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Bruni O, Biggio G, Malorgio E, Nobili L. Insomnia in children affected by autism spectrum disorder: The role of melatonin in treatment. Sleep Med 2024; 119:511-517. [PMID: 38805858 DOI: 10.1016/j.sleep.2024.05.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/08/2024] [Accepted: 05/23/2024] [Indexed: 05/30/2024]
Abstract
The present article explores the connection between insomnia and Autism Spectrum Disorder (ASD), focusing on the efficacy and safety of melatonin treatments as supported by existing research and current guidelines. In this narrative review a group of Italian experts provide an analysis of the various aspects of managing insomnia in children with ASD, highlighting key points that could enhance the quality of life for both patients and their caregivers. This includes the significance of comprehensively understanding the root causes of a child's sleep difficulties for more effective, long-term management. Insomnia, a condition frequently documented in neurodevelopmental disorders such as ASD, greatly affects the lives of patients and caregivers. Recent data show that melatonin-based formulations are effective and safe for treating ASD-related insomnia both short and long term. In particular, prolonged-release melatonin is poised to be the optimal choice for this patient population. This formulation is approved for the treatment of insomnia in children and adolescents aged 2-18 years suffering from ASD and/or Smith-Magenis syndrome, where sleep hygiene measures and behavioral treatments have not been sufficient. In support, emerging research in pediatric settings indicates long-term efficacy and safety, although further research efforts are still needed. Current guidelines recommend managing insomnia and sleep disturbances in ASD using a combination of behavioral and pharmacological methods, primarily melatonin. Recent concerns about accidental melatonin ingestion highlight the need for high purity standards, such as pharmaceutical-grade prolonged-release formulations. The article also summarizes emerging molecular mechanisms from preclinical research, suggesting future therapeutic approaches.
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Affiliation(s)
- Oliviero Bruni
- Dept of Developmental and Social Psychology, Sapienza University, Via dei Marsi 78, 00185, Rome, Italy.
| | - Giovanni Biggio
- Department of Life and Environmental Sciences, Institute of Neuroscience, CNR, University of Cagliari, 09042, Cagliari, Italy; Institute of Neuroscience, National Research Council (C.N.R.), University Campus, 09042, Cagliari, Italy.
| | - Emanuela Malorgio
- Italian Federation of Primary Care Pediatricians (Federazione Italiana Medici Pediatri, FIMP), Expert on Sleep Disorders AIMS, Torino, Italy.
| | - Lino Nobili
- IRCCS G. Gaslini Institute. Department of Neuroscience - Rehabilitation - Ophthalmology - Genetics - Child and Maternal Health (DINOGMI) - University of Genova, Italy.
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Marques C, Dinis M, Machado V, Botelho J, Lopes LB. Evaluating the Quality of Systematic Reviews on Pediatric Sedation in Dentistry: An Umbrella Review. J Clin Med 2024; 13:3544. [PMID: 38930074 PMCID: PMC11205123 DOI: 10.3390/jcm13123544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/05/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Sedation is a depression of a patient's state of consciousness, induced by medications, that can reach different levels of intensity during a medical procedure. Conscious sedation produces a minimally depressed level of consciousness without impairment of the ability to maintain an open airway, of protective reflexes or of responses to verbal and physical stimulation. This umbrella review is aimed at critically assessing the available systematic reviews (SRs) and meta-analyses (MA) on sedation in children/adolescents. An electronic database search was conducted that included Pubmed-Medline, Web of Science, Cochrane, Scopus, Scielo, Embase, LILACS and TRIP and the scope of which extended until January 2023. The risk of bias (RoB) of SRs was analyzed using the Measurement Tool to Assess SRs criteria 2 (AMSTAR2). Of 998 entries, 37 SRs were included. In terms of methodological quality, eight studies were assessed as having critically low quality, four studies had low quality, nine studies had moderate quality, and sixteen were considered to be of high quality. Based on the current guidelines, the most employed drugs in pediatric dentistry for sedation are nitrous oxide and midazolam; however, the available evidence supporting their use is insufficient and of low/critically low quality. The combined technique is recommended (nitrous oxide (30-50%) + midazolam). The optimal dose of oral midazolam is 0.75 mg/kg. The level of methodological quality of SRs is expected to increase according to the results and future directions of this umbrella review.
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Affiliation(s)
| | | | | | - João Botelho
- Egas Moniz Center for Interdisciplinary Research Center (CiiEM), Egas Moniz School of Health and Science, 2829-511 Almada, Portugal; (C.M.); (M.D.); (V.M.); (L.B.L.)
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Bolt R, Hyslop MC, Herbert E, Papaioannou DE, Totton N, Wilson MJ, Clarkson J, Evans C, Ireland N, Kettle J, Marshman Z, Norrington AC, Paton RH, Vernazza C, Deery C. The MAGIC trial: a pragmatic, multicentre, parallel, noninferiority, randomised trial of melatonin versus midazolam in the premedication of anxious children attending for elective surgery under general anaesthesia. Br J Anaesth 2024; 132:76-85. [PMID: 37953202 PMCID: PMC10797512 DOI: 10.1016/j.bja.2023.10.011] [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: 06/21/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Child anxiety before general anaesthesia and surgery is common. Midazolam is a commonly used premedication to address this. Melatonin is an alternative anxiolytic, however trials evaluating its efficacy in children have delivered conflicting results. METHODS This multicentre, double-blind randomised trial was performed in 20 UK NHS Trusts. A sample size of 624 was required to declare noninferiority of melatonin. Anxious children, awaiting day case elective surgery under general anaesthesia, were randomly assigned 1:1 to midazolam or melatonin premedication (0.5 mg kg-1, maximum 20 mg) 30 min before transfer to the operating room. The primary outcome was the modified Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF). Secondary outcomes included safety. Results are presented as n (%) and adjusted mean differences with 95% confidence intervals. RESULTS The trial was stopped prematurely (n=110; 55 per group) because of recruitment futility. Participants had a median age of 7 (6-10) yr, and 57 (52%) were female. Intention-to-treat and per-protocol modified Yale Preoperative Anxiety Scale-Short Form analyses showed adjusted mean differences of 13.1 (3.7-22.4) and 12.9 (3.1-22.6), respectively, in favour of midazolam. The upper 95% confidence interval limits exceeded the predefined margin of 4.3 in both cases, whereas the lower 95% confidence interval excluded zero, indicating that melatonin was inferior to midazolam, with a difference considered to be clinically relevant. No serious adverse events were seen in either arm. CONCLUSION Melatonin was less effective than midazolam at reducing preoperative anxiety in children, although the early termination of the trial increases the likelihood of bias. CLINICAL TRIAL REGISTRATION ISRCTN registry: ISRCTN18296119.
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Affiliation(s)
- Robert Bolt
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Marie C Hyslop
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Sheffield, UK
| | - Esther Herbert
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Sheffield, UK
| | - Diana E Papaioannou
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Sheffield, UK
| | - Nikki Totton
- Sheffield Clinical Trials Research Unit, ScHARR, University of Sheffield, Sheffield, UK
| | - Matthew J Wilson
- Sheffield School of Health & Related Research, University of Sheffield, Sheffield, UK
| | - Janet Clarkson
- Dundee Dental Hospital and School, University of Dundee, Dundee, UK
| | - Christopher Evans
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Nicholas Ireland
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Jennifer Kettle
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | - Zoe Marshman
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK
| | | | | | | | - Christopher Deery
- School of Clinical Dentistry, University of Sheffield, Sheffield, UK.
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Shah SB, Sinha R, Hussain SY, Kumar A, Gupta A. Allaying Pediatric Preoperative Anxiety, Where are we Now? - A Nationwide Survey. J Indian Assoc Pediatr Surg 2023; 28:479-485. [PMID: 38173638 PMCID: PMC10760609 DOI: 10.4103/jiaps.jiaps_114_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 07/08/2023] [Accepted: 07/23/2023] [Indexed: 01/05/2024] Open
Abstract
Background Preoperative anxiety (PA) in children is a common phenomenon associated with various negative patient outcomes. Allaying PA is accepted as a standard of care, but its use is not universal and often overlooked. This survey is designed to evaluate the nationwide current practice patterns and attitudes of anesthesiologists toward the practice of allaying PA in children. Materials and Methods A questionnaire of 25 questions, including information on methods of relieving PA in children, reasons for noncompliance, and associated complications, was framed. It was circulated among members of the Indian Society of Anaesthesiologists through an online survey of Google Forms and manually. Results Four hundred and fifty anesthesiologists were surveyed. Responses were predominantly from anesthesiologists practicing in medical colleges across the country. Although 97% of the surveyed respondents practiced anxiety-relieving strategies, only 37% used it consistently. Seventy-three percent of anesthesiologists practiced both pharmacological and nonpharmacological techniques. The most common reason for avoiding premedication was an anticipated difficult airway (88%). Inadequate sedation was a commonly reported problem. Ninety-five percent of participants felt that PA-relieving strategies should be integral to pediatric anesthesia practice. The most common reason for not following these practices was an inadequate hospital infrastructure (67%). Ninety-seven percent of the participants believed that more awareness is required on this crucial perioperative issue. Conclusion Only 37% of the surveyed anesthesiologists consistently used some form of PA-relieving strategy and the practice varied widely. Further improvement and team approach involving anesthesiologists, surgeons, and nurses is required to ensure the quality of pediatric PA-relieving services and establish it as a standard of care.
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Affiliation(s)
- Shreya Bharat Shah
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Renu Sinha
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Sana Yasmin Hussain
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Kumar
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Anju Gupta
- Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Jacobson JL, Tylka J, Glazer S, Zhang Y, Cosme R, Silvestri JM, Patwari PP. Melatonin Use in Pediatric Intensive Care Units: A Single-Center Experience. Med Sci (Basel) 2023; 11:55. [PMID: 37755159 PMCID: PMC10534299 DOI: 10.3390/medsci11030055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Revised: 08/07/2023] [Accepted: 08/21/2023] [Indexed: 09/28/2023] Open
Abstract
Growing evidence indicates that altered melatonin secretion during critical illness may influence the quality and quantity of sleep, delirium, and overall recovery. However, limited data exist regarding the use of melatonin in pediatric critical illness. Data were reviewed over a 5-year period at a tertiary pediatric intensive care unit for pediatric patients (ages 0-18 years) who were prescribed melatonin with the aim of identifying the frequency of and indications for use. Data collection included the hospital day of initiation, the dose, the frequency, the duration of use, and the length of stay. The results demonstrate that melatonin was infrequently prescribed (6.0% of patients admitted; n = 182) and that the majority of patients received melatonin as continuation of home medication (46%; n = 83 of 182). This group had significantly earlier melatonin use (0.9 ± 2.3 day of hospitalization; p < 0.0001) and significantly reduced lengths of stay compared to the other groups (mean LOS 7.2 ± 9.3 days; p < 0.0001). Frequently, clear documentation of indication for melatonin use was absent (20%; n = 37). In conclusion, given that melatonin is infrequently used within a tertiary PICU with the most common indication as the continuation of home medication, and often without clear documentation for indication, this presents an opportunity to emphasize a more attentive and strategic approach regarding melatonin use in the PICU population.
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Affiliation(s)
- Jessica L. Jacobson
- Department of Pharmacy, Rush University Medical Center (RUMC), Chicago, IL 60612, USA;
| | - Joanna Tylka
- Department of Pediatrics, RUMC, Rush University Children’s Hospital, Chicago, IL 60612, USA; (J.T.)
| | - Savannah Glazer
- Department of Pediatrics, RUMC, Rush University Children’s Hospital, Chicago, IL 60612, USA; (J.T.)
| | - Yanyu Zhang
- Bioinformatics and Biostatistics Core, RUMC, Chicago, IL 60612, USA
| | - Rosario Cosme
- Department of Psychiatry, RUMC, Chicago, IL 60612, USA
| | - Jean M. Silvestri
- Department of Pediatrics, RUMC, Rush University Children’s Hospital, Chicago, IL 60612, USA; (J.T.)
| | - Pallavi P. Patwari
- Department of Pediatrics, RUMC, Rush University Children’s Hospital, Chicago, IL 60612, USA; (J.T.)
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Sengupta S, Bhattacharya P, Nag DS, Sahay N. Search for the ideal route of premedication in children.. far from over? Indian J Anaesth 2022; 66:S188-S192. [PMID: 35874489 PMCID: PMC9298932 DOI: 10.4103/ija.ija_415_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
- Saikat Sengupta
- Senior Consultant, Apollo Multispeciality Hospitals, Kolkata, West Bengal
| | - Prithwis Bhattacharya
- Professor, Department of Anaesthesiology, Pacific Medical College and Hospital, Udaipur, Rajasthan
| | - Deb S. Nag
- Senior Consultant, Anaesthesiology, Tata Main Hospital, Jamshedpur, Jharkhand
| | - Nishant Sahay
- Additional Professor, All India Institute of Medical Sciences, Patna, Bihar, India
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