example, if a child with this diagnosis falls asleep around midnight, melatonin is administered at around 8 pm. 

You can start with 0.2 to 0.5 mg. Each week you can increase the dose by 0.2-0.5 mg until the desired effect. The greatest dose is 3 mg (5 mg in adolescents).

I follow several children with autism in my pediatric clinic. Three-quarters of them have sleep problems. It’s difficult for these children to both start falling asleep and continues sleeping through the night without waking up. And these sleep disorders can make the symptoms of autism worse.

That’s why insomnia is one of the biggest challenges for parents of a child with autism. In addition to behavioral strategies, melatonin treatment can be really helpful. The consequence is that the child has a reduced total sleep time. The child may present with increased levels of aggression, hyperactivity, inattention, and anxiety. With worsening symptoms of autism such as social difficulties and repetitive behaviors.

What are the sleep problems in children with autism?

They are frequently combined. There is difficulty falling asleep, with a long sleep latency time. Basically, the child goes to bed, and the parents start the sleep routine, But he falls asleep late. Many times the child refuses to sleep in his own bed.

In addition, there are often several nocturnal awakenings. In the morning the child may wake up very early. In practice, there is often an irregular sleep pattern. 

There may also be other problems, such as night terrors, movements during sleep, bruxism, sleepwalking, and sleep talking. 

The consequence is that the child has a reduced total sleep time. With irritability and tiredness during the day. 

The child may present with increased levels of aggression, hyperactivity, inattention, and anxiety. With worsening symptoms of autism such as social difficulties and repetitive behaviors.

Parents are also tired, and often exhausted. With all the problems that come along with the overwhelming task of managing a child with autism.

Sleep problems in children with autism are chronic, unlike in children without the condition. Only in a few children does sleep improve with time.

Why do children with autism often have sleep problems?

The causes of sleep disturbances in children with autism are not well known. 

They certainly have altered sleep architecture, if it is measured with a special instrument called polysomnography. They have prolonged sleep latency, and reduced total sleep time. They also have a reduction in R.E.M. sleep stages, which are critical for nighttime rest and for consolidating memory and learning.

Sleep problems are also caused by multiple factors.

There is research indicating that children with autism have reduced melatonin production, due to genetic causes. And so they have an alteration in the daily sleep-wake cycle. 

So the child is often awake when he or she should be sleeping, such as at night. Or to fall asleep at very irregular times.

In addition, there are medications that the child often has to take, due to associated complications. 

Even without having drug treatment, children with autism often have other conditions. Such as hyperactivity, seizures, tics, and others, and all of these can affect sleep.

In several children, there is a high level of anxiety and this increases insomnia at the time of falling asleep. Bedtime is also delayed by repetitive rituals often found in children with autism.

In addition, several children exhibit hypersensitivity to light, noise, and even touch. And it’s difficult for parents to perform some simple tasks, such as having them put on pajamas, or put on a certain type of bedding.

Family stress also contributes to sleep problems. 

Other causes of sleep problems in children with autism.

One must be careful not to underestimate other causes that can be treated.

For example, obstructive sleep apnea, such as with adenoids or other conditions.

Another cause of nocturnal waking is movements during sleep such as leg movements. Your child may have restless leg syndrome, although it is not easy to diagnose. Often in these children, there is a low ferritin level, that is, low iron stores. And therapy with iron supplementation can improve the disorder, and thus help the child sleep better.

Diseases that can cause sleep problems in children with autism.

Your child with autism may have a disease that can interfere with sleep. It is important to try to diagnose it in order to begin appropriate treatment.

The most common are:

Gastroesophageal reflux.

Dermatitis or eczema.

Belly pain and constipation.

Toothache.

Nocturnal cough.

What to do to help the child?

Behavioral strategies are the mainstay of therapy.

Good sleep hygiene is critical for the child and parents.

Behavioral strategies must be tailored to the child’s specific characteristics. Although they are not much different than those that are recommended for children without autism.

Often these behavioral techniques work on their own, without adding a medication.

A consistent, positive sleep routine is important. And then different sleep training techniques depending on the specific sleep problem. 

For children with autism, visual aids can be helpful to help them understand the bedtime routine.

Another helpful measure is to make the bedroom more comfortable for children with autism.

For example, try to limit light sources. Reduce noise. Reduce odors. Remove all distractions, such as electronic devices. 

You can find advice on this page: Strategies to Improve Sleep in Children with Autism.

Melatonin therapy in children with autism.

If behavioral strategies are not working, or in conjunction with them, melatonin may be helpful. Always contact your doctor before starting therapy. 

Melatonin is the drug for which there is the most scientific evidence in children with autism. And many studies show the efficacy and safety of this drug.

In my experience, it is the one that works best. Depending on the type of problem, you can use two types of melatonin. The regular one, which lasts a few hours, or the controlled release melatonin, which lasts a long time.

Rapid Action Melatonin

Fast-acting melatonin is useful in children who have difficulty falling asleep, with a long sleep latency time. It lasts only a few hours, so it is ineffective in solving the problem of nocturnal waking.

Melatonin helps to anticipate bedtime. The child falls asleep earlier.

Most children have good results with a dose of 1 to 3 mg, given 30-60 minutes before bedtime. There is an improvement in sleep latency and total sleep time. Melatonin is well tolerated with reduced side effects. 

Controlled release melatonin

This therapy is effective if your child, in addition to difficulty falling asleep, wakes up at night.

In my personal experience, it works quite well. There is also research showing an increase in sleep time by an average of 55 minutes. With improved quality of life for the child and family. After two years of treatment, no undesirable effects have been found on pubertal growth and development.

You can start with a low dose of 1 or 2 mg, 30-60 minutes before bedtime, to be increased if you do not have acceptable results.

Summary 

Sleep problems are common in children with autism. These cause a worsening of their condition and the quality of life of the whole family. It is important to treat these disorders. Certainly better sleep does not cure autism. But children with autism who sleep better have fewer symptoms and fewer behavioral problems. Along with behavioral measures and sleep hygiene, melatonin can help.

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About the author

Hi. My name is Sandro Cantoni. I’m a Pediatrician. I work in the General Pediatric Clinic. Hospital of Neuchatel, Switzerland.

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