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Jallouli S, Ghroubi S, Dhia IB, Yahia A, Elleuch MH, Sakka S, Mhiri C, Hammouda O. Effect of melatonin intake on postural balance, functional mobility and fall risk in persons with multiple sclerosis: a pilot study. Int J Neurosci 2024; 134:137-147. [PMID: 35708140 DOI: 10.1080/00207454.2022.2090353] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 06/03/2022] [Indexed: 10/18/2022]
Abstract
AIM To assess the safety and the effect of a nocturnal melatonin (MEL) ingestion on postural balance, functional mobility and fall risk the following morning in adults with multiple sclerosis (MS). METHODS Fourteen adults with relapsing-remitting MS (RR-MS) (28.36 ± 6.81 years) were evaluated before and after nocturnal ingestion of MEL (6 mg) or placebo (PLA). Evaluations included a posturographic test of static bipedal postural balance with dual-task in eyes open (EO) and eyes closed conditions, and a clinical test of unipedal balance. The physical performance tests were: Timed Up and Go test (TUGT) (mobility), Four Square Step Test (FSST) (fall risk), and Timed 25-foot walk test (T25FWT) (walking speed). Cognitive performance [Montreal Cognitive Assessment (MoCA) and Simple Reaction Time (SRT) tests] and sleep quality [Spiegel's sleep questionnaire (SSQ)] were also assessed. RESULTS In EO condition, MEL decreased the posturographic parameters [center of pressure (CoP) sway area (CoPAr), CoP path length (CoPL) and CoPL in the mediolateral axis (CoPLX)] more than PLA by 15.82% (p = 0.0006), 12.48% (p = 0.0004) and 14.25% (p = 0.0002), respectively. Durations of TUGT and FSST decreased following MEL session more than the PLA one by 14.52% (p = 0.017) and 19.85% (p = 0.0006), respectively. MEL increased the unipedal stance time, SSQ and MoCA scores more than PLA by 49.81% (p = 0.04), 32.21% (p = 0.004) and 11.87% (p = 0.008), respectively. CONCLUSION This pilot study showed that acute nocturnal MEL ingestion seems to be safe for enhancing postural balance, fun mobility and fall risk in RR-MS adults probably through improving sleep quality and cognitive function.
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Affiliation(s)
- Sonda Jallouli
- Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of Sfax, Sfax, Tunisia
- High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
| | - Sameh Ghroubi
- Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of Sfax, Sfax, Tunisia
- Department of Physical Medicine and Functional Rehabilitation, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Imen Ben Dhia
- Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of Sfax, Sfax, Tunisia
- High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
| | - Abdelmoneem Yahia
- Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of Sfax, Sfax, Tunisia
- Department of Physical Medicine and Functional Rehabilitation, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Mohamed Habib Elleuch
- Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of Sfax, Sfax, Tunisia
- Department of Physical Medicine and Functional Rehabilitation, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Salma Sakka
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease (LR12SP19), Habib Bourguiba University Hospital, University of Sfax, Sfax, Tunisia
| | - Chokri Mhiri
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease (LR12SP19), Habib Bourguiba University Hospital, University of Sfax, Sfax, Tunisia
| | - Omar Hammouda
- Interdisciplinary Laboratory in Neurosciences, Physiology and Psychology: Physical Activity, Health and Learning (LINP2), Paris Nanterre University, Nanterre, France
- Research Laboratory, Molecular Bases of Human Pathology, LR19ES13, Faculty of Medicine, University of Sfax, Sfax, Tunisia
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Jallouli S, Ghroubi S, Sakka S, Ben Dhia I, Damak M, Yahia A, Driss T, Mhiri C, Elleuch MH, Hammouda O. Effects of a nighttime melatonin ingestion on dynamic postural balance and muscle strength the following morning in people living with multiple sclerosis: A preliminary study. Clin Neurol Neurosurg 2024; 238:108165. [PMID: 38428060 DOI: 10.1016/j.clineuro.2024.108165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 02/02/2024] [Accepted: 02/05/2024] [Indexed: 03/03/2024]
Abstract
BACKGROUND Decreased endogenous melatonin concentrations in people with multiple sclerosis (PwMS) are associated with fatigue and pain that impair postural balance and muscle strength. Melatonin ingestion had analgesic and anti-fatigue effects. However, the acute effect of exogenous melatonin on dynamic postural stability and muscle strength has not been studied yet in PwMS. This study aimed to investigate the safety and the efficacy of a nighttime melatonin intake on dynamic postural balance and lower-extremity muscle strength the following morning in PwMS. METHODS Fourteen PwMS (28.36 ± 6.81 years) were assessed (8 a.m.) pre- and post-acute intake of melatonin or placebo (6mg, 30 minutes before nocturnal bedtime). Evaluated parameters included dynamic postural balance (force platform), lower-extremity muscle strength [Five-Repetition Sit-To-Stand Test (5-STST)], hand dexterity (Nine-Hole Peg Test), nociceptive pain [Visual Analogue Scale (VAS)], neuropathic pain [Neuropathic Pain 4 Questions (DN4)], sleep quality and fatigue perception [Hooper Index (HI)]. RESULTS In the frontal plane, melatonin reduced the center of pressure (CoP) path length (CoPL), CoPL in the anteroposterior axis (CoPLY) and CoP sway area (CoPAr) compared with placebo by 7.56% (p=0.02, Cohens'd (d)=1.24), 19.27% (p<0.001, d=2.60) and 13.82% (p<0.001, d=2.02), respectively. Melatonin induced a higher decrease in these posturographic parameters compared with placebo in the sagittal plane [CoPL: 9.10% (p=0.005, d=1.02), CoPLY: 4.29% (p=0.025, d=1.07) and CoPAr: 7.45% (p=0.038, d=0.74)]. Melatonin decreased 5-STST duration as well as VAS, DN4, HI-fatigue and HI-sleep scores compared with placebo by 8.19% (p=0.008, d=1.19), 5.74% (p=0.04, d=0.82), 27.30% (p=0.023, d=0.98), 40.15% (p=0.044, d=0.85) and 30.16% (p=0.012, d=1.10), respectively. CONCLUSION This preliminary study, among PwMS, showed that acute melatonin ingestion was safe and efficient for improving dynamic postural stability and lower-extremity muscle strength probably through its analgesic and anti-fatigue effects.
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Affiliation(s)
- Sonda Jallouli
- Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of Sfax, Tunisia; High Institute of Sport and Physical Education of Sfax, University of Sfax, Tunisia.
| | - Sameh Ghroubi
- Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of Sfax, Tunisia
| | - Salma Sakka
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease, LR12SP19, Habib Bourguiba University Hospital, University of Sfax, Tunisia
| | - Imen Ben Dhia
- Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of Sfax, Tunisia; High Institute of Sport and Physical Education of Sfax, University of Sfax, Tunisia
| | - Mariem Damak
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease, LR12SP19, Habib Bourguiba University Hospital, University of Sfax, Tunisia
| | - Abdelmoneem Yahia
- Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of Sfax, Tunisia
| | - Tarak Driss
- LINP2, UFR STAPS, University of Paris Nanterre, Nanterre, France
| | - Chokri Mhiri
- Laboratory of Neurogenetics, Parkinson's Disease and Cerebrovascular Disease, LR12SP19, Habib Bourguiba University Hospital, University of Sfax, Tunisia
| | - Mohamed Habib Elleuch
- Research laboratory: Evaluation and Management of Musculoskeletal System Pathologies, LR20ES09, Faculty of Medicine, University of Sfax, Tunisia
| | - Omar Hammouda
- LINP2, UFR STAPS, University of Paris Nanterre, Nanterre, France; Research Laboratory, Molecular bases of Human Pathology, LR19ES13, Faculty of Medicine of Sfax, University of Sfax, Tunisia
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Nguyen J, Zhang B, Hanson E, Mylonas D, Maski K. Neurobehavioral Associations with NREM and REM Sleep Architecture in Children with Autism Spectrum Disorder. CHILDREN 2022; 9:children9091322. [PMID: 36138632 PMCID: PMC9497778 DOI: 10.3390/children9091322] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 08/18/2022] [Accepted: 08/21/2022] [Indexed: 11/16/2022]
Abstract
Objective: Insomnia and daytime behavioral problems are common issues in pediatric autism spectrum disorder (ASD), yet specific underlying relationships with NonRapid Eye Movement sleep (NREM) and Rapid Eye Movement (REM) sleep architecture are understudied. We hypothesize that REM sleep alterations (REM%, REM EEG power) are associated with more internalizing behaviors and NREM sleep deficits (N3%; slow wave activity (SWA) 0.5–3 Hz EEG power) are associated with increased externalizing behaviors in children with ASD vs. typical developing controls (TD). Methods: In an age- and gender-matched pediatric cohort of n = 23 ASD and n = 20 TD participants, we collected macro/micro sleep architecture with overnight home polysomnogram and daytime behavior scores with Child Behavior Checklist (CBCL) scores. Results: Controlling for non-verbal IQ and medication use, ASD and TD children have similar REM and NREM sleep architecture. Only ASD children show positive relationships between REM%, REM theta power and REM beta power with internalizing scores. Only TD participants showed an inverse relationship between NREM SWA and externalizing scores. Conclusion: REM sleep measures reflect concerning internalizing behaviours in ASD and could serve as a biomarker for mood disorders in this population. While improving deep sleep may help externalizing behaviours in TD, we do not find evidence of this relationship in ASD.
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Affiliation(s)
- Jennifer Nguyen
- Department of Neurology, Division of Child Neurology, University of Rochester Medical Center, Rochester, NY 14642, USA
- Department of Pediatrics, Division of Developmental and Behavioral Pediatrics, University of Rochester Medical Center, Rochester, NY 14642, USA
| | - Bo Zhang
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Biostatistics and Research Design Center, Institutional Centers for Clinical and Translational Research, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Ellen Hanson
- Department of Medicine, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Dimitrios Mylonas
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02115, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Charlestown, MA 02129, USA
| | - Kiran Maski
- Department of Neurology, Boston Children’s Hospital, Harvard Medical School, Boston, MA 02115, USA
- Correspondence: ; Tel.: +1-857-218-5536; Fax: +1-781-216-2518
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Inthikoot N, Chonchaiya W. Sleep problems in children with autism spectrum disorder and typical development. Pediatr Int 2021; 63:649-657. [PMID: 33012067 DOI: 10.1111/ped.14496] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 08/16/2020] [Accepted: 09/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although higher sleep problems have been mostly reported in children with autism spectrum disorder (ASD) compared with typically developing (TD) children, particularly in Western countries, such evidence is relatively scarce in developing countries. We therefore investigated sleep difficulties in Thai children aged 3-16 years with ASD compared with age- and gender-matched TD children by using the Children's Sleep Habits Questionnaire (CSHQ)-Thai version. METHODS Sixty-five children with ASD (mean age 97.7, SD 44.5 months; boys 70.8%) and 65 TD individuals (mean age 98.5, SD 43.5 months) were enrolled at a university-based hospital in Bangkok. Background characteristics, sleep duration variables, and the CSHQ were completed by the participants' parents. The CSHQ subscales and total score between children with ASD and TD controls were then compared. RESULTS Children with ASD were more likely to have longer sleep latency than TD individuals for both weekdays and the weekend. Those with ASD had higher CSHQ subscales including bedtime resistance, sleep onset delay, sleep anxiety, and night waking in addition to the CSHQ total scores than TD controls. In the ASD group, those who took psychostimulants for treatment of ADHD had lower scores on the sleep duration subscale compared with unmedicated individuals. CONCLUSIONS Sleep difficulties were more prevalent in children with ASD compared with TD individuals. Parents should be advised to be aware of sleep problems in individuals with ASD. As such, sleep disturbances will be identified early, resulting in appropriate management and improved quality of life, not only for those with ASD but also their families.
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Affiliation(s)
- Nipaporn Inthikoot
- Division of Growth and Development, Department of Pediatrics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Maximizing Thai Children's Developmental Potential Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Weerasak Chonchaiya
- Division of Growth and Development, Department of Pediatrics, King Chulalongkorn Memorial Hospital, The Thai Red Cross Society, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Maximizing Thai Children's Developmental Potential Research Unit, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
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Cheng G, Ma T, Deng Z, Gutiérrez-Gamboa G, Ge Q, Xu P, Zhang Q, Zhang J, Meng J, Reiter RJ, Fang Y, Sun X. Plant-derived melatonin from food: a gift of nature. Food Funct 2021; 12:2829-2849. [PMID: 33877242 DOI: 10.1039/d0fo03213a] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
In recent years, people have become increasingly interested in bioactive ingredients from plants, especially antioxidant molecules such as melatonin, which are beneficial to human health. The purpose of this article is to provide new information on plant-derived foods with a high content of melatonin. We comprehensively summarize the content of melatonin in plant-derived foods and discuss the factors that influence melatonin levels to provide new ideas on enhancement. Additionally, we describe the biosynthetic pathway of melatonin and identify its major functions. Medicinal herbs are often rich in melatonin while many vegetables and fruits exhibit somewhat lower levels with wide variations among species. The genetic traits of plants, the phenological stage of the cultivar, the photoperiod, the level of stress to which the plants are exposed at the time of harvest, exposure to agrochemicals and determination methods are the main factors affecting the melatonin content. To date, standardization of uniform sampling times and the use of suitable pretreatments as well as determination methods have not been achieved. The results of the studies reviewed highlight the potentially important role of plant melatonin in influencing the progression of human diseases. Based on the health promotional aspects of melatonin, consuming foods containing higher concentrations of tryptophan and melatonin is suggested.
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Affiliation(s)
- Guo Cheng
- College of Enology, College of Food Science and Engineering, Northwest A&F University, Yangling, 712100, China.
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Abramova R, Campbell P, Baron J, Patel K, Parmar S. Review of Melatonin Supplementation for Sleep Disorders in Pediatric Special Populations. J Pharm Pract 2019; 33:533-539. [PMID: 31106650 DOI: 10.1177/0897190019845982] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To determine which pediatric populations, if any, benefit from exogenous melatonin supplementation. METHODS PubMed was utilized for the purposes of this systematic review. The studies selected evaluated melatonin use in pediatric special populations and included randomized controlled trials, crossover studies, and meta-analyses. Each study's objectives, measures of outcomes, and dosing strategies of melatonin were reviewed along with the results and author's conclusions. RESULTS Our analysis of the available data offers mixed results and recommendations with regard to the decision of whether to add supplementation of melatonin. CONCLUSION With further regulation of melatonin supplements, it may be plausible to hold larger, multicenter trials and come to a firm recommendation in the future. At this time, we believe that the benefit of exogenous melatonin supplementation outweighs the risks of adverse events and therefore would recommend its use in aiding patients in improving their sleep. Exogenous supplementation with melatonin should be used at the physician's and patient's discretion.
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Affiliation(s)
- Rachel Abramova
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Peter Campbell
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Jessica Baron
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Khilna Patel
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Sapna Parmar
- Northwell Health/Steven & Alexandra Cohen Children's Medical Center, New York, NY, USA
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Esposito S, Laino D, D'Alonzo R, Mencarelli A, Di Genova L, Fattorusso A, Argentiero A, Mencaroni E. Pediatric sleep disturbances and treatment with melatonin. J Transl Med 2019; 17:77. [PMID: 30871585 PMCID: PMC6419450 DOI: 10.1186/s12967-019-1835-1] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Accepted: 03/06/2019] [Indexed: 01/08/2023] Open
Abstract
Background There are no guidelines concerning the best approach to improving sleep, but it has been shown that it can benefit the affected children and their entire families. The aim of this review is to analyse the efficacy and safety of melatonin in treating pediatric insomnia and sleep disturbances. Main body Sleep disturbances are highly prevalent in children and, without appropriate treatment, can become chronic and last for many years; however, distinguishing sleep disturbances from normal age-related changes can be a challenge for physicians and may delay treatment. Some published studies have shown that melatonin can be safe and effective not only in the case of primary sleep disorders, but also for sleep disorders associated with various neurological conditions. However, there is still uncertainty concerning dosing regimens and a lack of other data. The dose of melatonin should therefore be individualised on the basis of multiple factors, including the severity and type of sleep problem and the associated neurological pathology. Conclusions Melatonin can be safe and effective in treating both primary sleep disorders and the sleep disorders associated with various neurological conditions. However, there is a need for further studies aimed at identifying the sleep disordered infants and children who will benefit most from melatonin treatment, and determining appropriate doses based on the severity and type of disorder.
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Affiliation(s)
- Susanna Esposito
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy.
| | - Daniela Laino
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Renato D'Alonzo
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Annalisa Mencarelli
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Lorenza Di Genova
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Antonella Fattorusso
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
| | - Alberto Argentiero
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Elisabetta Mencaroni
- Pediatric Clinic, Department of Surgical and Biomedical Sciences, Università degli Studi di Perugia, Piazza Menghini 1, 06129, Perugia, Italy
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Boafo A, Greenham S, Alenezi S, Robillard R, Pajer K, Tavakoli P, De Koninck J. Could long-term administration of melatonin to prepubertal children affect timing of puberty? A clinician's perspective. Nat Sci Sleep 2019; 11:1-10. [PMID: 30774488 PMCID: PMC6362935 DOI: 10.2147/nss.s181365] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Exogenous melatonin can be used to treat sleep disturbance in adults, children, and adolescents. While its short-term use is considered safe, there are some concerns that long-term use might delay children's sexual maturation, possibly by disrupting the decline in nocturnal melatonin levels that occur at the onset of puberty. This narrative review aimed to summarize some of the current knowledge about the potential effects of exogenous melatonin on puberty. We found no clinical studies that experimentally tested the effects of melatonin on pubertal timing in children, but we reviewed the small number of observational studies. We also drew on animal data to try to answer our question. The photoperiod and melatonin-mediated seasonal transitions in sexual activity and breeding in some mammals across the seasons have been used as a model of sexual development in mammals, including humans. The switch from non-sexual activity (in the non-breeding period) to sexual activity (in the breeding period) has been likened to the onset of puberty as there are similarities between the two. We conclude that to investigate an association between melatonin and pubertal timing, it will be important to conduct long-term randomized controlled trials of latency age children and also examine the cellular and systems-level interactions between melatonin and kisspeptin, a recently identified neuropeptide with a locus of action at the gonadotropin releasing hormone neurons that is important in contributing to the timing of puberty onset.
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Affiliation(s)
- Addo Boafo
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada, .,Department of Psychiatry, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada,
| | - Stephanie Greenham
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada, .,School of Psychology, University of Ottawa, Ottawa, ON, Canada
| | - Shuliweeh Alenezi
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada, .,Department of Psychiatry, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada,
| | - Rébecca Robillard
- School of Psychology, University of Ottawa, Ottawa, ON, Canada.,Sleep Research Unit, Royal's Institute of Mental Health Research, Ottawa, ON, Canada
| | - Kathleen Pajer
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada, .,Department of Psychiatry, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada,
| | - Paniz Tavakoli
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada,
| | - Joseph De Koninck
- School of Psychology, University of Ottawa, Ottawa, ON, Canada.,Sleep Research Unit, Royal's Institute of Mental Health Research, Ottawa, ON, Canada
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Pharmacological Approach to Sleep Disturbances in Autism Spectrum Disorders with Psychiatric Comorbidities: A Literature Review. Med Sci (Basel) 2018; 6:medsci6040095. [PMID: 30366448 PMCID: PMC6313590 DOI: 10.3390/medsci6040095] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/04/2018] [Accepted: 10/17/2018] [Indexed: 02/05/2023] Open
Abstract
Autism is a developmental disability that can cause significant emotional, social and behavioral dysfunction. Sleep disorders co-occur in approximately half of the patients with autism spectrum disorder (ASD). Sleep problems in individuals with ASD have also been associated with poor social interaction, increased stereotypy, problems in communication, and overall autistic behavior. Behavioral interventions are considered a primary modality of treatment. There is limited evidence for psychopharmacological treatments in autism; however, these are frequently prescribed. Melatonin, antipsychotics, antidepressants, and α agonists have generally been used with melatonin, having a relatively large body of evidence. Further research and information are needed to guide and individualize treatment for this population group.
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Posadzki PP, Bajpai R, Kyaw BM, Roberts NJ, Brzezinski A, Christopoulos GI, Divakar U, Bajpai S, Soljak M, Dunleavy G, Jarbrink K, Nang EEK, Soh CK, Car J. Melatonin and health: an umbrella review of health outcomes and biological mechanisms of action. BMC Med 2018; 16:18. [PMID: 29397794 PMCID: PMC5798185 DOI: 10.1186/s12916-017-1000-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 12/20/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Our aims were to evaluate critically the evidence from systematic reviews as well as narrative reviews of the effects of melatonin (MLT) on health and to identify the potential mechanisms of action involved. METHODS An umbrella review of the evidence across systematic reviews and narrative reviews of endogenous and exogenous (supplementation) MLT was undertaken. The Oxman checklist for assessing the methodological quality of the included systematic reviews was utilised. The following databases were searched: MEDLINE, EMBASE, Web of Science, CENTRAL, PsycINFO and CINAHL. In addition, reference lists were screened. We included reviews of the effects of MLT on any type of health-related outcome measure. RESULTS Altogether, 195 reviews met the inclusion criteria. Most were of low methodological quality (mean -4.5, standard deviation 6.7). Of those, 164 did not pool the data and were synthesised narratively (qualitatively) whereas the remaining 31 used meta-analytic techniques and were synthesised quantitatively. Seven meta-analyses were significant with P values less than 0.001 under the random-effects model. These pertained to sleep latency, pre-operative anxiety, prevention of agitation and risk of breast cancer. CONCLUSIONS There is an abundance of reviews evaluating the effects of exogenous and endogenous MLT on health. In general, MLT has been shown to be associated with a wide variety of health outcomes in clinically and methodologically heterogeneous populations. Many reviews stressed the need for more high-quality randomised clinical trials to reduce the existing uncertainties.
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Affiliation(s)
- Pawel P Posadzki
- Centre for Population Health Sciences, 11 Mandalay Road, Level 18 Clinical Sciences Building, Lee Kong Chian School of Medicine, Novena Campus, Nanyang Technological University , Singapore, 308232, Singapore.
| | - Ram Bajpai
- Centre for Population Health Sciences, 11 Mandalay Road, Level 18 Clinical Sciences Building, Lee Kong Chian School of Medicine, Novena Campus, Nanyang Technological University , Singapore, 308232, Singapore
| | - Bhone Myint Kyaw
- Centre for Population Health Sciences, 11 Mandalay Road, Level 18 Clinical Sciences Building, Lee Kong Chian School of Medicine, Novena Campus, Nanyang Technological University , Singapore, 308232, Singapore
| | - Nicola J Roberts
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, G4 0BA, UK
| | - Amnon Brzezinski
- The Hebrew University Medical School, Hadassah Hebrew University Medical Center, 91120, Jerusalem, Israel
| | - George I Christopoulos
- Nanyang Business School, Division of Strategy Management and Organisation, Nanyang Technological University, Singapore, 639798, Singapore
| | - Ushashree Divakar
- Centre for Population Health Sciences, 11 Mandalay Road, Level 18 Clinical Sciences Building, Lee Kong Chian School of Medicine, Novena Campus, Nanyang Technological University , Singapore, 308232, Singapore
| | - Shweta Bajpai
- Centre for Population Health Sciences, 11 Mandalay Road, Level 18 Clinical Sciences Building, Lee Kong Chian School of Medicine, Novena Campus, Nanyang Technological University , Singapore, 308232, Singapore
| | - Michael Soljak
- Centre for Population Health Sciences, 11 Mandalay Road, Level 18 Clinical Sciences Building, Lee Kong Chian School of Medicine, Novena Campus, Nanyang Technological University , Singapore, 308232, Singapore
| | - Gerard Dunleavy
- Centre for Population Health Sciences, 11 Mandalay Road, Level 18 Clinical Sciences Building, Lee Kong Chian School of Medicine, Novena Campus, Nanyang Technological University , Singapore, 308232, Singapore
| | - Krister Jarbrink
- Centre for Population Health Sciences, 11 Mandalay Road, Level 18 Clinical Sciences Building, Lee Kong Chian School of Medicine, Novena Campus, Nanyang Technological University , Singapore, 308232, Singapore
| | - Ei Ei Khaing Nang
- Centre for Population Health Sciences, 11 Mandalay Road, Level 18 Clinical Sciences Building, Lee Kong Chian School of Medicine, Novena Campus, Nanyang Technological University , Singapore, 308232, Singapore
| | - Chee Kiong Soh
- School of Civil and Environmental Engineering, College of Engineering, Nanyang Technological University, Singapore, 639798, Singapore
| | - Josip Car
- Centre for Population Health Sciences, 11 Mandalay Road, Level 18 Clinical Sciences Building, Lee Kong Chian School of Medicine, Novena Campus, Nanyang Technological University , Singapore, 308232, Singapore.,Global eHealth Unit, School of Public Health, Imperial College London, London, W6 8RP, UK
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Famuyiwa O, Adewuya A. Reflections on melatonin: focus on child mental health. PSYCHIATRIC BULLETIN 2018. [DOI: 10.1192/pb.bp.107.017889] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Aims and MethodTo examine the propriety of the use of melatonin in child and adolescent psychiatry based on findings retrieved from multiple electronic databases including the Cochrane Library resource, covering 1950–2007.ResultsThere is evidence for the effectiveness of melatonin in the initiation of sleep in children with a variety of neurodevelopmental disorders but its value in improving quality of sleep is doubtful. Like hormones in general, melatonin has multifarious action sites and hence potential for many side-effects. Posological issues and long-term side-effects are yet to be validly determined.Clinical ImplicationsSleep hygiene should be a major component of the routine intervention programme for insomnia and melatonin judiciously prescribed until the safety of long-term use is known.
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12
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McLay LLK, France K. Empirical research evaluating non-traditional approaches to managing sleep problems in children with autism. Dev Neurorehabil 2016; 19:123-34. [PMID: 24724691 DOI: 10.3109/17518423.2014.904452] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This paper examines the efficacy of non-behavioural and non-pharmacological approaches to the treatment of sleep disturbance in individuals with autism spectrum disorder. METHODS A systematic search of electronic databases and reference lists identified eight studies that met inclusion criteria. Studies were evaluated according to (a) treatment used, (b) participants, (c) experimental design, (d) baseline measures, (e) dependent variables, (f) follow-up measures, (g) reliability and treatment integrity, (h) results and certainty of evidence and (i) implications for treatment. RESULTS Positive outcomes were reported for the use of massage therapy and vitamin supplements. Aromatherapy was reported to have no effect on sleep. No studies were found that examined other non-traditional treatment approaches, nor did any of the studies provide conclusive evidence. CONCLUSIONS The limited corpus of evidence and the methodological limitations suggests that the efficacy of non-traditional approaches to treatment of sleep problems in individuals with autism is yet to be demonstrated.
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Affiliation(s)
| | - Karyn France
- a School of Health Sciences, University of Canterbury , Christchurch , New Zealand
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13
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Pharmacological management of behavioral and psychiatric symptoms in older adults with intellectual disability. Drugs Aging 2016; 32:95-102. [PMID: 25573538 DOI: 10.1007/s40266-014-0236-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Given medical and social advances, the life expectancy of individuals with intellectual disability (ID) has increased dramatically, leading to a generation of older individuals with such disabilities. This review focuses on the pharmacological treatment of behavioral and psychiatric symptoms and disorders in older adults with ID. Older adults with ID often present with medical co-morbidities and mental health issues. Medication management of behavioral and psychiatric problems is complicated by a higher risk for adverse events, lack of decision-making capacity, and complex care networks. Some studies have shown that individuals with ID and co-morbid mental disorders are undertreated in comparison with those with similar disorders in the general population, resulting in poorer outcomes. However, older adults with ID are also at risk of polypharmacy, and older age is a risk factor for development of side effects. A general principle is that medication treatment for psychiatric disorders in older individuals with ID should be started at low dosages and increased cautiously while monitoring response and side effects. The use of psychotropic drugs for older individuals with ID and behavioral problems remains controversial, particularly in those with dementia.
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Paprocka J, Kijonka M, Pęcka M, Sokół M. Melatonin in Epilepsy: A New Mathematical Model of Diurnal Secretion. Int J Endocrinol 2016; 2016:3861461. [PMID: 27478439 PMCID: PMC4961834 DOI: 10.1155/2016/3861461] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 06/05/2016] [Accepted: 06/13/2016] [Indexed: 02/07/2023] Open
Abstract
Purpose. The main objective of the study was to create a mathematical model that describes the melatonin circadian secretion and, then the functionality of the model was tested by a comparison of the melatonin secretions in children with and without epilepsy. Material and Methods. The patients were divided into the epilepsy group (EG, n = 52) and the comparison group (CG, n = 30). The melatonin level was assessed by a radioimmunoassay method. The diurnal melatonin secretion was described using a nonlinear least squares method. Spearman's rank correlation coefficient was chosen to estimate the dependence of the acquired data. The model reproduces blood concentration profiles and its parameters were statistically analyzed using the Mann-Whitney-Wilcoxon test and logistic regression. Results. The correlation analysis performed for the EG and CG groups showed moderate correlations between age and the melatonin secretion model parameters. Patients with epilepsy are characterized by an increased phase shift of melatonin release.
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Affiliation(s)
- Justyna Paprocka
- Department of Paediatrics and Developmental Age Neurology, School of Medicine in Katowice, Medical University of Silesia, Ulica Medyków 16, 40-752 Katowice, Poland
- *Justyna Paprocka:
| | - Marek Kijonka
- Department of Medical Physics, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ulica Wybrzeże Armii Krajowej 15, 44-101 Gliwice, Poland
| | - Marcin Pęcka
- Faculty of Automatic Control, Electronics and Computer Science Biomedical Engineering, Silesian University of Technology, Ulica Akademicka 2A, 44-100 Gliwice, Poland
| | - Maria Sokół
- Department of Medical Physics, Maria Skłodowska-Curie Memorial Cancer Center and Institute of Oncology, Gliwice Branch, Ulica Wybrzeże Armii Krajowej 15, 44-101 Gliwice, Poland
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15
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Renaud J, Dumont F, Khelfaoui M, Foisset S, Letourneur F, Bienvenu T, Khwaja O, Dorseuil O, Billuart P. Identification of intellectual disability genes showing circadian clock-dependent expression in the mouse hippocampus. Neuroscience 2015; 308:11-50. [DOI: 10.1016/j.neuroscience.2015.08.066] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 08/24/2015] [Accepted: 08/26/2015] [Indexed: 10/23/2022]
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Abstract
Children with neurodevelopmental disorders are at risk of sleep problems, typically difficulty getting to sleep, sleep/wake rhythm disturbances and reduced duration of sleep (insomnia). This may be associated with abnormally timed or inadequate secretion of melatonin, a naturally-occurring hormone involved in coordinating the body's sleep-wake cycle. Previously, we reviewed the use of a melatonin product licensed for primary insomnia in adults aged over 55 years. Here we review off-label and unlicensed use of melatonin in children with attention-deficit hyperactivity disorder (ADHD) or autism spectrum disorder or related neurodevelopmental disorders.
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Mumford RA, Mahon LV, Jones S, Bigger B, Canal M, Hare DJ. Actigraphic investigation of circadian rhythm functioning and activity levels in children with mucopolysaccharidosis type III (Sanfilippo syndrome). J Neurodev Disord 2015; 7:31. [PMID: 26388955 PMCID: PMC4574189 DOI: 10.1186/s11689-015-9126-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2015] [Accepted: 08/24/2015] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Sleep disturbance is part of the behavioural phenotype of the rare genetic condition mucopolysaccharidosis (MPS) type III. A growing body of evidence suggests that underlying disturbance in circadian rhythm functioning may explain sleep problems within the MPS III population. METHODS Actigraphic data were recorded in eight children with MPS III over 7-10 days and compared to age-matched typically developing controls. Parameters of circadian rhythmicity and activity levels across a 24-h period were analysed. RESULTS Statistically and clinically significant differences between the two groups were noted. Analysis indicated that children with MPS III showed significantly increased fragmentation of circadian rhythm and reduced stability with external cues (zeitgebers), compared to controls. Average times of activity onset and offset were indicative of a phase delayed sleep-wake cycle for some children in the MPS III group. Children with MPS III had significantly higher activity levels during the early morning hours (midnight-6 am) compared to controls. CONCLUSIONS Results are consistent with previous research into MPS III and suggest that there is an impairment in circadian rhythm functioning in children with this condition. Implications for clinical practice and the management of sleep difficulties are discussed.
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Affiliation(s)
- Rachel A. Mumford
- />Psychological Services, Alder Hey Children’s Hospital, Liverpool, UK
| | - Louise V. Mahon
- />Manchester Mental Health & Social Care NHS Trust, Manchester, UK
| | - Simon Jones
- />Genetic Medicine Unit, St Mary’s Hospital, Manchester, UK
| | - Brian Bigger
- />Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Maria Canal
- />Faculty of Life Sciences, University of Manchester, Manchester, UK
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18
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Van Haren K, Bonkowsky JL, Bernard G, Murphy JL, Pizzino A, Helman G, Suhr D, Waggoner J, Hobson D, Vanderver A, Patterson MC. Consensus statement on preventive and symptomatic care of leukodystrophy patients. Mol Genet Metab 2015; 114:516-26. [PMID: 25577286 DOI: 10.1016/j.ymgme.2014.12.433] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 12/18/2014] [Accepted: 12/18/2014] [Indexed: 10/24/2022]
Abstract
Leukodystrophies are inherited disorders whose primary pathophysiology consists of abnormal deposition or progressive disruption of brain myelin. Leukodystrophy patients manifest many of the same symptoms and medical complications despite the wide spectrum of genetic origins. Although no definitive cures exist, all of these conditions are treatable. This report provides the first expert consensus on the recognition and treatment of medical and psychosocial complications associated with leukodystrophies. We include a discussion of serious and potentially preventable medical complications and propose several preventive care strategies. We also outline the need for future research to prioritize clinical needs and subsequently develop, validate, and optimize specific care strategies.
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Affiliation(s)
- Keith Van Haren
- Department of Neurology, Lucile Packard Children's Hospital and Stanford University School of Medicine, Stanford, CA, USA.
| | - Joshua L Bonkowsky
- Department of Pediatrics and Neurology, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Genevieve Bernard
- Departments of Pediatrics, Neurology and Neurosurgery Montreal Children's Hospital/McGill University Health Center, Montreal, Canada
| | - Jennifer L Murphy
- Department of Neurology, Children's National Medical Center, Washington DC, USA
| | - Amy Pizzino
- Department of Neurology, Children's National Medical Center, Washington DC, USA
| | - Guy Helman
- Department of Neurology, Children's National Medical Center, Washington DC, USA
| | | | | | | | - Adeline Vanderver
- Department of Neurology, Children's National Medical Center, Washington DC, USA; Department of Integrated Systems Biology, George Washington University School of Medicine, Washington DC, USA; Center for Genetic Medicine Research, Children's National Health System, Washington DC, USA
| | - Marc C Patterson
- Departments of Neurology, Pediatrics and Medical Genetics, Mayo Clinic, Rochester, MN, USA
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Bruni O, Alonso-Alconada D, Besag F, Biran V, Braam W, Cortese S, Moavero R, Parisi P, Smits M, Van der Heijden K, Curatolo P. Current role of melatonin in pediatric neurology: clinical recommendations. Eur J Paediatr Neurol 2015; 19:122-33. [PMID: 25553845 DOI: 10.1016/j.ejpn.2014.12.007] [Citation(s) in RCA: 154] [Impact Index Per Article: 17.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Accepted: 12/09/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND/PURPOSE Melatonin, an indoleamine secreted by the pineal gland, plays a key role in regulating circadian rhythm. It has chronobiotic, antioxidant, anti-inflammatory and free radical scavenging properties. METHODS A conference in Rome in 2014 aimed to establish consensus on the roles of melatonin in children and on treatment guidelines. RESULTS AND CONCLUSION The best evidence for efficacy is in sleep onset insomnia and delayed sleep phase syndrome. It is most effective when administered 3-5 h before physiological dim light melatonin onset. There is no evidence that extended-release melatonin confers advantage over immediate release. Many children with developmental disorders, such as autism spectrum disorder, attention-deficit/hyperactivity disorder and intellectual disability have sleep disturbance and can benefit from melatonin treatment. Melatonin decreases sleep onset latency and increases total sleep time but does not decrease night awakenings. Decreased CYP 1A2 activity, genetically determined or from concomitant medication, can slow metabolism, with loss of variation in melatonin level and loss of effect. Decreasing the dose can remedy this. Animal work and limited human data suggest that melatonin does not exacerbate seizures and might decrease them. Melatonin has been used successfully in treating headache. Animal work has confirmed a neuroprotective effect of melatonin, suggesting a role in minimising neuronal damage from birth asphyxia; results from human studies are awaited. Melatonin can also be of value in the performance of sleep EEGs and as sedation for brainstem auditory evoked potential assessments. No serious adverse effects of melatonin in humans have been identified.
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Affiliation(s)
- Oliviero Bruni
- Department of Developmental and Social Psychology, Sapienza University, Rome, Italy
| | - Daniel Alonso-Alconada
- Institute for Women's Health, University College London, London, UK; Department of Cell Biology and Histology, University of the Basque Country, Spain
| | - Frank Besag
- South Essex Partnership University NHS Foundation Trust, Bedfordshire, & Institute of Psychiatry, London, UK
| | - Valerie Biran
- Neonatal Intensive Care Unit, Hôpital Robert Debré, Assistance Publique-Hôpitaux de Paris, Univ Paris Diderot, 75019 Paris, France; Univ Paris Diderot, Sorbonne Paris Cité, INSERM, U1141, 75019 Paris, France
| | - Wiebe Braam
- 's Heeren Loo, Department Advisium, Wekerom, The Netherlands; Governor Kremers Centre, University Maastricht, The Netherlands
| | - Samuele Cortese
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; School of Medicine, and the Centre for ADHD and Neurodevelopmental Disorders Across the Lifespan, Institute of Mental Health, University of Nottingham, UK; New York University Child Study Center, NY, USA
| | - Romina Moavero
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Italy; Neurology Unit, Neuroscience Department, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pasquale Parisi
- Child Neurology-Chair of Pediatrics, c/o Sant'Andrea Hospital, NESMOS Department, Faculty of Medicine & Psychology, Sapienza University, Rome, Italy
| | - Marcel Smits
- Governor Kremers Centre, University Maastricht, The Netherlands; Department of Sleep-wake Disorders and Chronobiology, Hospital Gelderse Vallei Ede, The Netherlands
| | - Kristiaan Van der Heijden
- Leiden Institute for Brain and Cognition & Institute of Education and Child Studies, Leiden University, The Netherlands
| | - Paolo Curatolo
- Child Neurology and Psychiatry Unit, Systems Medicine Department, Tor Vergata University of Rome, Italy.
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Cohen S, Conduit R, Lockley SW, Rajaratnam SMW, Cornish KM. The relationship between sleep and behavior in autism spectrum disorder (ASD): a review. J Neurodev Disord 2014; 6:44. [PMID: 25530819 PMCID: PMC4271434 DOI: 10.1186/1866-1955-6-44] [Citation(s) in RCA: 208] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 11/26/2014] [Indexed: 01/27/2024] Open
Abstract
Although there is evidence that significant sleep problems are common in children with autism spectrum disorder (ASD) and that poor sleep exacerbates problematic daytime behavior, such relationships have received very little attention in both research and clinical practice. Treatment guidelines to help manage challenging behaviors in ASD fail to mention sleep at all, or they present a very limited account. Moreover, limited attention is given to children with low-functioning autism, those individuals who often experience the most severe sleep disruption and behavioral problems. This paper describes the nature of sleep difficulties in ASD and highlights the complexities of sleep disruption in individuals with low-functioning autism. It is proposed that profiling ASD children based on the nature of their sleep disruption might help to understand symptom and behavioral profiles (or vice versa) and therefore lead to better-targeted interventions. This paper concludes with a discussion of the limitations of current knowledge and proposes areas that are important for future research. Treating disordered sleep in ASD has great potential to improve daytime behavior and family functioning in this vulnerable population.
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Affiliation(s)
- Simonne Cohen
- />School of Psychological Sciences, Faculty of Biomedical and Psychological Sciences, Monash University, Melbourne, Australia
| | - Russell Conduit
- />School of Health Sciences, Royal Melbourne Institute of Technology, Melbourne, Australia
| | - Steven W Lockley
- />School of Psychological Sciences, Faculty of Biomedical and Psychological Sciences, Monash University, Melbourne, Australia
- />Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, USA
- />Division of Sleep Medicine, Harvard Medical School, Boston, USA
| | - Shantha MW Rajaratnam
- />School of Psychological Sciences, Faculty of Biomedical and Psychological Sciences, Monash University, Melbourne, Australia
- />Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, USA
- />Division of Sleep Medicine, Harvard Medical School, Boston, USA
| | - Kim M Cornish
- />School of Psychological Sciences, Faculty of Biomedical and Psychological Sciences, Monash University, Melbourne, Australia
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21
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Muszyńska B, Maślanka A, Sułkowska-Ziaja K, Opoka W, Szopa A. Analysis of 5-Methyltryptamine,L-Tryptophan, 5-Hydroxy-L-Tryptophan, and Melatonin in the Bulbs of Garlic by Thin-Layer Chromatographic Method Coupled with Densitometric Detection. JPC-J PLANAR CHROMAT 2014. [DOI: 10.1556/jpc.27.2014.3.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Johns NP, Johns J, Porasuphatana S, Plaimee P, Sae-Teaw M. Dietary intake of melatonin from tropical fruit altered urinary excretion of 6-sulfatoxymelatonin in healthy volunteers. JOURNAL OF AGRICULTURAL AND FOOD CHEMISTRY 2013; 61:913-919. [PMID: 23252791 DOI: 10.1021/jf300359a] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This study assessed the melatonin content of six tropical fruits and examined whether human consumption could contribute to dietary melatonin as measured by 6-sulfatoxymelatonin (aMT6-s, a marker of circulating melatonin in the body). Melatonin was extracted using methanol and analyzed by high-performance liquid chromatography. In a clinical crossover study, 30 healthy volunteers consumed selected fruits one at a time, with a 1week wash-out period between fruits, until completing all six fruits. Most fruits had moderate melatonin content. Significant increases in urine aMT6-s concentrations were seen after the consumption of pineapple (266%, p = 0.004), banana (180%, p = 0.001), and orange (47%, p = 0.007). The need to analyze melatonin both in fruit and as in vivo uptake was demonstrated. Further study is warranted regarding the clinical effect of fruit consumption in people with age-related melatonin reduction problems such as sleeplessness and illnesses involving oxidative damage.
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Jan JE, Bax MCO, Owens JA, Ipsiroglu OS, Wasdell MB. Neurophysiology of circadian rhythm sleep disorders of children with neurodevelopmental disabilities. Eur J Paediatr Neurol 2012; 16:403-12. [PMID: 22264650 DOI: 10.1016/j.ejpn.2012.01.002] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2011] [Revised: 12/28/2011] [Accepted: 01/01/2012] [Indexed: 01/18/2023]
Abstract
This article reviews circadian rhythm sleep disorders (CRSDs) of children with neurodevelopmental disabilities. These sleep disturbances frequently occur in this population but they are misunderstood and under diagnosed. The causes and features of CRSD in children with brain disorders differ in many ways from those seen in typically developing children. It is the brain, including the eyes, which regulates sleep and circadian rhythmicity by modulating pineal melatonin production/secretion and when there is significant brain damage, the sleep/wake patterns may be modified. In most instances CRSD are not disorders of the suprachiasmatic nuclei because these small hypothalamic structures only adjust their functions to the changing photic and non-photic modulatory influences. Each form of CRSD is accompanied by characteristic changes in serum melatonin levels and clinical features. When nocturnal melatonin production/secretion is inappropriately timed or impaired in relation to the environment, timed melatonin replacement therapy will often be beneficial. In this review an attempt is made to clarify the neurophysiological mechanisms underlying the various forms of CRSD because without understanding the photic and non-photic influences on sleep, these sleep disorders can not be fully characterized, defined or even appropriately treated. In the future, the existing definitions for the different forms of CRSD should be modified by experts in pediatric sleep medicine in order to include children with neurodevelopmental disabilities.
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Affiliation(s)
- James E Jan
- Pediatric Neurology, University of British Columbia, Vancouver, BC, Canada.
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Takaesu Y, Komada Y, Inoue Y. Melatonin profile and its relation to circadian rhythm sleep disorders in Angelman syndrome patients. Sleep Med 2012; 13:1164-70. [PMID: 22841843 DOI: 10.1016/j.sleep.2012.06.015] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Revised: 06/05/2012] [Accepted: 06/14/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sleep problems are known to be common in Angelman syndrome (AS), a neurodevelopmental disorder which is associated with an abnormality of chromosome 15q11-q13. However, the circadian aspect of sleep disorders in AS and an effective treatment for the disorder have yet to be established. METHODS We elucidated the sleep-wake patterns of AS patients and its relationship to the serum melatonin levels. The serum melatonin levels of 15 AS patients were measured every 4h for one day and the values were compared with those of age-matched controls. We also examined the effectiveness of the oral administration of melatonin on AS patients with circadian rhythm sleep disorders (CRSD). RESULTS A total of eight of the 15 AS patients had CRSD (irregular sleep-wake type, n=4; free-running type n=2; delayed sleep phase type, n=2). The nighttime serum melatonin levels of the AS patients were significantly lower than those of the controls at the measured time points during the night. The nocturnal melatonin levels were comparably low both in AS patients with and without CRSD except for the cases with delayed sleep phase type, which showed normal but delayed peak melatonin level. Six out of eight CRSD cases were given a daily dose of 1mg of melatonin between 18:00 and 19:00 regularly for three months. After receiving the treatment, the sleep patterns improved in four cases. CONCLUSION This study revealed a high prevalence of CRSD in AS patients, which may be related to abnormal serum melatonin profiles.
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Khan S, Heussler H, McGuire T, Dakin C, Pache D, Cooper D, Norris R, Flenady V, Charles B. Melatonin for non-respiratory sleep disorders in visually impaired children. Cochrane Database Syst Rev 2011:CD008473. [PMID: 22071850 DOI: 10.1002/14651858.cd008473.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Exogenous melatonin helps in regulating the circadian rhythm and is widely used for the management of sleep disorders in visually impaired children. OBJECTIVES The aim of the review was to assess melatonin therapy for treatment of non-respiratory sleep disorders in visually impaired children, with regard to improvement in sleep habit, sleep scheduling and sleep maintenance, when compared with placebo or no treatment. SEARCH METHODS We searched the following databases between February 2011 and July 2011: the Cochrane Central Register of Controlled Trials (CENTRAL) 2011(1) searched on 4th February 2011; MEDLINE (1950 to June Week 3, 2011) searched on 20th June 2011; EMBASE (1980 to June Week 4, 2011) searched on 7th July 2011; CINAHL (1937 to 21 September 2011); the metaRegister of Controlled Trials (this includes ClinicalTrial.gov) searched 20 July 2011, and reference lists of papers identified after initial screening. SELECTION CRITERIA We planned to include randomized controlled trials (RCTs) and quasi-RCTs, including cross-over studies. Treatment would be exogenous melatonin. Control groups could be placebo, other medication for sleep disorders or no treatment. Outcomes sought were improved sleep with regard to timing and duration, quality of life and adverse events. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for inclusion in the review. MAIN RESULTS We did not find any studies fulfilling the inclusion criteria, therefore no outcome data are reported.We identified nine studies after initial screening and, after further evaluation, we excluded these. The excluded studies involved a total of 163 individuals aged two years to 18 years. We excluded studies for three main reasons: they were non-randomized or case series studies, they were studies of people over 18 years of age or even where the study was randomised, the study population was mixed and results pertaining to the visually impaired cohort could not be independently evaluated. No significant adverse effects of melatonin were reported in these excluded studies. AUTHORS' CONCLUSIONS There is currently no high quality data to support or refute the use of melatonin for sleep disorders in visually impaired children. Placebo-controlled trials examining important clinical outcomes such as sleep quality, sleep latency, duration of sleep and night-time awakenings are needed. As the numbers of children meeting study inclusion criteria are likely to be low at individual sites, multicentre collaboration between developmental paediatricians, sleep physicians and other health care professionals is essential to achieve sufficient sample size for controlled studies. Such collaboration would help facilitate local recruitment at multiple sites, with study oversight being provided by paediatricians with expertise in sleep disorders. Participation of collaborators with experience in evidence-based practice research is also desirable due to the lack of protocols on melatonin therapy in the target population.
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Affiliation(s)
- Sohil Khan
- 1School of Pharmacy, The University of Queensland, Brisbane, Australia.
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Simard-Tremblay E, Constantin E, Gruber R, Brouillette RT, Shevell M. Sleep in children with cerebral palsy: a review. J Child Neurol 2011; 26:1303-10. [PMID: 21670393 DOI: 10.1177/0883073811408902] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Children with neurodevelopmental disabilities, such as cerebral palsy, are considered to be a population at risk for the occurrence of sleep problems. Moreover, recent studies on children with cerebral palsy seem to indicate that this population is at higher risk for sleep disorders. The importance of the recognition and treatment of sleep problems in children with cerebral palsy cannot be overemphasized. It is well known that the consequences of sleep disorders in children are broad and affect both the child and family. This review article explores the types and possible risk factors associated with the development of sleep problems in children with cerebral palsy and the impact of this disorder on the child and family. In addition, a brief summary of current diagnostic and treatment modalities is provided. Finally, the characteristics, diagnostic techniques, and management of sleep-related breathing disorders in children with cerebral palsy are discussed.
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Guénolé F, Godbout R, Nicolas A, Franco P, Claustrat B, Baleyte JM. Melatonin for disordered sleep in individuals with autism spectrum disorders: systematic review and discussion. Sleep Med Rev 2011; 15:379-87. [PMID: 21393033 DOI: 10.1016/j.smrv.2011.02.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2010] [Revised: 02/05/2011] [Accepted: 02/07/2011] [Indexed: 11/29/2022]
Abstract
Sleep disturbance is common in autism spectrum disorders (ASD) and melatonin is widely prescribed in such cases despite a lack of guidelines. The aim of this paper is to provide a systematic review of efficacy and safety of exogenous melatonin for treating disordered sleep in individuals with ASD. We performed a Pubmed(®) documentary search enlarged by a manual review of references, which finally supplied 12 citations (4 case reports, 3 retrospective studies, 2 open-label clinical trials, and 3 placebo-controlled trials). As a whole, we found that the literature supports the existence of a beneficial effect of melatonin on sleep in individuals with ASD, with only few and minor side effects. However, considering the small number of studies and their methodological limits, these conclusions cannot yet be regarded as evidence-based. Randomized controlled trials and long-term follow-up data are still lacking to better assess efficacy and safety of exogenous melatonin for disordered sleep in individuals with ASD.
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Affiliation(s)
- Fabian Guénolé
- CHU de Caen, Service de Psychiatrie de l'enfant et de l'adolescent, Avenue Clemenceau, Caen F-14000, France.
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Therapeutic Options in the Management of Sleep Disorders in Visually Impaired Children: A Systematic Review. Clin Ther 2011; 33:168-81. [DOI: 10.1016/j.clinthera.2011.03.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/07/2011] [Indexed: 11/17/2022]
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Kronk R, Bishop EE, Raspa M, Bickel JO, Mandel DA, Bailey DB. Prevalence, nature, and correlates of sleep problems among children with fragile X syndrome based on a large scale parent survey. Sleep 2010; 33:679-87. [PMID: 20469810 PMCID: PMC2864883 DOI: 10.1093/sleep/33.5.679] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
STUDY OBJECTIVES This study reports on current child sleep difficulties reported by parents of children with Fragile X syndrome (FXS). We address prevalence and type of sleep problems (e.g., difficulty falling asleep, frequent awakenings); type and effectiveness of medical and behavioral treatments (e.g., medication, surgery, environmental changes); and explore specific child and family characteristics (e.g., child age, child gender, co-occurring conditions) as possible predictors of child sleep difficulties. DESIGN/PARTICIPANTS This study is part of a larger survey addressing needs of families with children with FXS. This article focuses on the families who responded to the survey sleep questions, had one or more children with the full mutation FXS, and who reside in the United States. The mean age for male and female children in this group was 15 years and 16 years respectively (N=1295). RESULTS Parents reported that 32% of the children with FXS currently experience sleep difficulties; 84% of those children are reported to have > or =2 current sleep problems. Problems falling asleep and frequent night awakenings were the most frequently reported difficulties; 47% of males and 40% of females received > or =1 medication to help with sleep. Children with more problematic health or behavioral characteristics had a higher likelihood of having current sleep problems. CONCLUSIONS Our survey provides the most representative sample to date of sleep problems in children with FXS or any other neurodevelopmental disability. This large scale survey establishes a foundation for the prevalence of sleep disorders in children with FXS.
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Affiliation(s)
- Rebecca Kronk
- Children's Hospital of Pittsburgh of UPMC, Child Development Unit, Fragile X Center, UCLID Center, University of Pittsburgh, 45th & Penn, Pittsburgh, PA 15201, USA.
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Kronk R, Dahl R, Noll R. Caregiver reports of sleep problems on a convenience sample of children with fragile X syndrome. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2009; 114:383-392. [PMID: 19792059 DOI: 10.1352/1944-7588-114.6.383] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Caregivers reported on sleep in a convenience sample of 90 children with fragile X syndrome utilizing a standardized assessment tool, the Children's Sleep Habits Questionnaire (CSHQ), and a 14-day sleep diary. CSHQ data indicated that 47% of participants had sleep problems at a level that suggested referral and further evaluation. Sleep diary data indicated high rates of several sleep problems. These problems did not appear to follow a typical developmental trajectory and were not related to gender or demographic variables. Nineteen percent of the sample was currently receiving medication to improve sleep; however, there were no significant differences between those receiving medications and those not receiving medications.
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Abstract
Pediatric insomnia is common in children and adolescents, particularly in children who have comorbid medical, psychiatric, and neurodevelopmental disorders, and may be associated with cognitive, emotional, and psychosocial impairments that often result in significant caregiver burden. Although several behavioral interventions for pediatric insomnia are effective, there is a relative paucity of empiric evidence supporting the use of pharmacologic treatment. Sedative/hypnotic drugs are frequently used in clinical practice to treat pediatric insomnia, and guidelines for the use of these medications in general as well as for specific medications have been developed. This review presents expert consensus guidelines for the use of these medications in clinical practice, with a focus on the different classes of pharmacologic agents that are most commonly prescribed.
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Affiliation(s)
- Judith A Owens
- Department of Pediatrics, Alpert Medical School at Brown University, Ambulatory Pediatrics Potter 200, 593 Eddy Street, Providence, RI 02903, USA.
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Hoebert M, van der Heijden KB, van Geijlswijk IM, Smits MG. Long-term follow-up of melatonin treatment in children with ADHD and chronic sleep onset insomnia. J Pineal Res 2009; 47:1-7. [PMID: 19486273 DOI: 10.1111/j.1600-079x.2009.00681.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
We conducted this study to assess long-term melatonin treatment course, effectiveness and safety in children with attention-deficit/hyperactivity disorder (ADHD) and chronic sleep onset insomnia (CSOI). This was conducted by means of a structured questionnaire for the parents. The subjects of this study consisted of participants who previously participated in a randomised clinical trial on melatonin efficacy. The response rate was 93% (94/101). The mean time to follow up was 3.7 yr. No serious adverse events or treatment related co-morbidities were reported. Sixty-five percent of the children still used melatonin daily and 12% occasionally. Temporal discontinuation of treatment resulted in a delay of sleep onset in 92% of the children. Nine percent of the children could discontinue melatonin completely because of improvement of sleep onset insomnia. Long-term melatonin treatment was judged to be effective against sleep onset problems in 88% of the cases. Improvement of behaviour and mood was reported in 71% and 61% respectively. We conclude that melatonin remains an effective therapy on the long term for the treatment of CSOI in children with ADHD and has no safety concerns regarding serious adverse events or treatment related co-morbidity. Discontinuation of melatonin treatment usually leads to a relapse of sleep onset insomnia and in resuming melatonin treatment, even after several years of treatment.
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Affiliation(s)
- Michel Hoebert
- Department of Neurology, Elisabeth Hospital, Tilburg, The Netherlands
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Braam W, Smits MG, Didden R, Korzilius H, Van Geijlswijk IM, Curfs LMG. Exogenous melatonin for sleep problems in individuals with intellectual disability: a meta-analysis. Dev Med Child Neurol 2009; 51:340-9. [PMID: 19379289 DOI: 10.1111/j.1469-8749.2008.03244.x] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Recent meta-analyses on melatonin has raised doubts as to whether melatonin is effective in treating sleep problems in people without intellectual disabilities. This is in contrast to results of several trials on melatonin in treating sleep problems in individuals with intellectual disabilities. To investigate the efficacy of melatonin in treating sleep problems in individuals with intellectual disabilities, we performed a meta-analysis of placebo-controlled randomized trials of melatonin in individuals with intellectual disabilities and sleep problems. Data were selected from articles published on PubMed, Medline, and Embase between January 1990 and July 2008. We examined the influence of melatonin on sleep latency, total sleep time, and number of wakes per night. Quality of trials was assessed using the Downs and Black checklist. Nine studies (including a total of 183 individuals with intellectual disabilities) showed that melatonin treatment decreased sleep latency by a mean of 34 minutes (p<0.001), increased total sleep time by a mean of 50 minutes (p<0.001), and significantly decreased the number of wakes per night (p<0.05). Melatonin decreases sleep latency and number of wakes per night, and increases total sleep time in individuals with intellectual disabilities.
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Affiliation(s)
- Wiebe Braam
- 's Heeren Loo Zuid, Wekerom, The Netherlands.
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Dodd A, Hare DJ, Arshad P. The use of melatonin to treat sleep disorder in adults with intellectual disabilities in community settings - the evaluation of three cases using actigraphy. JOURNAL OF INTELLECTUAL DISABILITY RESEARCH : JIDR 2008; 52:547-553. [PMID: 18444986 DOI: 10.1111/j.1365-2788.2008.01063.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
BACKGROUND Sleep disorders are known to be very prevalent in adults with intellectual disabilities (ID) but to date there has been limited objective assessment of either sleep disorders or of interventions such as the use of melatonin. METHODOLOGY A protocol-driven assessment and intervention procedure was followed with three people with moderate to severe ID identified as having a possible sleep disorder. Actigraphic assessment was used to determine the nature of the sleep disorder, after which sleep hygiene advice and then individual treatment with melatonin were provided, following which further actigraphic assessment was carried out. Behavioural disturbance was formally assessed before and after the intervention phase. RESULTS Following treatment with melatonin, changes in circadian rhythm were noted, together with improvements in challenging behaviour, but no significant effects were noted with regard to either quantity or quality of sleep. CONCLUSIONS A standardised procedure for assessment and treatment of sleep disorders in people with ID was established. Although no apparent effects on sleep quantity or quality were noted, this may reflect factors inherent in the sample, rather than the relative efficacy of melatonin treatment per se.
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Affiliation(s)
- A Dodd
- Pennine Care NHS Trust, UK
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Robinson PD, Waters K. Are children just small adults? The differences between paediatric and adult sleep medicine. Intern Med J 2007; 38:719-31. [PMID: 18771426 DOI: 10.1111/j.1445-5994.2008.01719.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Several important physiological and maturational changes occur in sleep development during the paediatric age range, particularly during infancy and in early childhood. As the pathology of sleep apnoea is superimposed onto a developing and often plastic physiological system, children often show a different pathophysiology to their adult counterparts. These factors need to be incorporated into the evaluation of a child's sleep problems. Particular attention should be paid to the developmental stage of the child. Investigation, interpretation and subsequent management provide further unique challenges and during successive reviews predicted normal changes must also be taken into account. This review article discusses the important physiological and maturational changes that occur in sleep during childhood, some common paediatric sleep conditions and their presentation and the appropriate evaluation and management of these conditions. In the course of the discussion, we have stressed important differences between paediatric and adult sleep medicine.
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Affiliation(s)
- P D Robinson
- Department of Respiratory Medicine, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.
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