Non-pharmacological and melatonin interventions for pediatric sleep initiation and maintenance problems: A systematic review and network meta-analysis

Melatonin use in managing insomnia in typically developing (TD) children: A technical report

Although melatonin is widely used globally for the management of insomnia in children and adolescents, there are few clinical guidelines available for healthcare practitioners, particularly in typically developing (TD) children. Because existing data are either sparse or inconclusive, a task force comprised of pediatric sleep researchers and clinicians was established by the International Pediatric Sleep Association (IPSA) to first examine the available literature and to develop a set of evidence-based (when possible) and consensus-based recommendations to guide practitioners in decision-making regarding melatonin use in pediatric insomnia. A summary of the evidence pertaining to melatonin's use in pediatric clinical settings, and efficacy and safety in TD children is presented below as a companion to an accompanying list of specific recommendations.

Umbrella Review and Meta-Analysis: The Efficacy of Nonpharmacological Interventions for Sleep Disturbances in Children and Adolescents

OBJECTIVE

We conducted an umbrella review of systematic reviews (SRs), with or without meta-analysis (MA), of randomized controlled trials (RCTs) assessing nonpharmacological sleep interventions for children and adolescents across various clinical populations.

METHOD

We searched multiple electronic databases up to January 24, 2024. Meta-analyzable data from RCTs in the retrieved SRs/MAs were pooled using Metaumbrella. Primary outcomes were subjective/objective child sleep parameters. Additional outcomes included child health/functioning and parental sleep/health. The quality of the MAs/SRs was assessed with Assessment of Multiple Systematic Reviews (AMSTAR-2), and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

RESULTS

We included 93 SRs/MAs covering 393 RCTs, with 25 (17%, 39%, and 30%: high, moderate, and low quality) providing data for quantitative synthesis. Behavioral interventions, usually multicomponent including parent training, psychoeducation, and/or specific sleep therapy/strategies, showed beneficial effects on night waking, sleep duration, overall sleep disturbance, mood/depression, and maternal sleep quality (standardized mean difference [SMD] = 0.10-0.80) in participants with sleep problems without a formal sleep disorder diagnosis. For those with a formal diagnosis (mainly insomnia), benefits were found for night waking, sleep efficiency (subjective/actigraphically measured), and sleep onset latency (mean SMD = 0.49-0.97). Those with attention-deficit/hyperactivity disorder (ADHD) improved in bedtime resistance, night waking, parasomnias, sleep anxiety, ADHD symptoms, sleep disturbance, and quality of life (mean SMD = 0.18-0.49). For those with autism, sleep disturbance improved (mean SMD = 0.70). However, all findings were of low to very low certainty of evidence.

CONCLUSION

Among nonpharmacological interventions for sleep difficulties in youth, only behavioral interventions are supported by meta-analytic evidence, yet with small-to-moderate effect sizes and limited certainty of evidence.

PLAIN LANGUAGE SUMMARY

This "umbrella review" (a review of reviews) analyzed 93 systematic reviews and meta-analyses of randomized controlled trials examining nonmedication sleep interventions for children and adolescents. The authors found that behavioral interventions, including parent training and psychoeducation, had positive effects on sleep issues like night waking, with effect sizes ranging from small to moderate. Improvements were also seen in children with ADHD and autism. However, the quality of the evidence for these benefits was rated as low to very low. This suggests that while behavioral approaches may help, more robust evidence is needed to confirm their benefits.

STUDY PREREGISTRATION INFORMATION

The efficacy and tolerability of nonpharmacological interventions for sleep problems in children and adolescents: protocol for an umbrella review of systematic reviews and meta-analyses of randomised controlled trials. https://osf.io; j9qna/.

Cognitive-Behavioral Therapists' Experience on Relevance of Sleep and Sleep Disorders in Training and Clinical Practice: A Survey Study from Italy

BACKGROUND/OBJECTIVES

Based on previous data reporting the status of health professionals' training about sleep clinical psychophysiology, insomnia, and its treatment in the US and Canada, this paper aims at providing a snapshot of the Italian situation, considering health professionals qualified to offer cognitive behavioral therapy (CBT). Adding information on different countries is important, as national health systems differ significantly, and distinct evidence-based pathways for change may be proposed.

METHODS

Two hundred and thirteen CBT professionals (180 females; 33 males) answered a 5 min survey about their training and experience in recognizing and treating behavioral sleep disorders in their practice. The questionnaire was diffused through the mailing list of the Italian Behavioral and Cognitive Therapy Society (Società Italiana di Terapia Comportamentale e Cognitiva, SITCC) throughout December 2023 and January 2024.

RESULTS

A total of 213 participants completed the survey. Only a minor proportion of respondents (37.1%) reported having received training for diagnosis and treatment of insomnia or other behavioral sleep disorders. Familiarity with psychological therapeutics for sleep was mainly associated with knowledge of sleep hygiene rules, relaxation, and mindfulness techniques, but not with core CBT strategies for insomnia (i.e., sleep restriction and stimulus control) and sleep regulation. The less familiar therapeutics were those for pediatric insomnia.

CONCLUSIONS

The results of this study highlight scarce knowledge and consideration of sleep problems in CBT practice in Italy. As insomnia is prevalent, an independent mental disorder, and a predictor for mental and somatic comorbid conditions, these findings underscore an urgency to enlarge and strengthen CBT professionals' training on sleep psychophysiology, sleep clinical psychology, insomnia, behavioral sleep problems, and their treatment.

Sleep disorders in children: classification, evaluation, and management. A review

Sleep is essential for the cognitive, emotional, and physical development of children. Common sleep problems occur in 20-30% of children and are often resolved by improved sleep hygiene. Sleep disorders are more severe conditions, e.g., insomnia, obstructive sleep apnea, and circadian rhythm disturbances. If left untreated, these can have significant long-term consequences, including impaired cognitive function, increased risk of psychiatric conditions like anxiety and depression, and higher risk of obesity and cardiovascular diseases. To prevent these complications, timely recognition and management is essential. In this paper, we address the medical perspectives of common sleep disturbances in children, focusing on their diagnosis and treatment. Sleep hygiene education, behavioral interventions, and ambient adaptations are first-line interventions for managing all sleep disturbances in children. In cases where behavioral approaches are insufficient, other (non-)pharmacological options are discussed, with a focus on their efficacy and safety in children. Conclusions: Finally, potential long-term consequences and directions for future research are discussed that may improve sleep-related health and well-being.

Sleep interventions in pediatric oncology: A systematic review of the evidence

Sleep concerns are common during pediatric cancer treatment and can last into survivorship. The current systematic review sought to identify intervention studies that addressed sleep as a primary or secondary outcome during pediatric cancer treatment up to 5 years after completing treatment. Quality assessment was rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The review identified 16 studies with a total of 943 participants that tested a wide range of interventions including psycho-educational, stress management techniques, medications, and physical activity. Most studies included tested interventions in small samples. None of the included studies had a high risk of bias for all domains, but all included studies had a high risk of bias for at least two risk domains. Several feasible pilot studies were identified that warrant further research to test efficacy. Implications for future research and clinical practice to manage sleep concerns are discussed.

The management of sleep disturbances in children with attention-deficit/hyperactivity disorder (ADHD): an update of the literature

INTRODUCTION

Sleep disorders represent an important comorbidity in individuals with ADHD. While the links between ADHD and sleep disturbances have been extensively investigated, research on the management of sleep disorders in individuals with ADHD is relatively limited, albeit expanding.

AREAS COVERED

The authors searched PubMed, Medline, PsycInfo, Embase+Embase Classic, Web of Sciences databases, and clinicaltrials.gov up to 4 January 2024, for randomized controlled trials (RCTs) of any intervention for sleep disorders associated with ADHD. They retained 16 RCTs (eight on pharmacological and eight on non-pharmacological interventions), supporting behavioral intervention and melatonin, and nine ongoing RCTs registered on clinicaltrials.gov.

EXPERT OPINION

The pool of RCTs testing interventions for sleep disorders in individuals with ADHD is expanding. However, to inform clinical guidelines, there is a need for additional research in several areas, including 1) RCTs based on a precise phenotyping of sleep disorders; 2) pragmatic RCTs recruiting neurodevelopmental populations representative of those seen in clinical services; 3) trials testing alternative interventions (e.g. suvorexant or light therapy) or ways to deliver them (e.g. online); 4) sequential and longer-term RCTs; 5) studies testing the impact of sleep interventions on outcomes other than sleep; 6) and implementation of advanced evidence synthesis and precision medicine approaches.

Associations of evening-type and insomnia symptoms with depressive symptoms among youths

BACKGROUND

Evening-type and insomnia symptoms are significantly related to each other and independently associated with depressive symptoms, yet few studies have examined the potential interaction between these two conditions. Therefore, we aimed to examine the associations of evening-type and insomnia symptoms with depressive symptoms among Chinese youths, with a specific focus on the joint effects of the two conditions on depressive symptoms.

METHODS

Participants aged between 12 and 25 were invited to participate in an online survey from December 15, 2022, to May 26, 2023. Multivariate logistic regression models and additive interaction models were used to examine the independent and joint effects of chronotypes and insomnia symptoms on depressive symptoms, respectively.

RESULTS

Of the 6145 eligible youths, the prevalence of evening-type and insomnia symptoms were 24.9 % and 29.6 %, respectively. Both evening-type (adjusted OR, [AdjOR]: 3.21, 95 % CI: 2.80-3.67) and insomnia symptoms (AdjOR: 10.53, 95 % CI: 9.14-12.12) were associated with an increased risk of depressive symptoms. In addition, the additive interaction models showed that there is an enhanced risk of depression related to interaction between evening-type and insomnia symptoms (relative excess risk due to interaction, [RERI]: 11.66, 95 % CI: 7.21-16.11).

CONCLUSIONS

The present study provided additional evidence demonstrating the presence of interaction between evening-type and insomnia symptoms, which can lead to a higher risk of depressive symptoms. Our findings argue the need for addressing both sleep and circadian factors in the management of depressive symptoms in young people.

Depression, anxiety, lower sleep quality and social support in square cabin hospitals during Shanghai's COVID-19 lockdown, China

Objectives

To investigate and compare the associated factors of depression, anxiety, and other psychological differences between patients with Corona Virus Disease 2019 quarantined in square cabin hospitals (SCH) and isolation wards (IW) in China.

Methods

Cluster sampling method was performed during Shanghai's Two-Month Lockdown in 2022. Hospital Anxiety and Depression Scale Depression subscale (HADS-D), 7-tiem Generalized Anxiety Disorder Scale (GAD-7), Pittsburgh sleep quality index (PSQI), and Perceived Social Support Scale (PSSS) were used to investigate psychological differences.

Results

The HADS-D and GAD-7 scores of SCH patients were significantly higher than those in IW (p < 0.001; p = 0.0295). Sleep latency (SCH-IW = -3.76, p < 0.001), sleep duration (SCH-IW = -2.22, p < 0.05), habitual sleep efficiency (SCH-IW = -4.11, p < 0.001), sleep disturbance (SCH-IW = -3.59, p < 0.001) and use of sleep medication (SCH-IW = -5.18, p < 0.001) of SCH patients were significantly worse. Depression was the main emotional problem of quarantined patients. Patients in SCH had lower social support. Sleep disorders and the lowest oxygen saturation ≤ 93% were risk factors for depression, while social support and child status were protective factors. Myalgia and constipation were risk factors for anxiety, while marital status was the protective factor.

Conclusion

Patients quarantined in SCH had higher risks of depression and anxiety, lower sleep quality and social support. Somatic discomfort and sleep disorders exacerbated depression and anxiety, which could be ameliorated by social support and taken into consideration in future SCH construction.

Factors contributing to U.S. parents' decisions to administer melatonin to children

OBJECTIVE

Pediatric melatonin use is increasingly prevalent in the U.S. despite limited research on its efficacy and long-term safety. The current study investigated factors contributing to parents' decisions whether to give children melatonin.

METHODS

Parents of children 1.0-13.9 years completed an online questionnaire on children's health, sleep, and melatonin use. Parents who reported giving melatonin to their child were asked open-ended follow-up questions on why their child takes melatonin and why they stopped (if applicable). Responses were assigned to categories through thematic coding.

RESULTS

Data were analyzed on 212 children who either consumed melatonin in the past 30 days (n = 131) or took melatonin previously (n = 81). Among children who recently took melatonin, 51.1 % exhibited bedtime resistance and 46.2 % had trouble falling asleep. Parents most commonly gave children melatonin to: help them fall asleep (49.3 %), wind down before bedtime (22.7 %), facilitate changes in their sleep routine (17.5 %), and/or change their circadian rhythm (11.4 %). Parents stopped giving melatonin because their child did not need it anymore (32.0 %), experienced negative side effects (9.3 %), and/or concerns about health and safety (13.3 %). Finally, parents initiated melatonin use on their own (50.0 %), were encouraged by a friend or family member (27.4 %), and/or followed the recommendation of a health provider (48.1 %).

CONCLUSIONS

Parents administered melatonin to children for a number of reasons and discontinued melatonin based on their own observations of a variety of effects. Parents frequently initiated use without the recommendation of a medical professional. Further research on indications and efficacy of melatonin and wider dissemination of guidelines are needed to help parents make informed decisions regarding children's sleep health.