How Can Melatonin Be Used to Help Sleep?

Patient Presentation
A 20-year-old male came to clinic because of several nights of insomnia. He had several nights where he suddenly significantly changed the time he normally went to sleep, and then for the next 5 evenings when he could restart his normal bedtime, he had a hard time being able to initiate sleep. “I just sit there with my eyes wide awake and just can’t fall asleep,” he said. “I finally get to sleep about 4 hours later and then I can’t get up in the morning. When I do wake up I’m too scared to drive to my college classes,” he related. He denied any depression or anxiety. He said he had normal stress about his classes but was doing well. He was studying software engineering and therefore was often using electronic devices up until the time he went to bed. He denied any medications or drug use. He said that sometimes eating some food would help him fall asleep but a bigger meal made it worse. The past medical history showed a healthy male, who had previous episodes of a similar sleep problem that generally stopped after 1-2 nights. The family history showed some diabetes, and occasional insomnia in the father. There was no history of mental health problems. The review of systems was normal.

The pertinent physical exam showed a healthy male with normal vital signs and physical examination. The diagnosis of a short term sleep-onset problem was made. The patient was counseled to improve his sleep hygiene with careful attention to his schedule and also the amount of screen use he had. “Because you are using computers for school and will be for work, you are going to have to be very aware of the amount of the use, and the timing of the use, as you seem to be more prone to this sleep problem. Having a bedtime routine where you can stop the computers, maybe read or listen to music for a little while in a chair or couch and then go to your bed will probably help,” the pediatrician counseled. “Your bed should be for sleeping and not for other things like coding and homework. You can also try drinking something warm, making sure there is low-lighting in the room,” he added. “Since you are already having a problem you can also try some melatonin for a few days as a sleep aid. You should take it 2 hours before you want to fall asleep and you can do it for about a week if you need to. If it is not working call me. If this happens again, try restarting your schedule and sleep practices, and if needed you can try the melatonin again,” he said.

Discussion
Sleep is regulated by the homeostatic sleep drive and the circadian system which controls periods of activity and inactivity throughout the day. The circadian rhythm is slightly longer than 24 hours in humans and is controlled by the hypothalmic suprachiasmatic nucleus. When the circadian system and the external environment are misaligned, such that sleep occurs outside of normal times, a circadian rhythm sleep disorder can occur.

Everyone experiences disturbances of sleep throughout their lifetime. During adolescence, there is a normal physiologic change so that there is a shift to a later sleep phase for adolescents. Adolescents also commonly have inadequate sleep that occurs on an ongoing basis because of societal norms of having to awaken early in the morning. Pediatric insomnia is defined as “repeated difficulty in sleep initiation, duration, consolation, or quality that occurs despite age-appropriate time and opportunity for sleep and results in daytime functional impairment for the child and/or family.” Mild or transient problems are not a sleep disorder or insomnia. The problem must be more consistent, and be developmentally inappropriate.

Adolescents and young adults can have circadian rhythm problems occur.

Delayed sleep phase disorder (DSPD) is the most common in this group with a the prevalence of 7-16%. DSPD delays sleep onset by 3 to 4 hours compared to usual normative evening time (i.e. 10-11 PM). If left alone, the sleep is normal in quality and duration. Sleep wakening is then necessarily delayed causing problems with social needs (e.g. not getting up in time to go to school). The adolescent then has inadequate sleep which then leads to poor sleep hygiene which helps to change the intrinsic circadian rhythm which continues to cause the delayed sleep onset. Overtime, DSPD develops. DSPD is treated using good sleep hygiene but other interventions may be necessary.

  • Chronotherapy delays sleep onset progressively over several days until the normal sleep onset time is achieved and then anchors that new time with post-sleep morning light.
    Light therapy especially in the morning can be helpful.

  • Light in the evening delays sleep onset and light in the morning advances it (i.e. makes it earlier in the evening the next night). Light intensity between 2500-10000 lux will advance circadian rhythms.
  • Melatonin can also be used.

Sleep hygiene including establishing regular sleep routines and timing that can be consistently adhered to (both for sleep onset and duration), limiting technology devices especially those with a blue screen such as television and computers, limiting caffeine and energy-dense food before bedtime, regular exercise during the day and not in the evening and treatment for any underlying problems such as depression or anxiety.

Psychophysiologic insomnia (PPI) is a sleep-onset disorder and is not a circadian rhythm sleep disorder. Individuals have a very hard time initiating sleep and then difficulty in wakening in the morning. PPI and DSPD can be concurrent.

To learn more about circadian rhythms in newborns click here and a review of sleep hygiene for infants can be found here.

Learning Point
Melatonin is an indolamine that is made in the pineal gland and has chronobiotic and hypnotic properties. It also has anti-inflammatory, antioxidant and free radical scavenging abilities. Circulating endogeneous levels are high in childhood and decrease during puberty. It is metabolized by the liver and has a half-life of 45-60 minutes. Medications such as oral contraceptives and cimetidine decrease melatonin metabolism and carbamazepine and ompeprazole can increase melatonin metabolism. In humans endogenous melatonin starts to rise about 2 hours before sleep onset and peaks about 5 hours after sleep onset.

It can be used to help re-entrain short-term or long-term circadian rhythm problems or be used to help prevent sleep disruption following environment insults. It has also been used to treat headaches and seizures.

  • For PPI, melatonin is taken 2 hours before desired sleep onset as a soporific (weak sleep aid). Dosages vary but 0.2-0.5 mg can be used as a starting point.
  • For DSPD, melatonin is taken 5 hours before desired sleep onset to help retrain the system. Dosages vary but small doses have been found to be as effective. For children a 0.2-0.5 starting dose or 0.5- 1 mg in adults, which can be increased by 0.2-0.5 mg weekly until desired effect with a maximum of 3 mg in children/teens 40 kg is one regimen. Once a consistent, desired bedtime is achieved, smaller dose (such as 0.2-0.5 mg) given 2 hours before desired sleep onset helps to establish the circadian pattern.
  • For jet lag in adults 3 mg is often prescribed.
  • In children with long-term insomnia such as those with neurological disease can benefit. Melatonin should be re-evaluated at not less than 1 month after starting to determine effectiveness. Melatonin treatment is recommended to be stopped for at least 1 week yearly to again evaluate need for ongoing treatment.
    Long-term therapy can be stopped just before or after puberty.

Melatonin is considered safe but side effects can include drowsiness, headache, hypothermia, dizziness, diarrhea, enuresis, and rash.

Questions for Further Discussion
1. What health problems are associated with inadequate sleep? For a review click here.
2. What sleep hygiene recommendations do you offer families?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Sleep Disorders

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Bartlett DJ, Biggs SN, Armstrong SM. Circadian rhythm disorders among adolescents: assessment and treatment options. Med J Aust. 2013 Oct 21;199(8):S16-20.

Reiter J, Rosen D. The diagnosis and management of common sleep disorders in adolescents. Curr Opin Pediatr. 2014 Aug;26(4):407-12.

Meltzer LJ, Mindell JA. Systematic review and meta-analysis of behavioral interventions for pediatric insomnia. J Pediatr Psychol. 2014 Sep;39(8):932-48.

Bruni 0, Alonso-Alconada D, et.al. Current role of melatonin in pediatric neurology: clinical recommendations. Eur J Paediatr Neurol. 2015 Mar;19(2):122-33.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What are Paraphilias and How Common is Zoophilia in Adolescents?

Patient Presentation
After seeing several adolescents in an afternoon, some residents and an attending were having a general discussion about adolescent sexuality. The attending noted it was important to gain the appropriate trust from the teen or young adult. “I try to be open to anything an adolescent may tell me and not to be surprised. Sometimes they will say something just to see if they can shock you, but most are saying something that is important to them or have questions because they just want to know about it. Often they are wondering if their bodies or their thoughts they are normal,” the attending said. He also stated that it was important to keep in mind that just because a person has sexual thoughts, feelings or performs certain sexual acts, these do not necessarily define the sexual orientation or sexual practices of an individual. He went on, “There is a difference between someone being curious or seeking novelty and more consistent or less common sexual practices.” One of the residents said, “I grew up around a lot of farms, and it was always the high school joke that some of the boys had their first sexual experiences with some of the animals on the farm. While it might have happened because of the opportunity, I don’t know how common it actually was or is.”

Discussion
Teens may also have normal curiosity and thoughts about sexuality and various sexual practices. They may also have the opportunity to explore or engage in some practices in person or through the Internet. For example, a teen inadvertently or purposefully watches sexual intercourse between his/her parents or between peers at a party. This is not a paraphilia or an atypical sexual interest.

“Paraphilias are defined as intense and persistent sexual interests outside of foreplay and genital stimulation with phenotypically normal, consenting adults.” Examples of paraphilias are voyeurism, exhibitionism, and fetishism. Most people with paraphilias do not have a mental disorder and people with paraphilias may or may not act on the interest. Paraphilic disorders are distinct from paraphilias. Paraphilic disorders occur when the atypical sexual interest causes distress or is bothersome to the individual, or in some way causes distress or injury to another individual. There are numerous paraphilias and paraphilic disorders that are named based on the sexual interest.

Learning Point
Zoophilia is a persistent sexual interest in animals. Bestiality is “the legal term for the criminal offense of engaging in sexual relations with an animal or animals.” Bestiality laws are common because of the harm to animals who obviously cannot provide consent. There is not a great deal of medical professional literature on the subject and overall the practice appears to be rare.

Three of the studies below (Holoyda and Newman, Ranger and Fedoroff, and Satapathy et.al.), cited the 1948 Kinsey report where he “…reported that 8 percent of males had participated in some form of sexual activity with animals and that 40-50 percent of boys growing up on a farm had sex with an animal at least once. Kinsey also reported that 1.5 percent of females had contact with animals before adolescence….”

Some limited data has found zoophilia/zoophilic disorder among people who were sexually abused, or are violent or sex offenders. One 2016 case report discusses an adolescent male who was illiterate, who had experienced childhood sexual abuse and lived near a farm. A meta-analysis by Seto and Lalumiere found a 14% rate of bestality among juvenile sex offenders (JSOs). In another study of JSOs, rates for bestiality was 3.9-38% for JSO in the literature the authors reviewed. Their own data showed 37.5% self-reported bestiality which increased to 81.3% when the JSOs underwent polygraph examination.

Questions for Further Discussion
1. What are treatment options for paraphilic disorders?
2. What are special health needs of incarcerated youth?
3. How common is teen violence?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sexual Health and Teen Sexual Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Kinsey A, Wardell C, Pomeroy B, Martin CE. Philadelphia: W.B. Saunders; 1948. Sexual Behavior in the Human Male.

Hensley C, Tallichet SE, Dutkiewicz EL. Childhood bestiality: a potential precursor to adult interpersonal violence. J Interpers Violence. 2010 Mar;25(3):557-67.

Seto MC, Lalumiere ML. What is so special about male adolescent sexual offending? A review and test of explanations through meta-analysis. Psychol Bull. 2010 Jul;136(4):526-75.

Holoyda B, Newman W. Zoophilia and the law: legal responses to a rare paraphilia. J Am Acad Psychiatry Law. 2014;42(4):412-20.

Ranger R, Fedoroff P. Commentary: Zoophilia and the law. J Am Acad Psychiatry Law. 2014;42(4):421-6.

Schenk AM, Cooper-Lehki C, Keelan CM, Fremouw WJ. Underreporting of bestiality among juvenile sex offenders: polygraph versus self-report. J Forensic Sci. 2014 Mar;59(2):540-2.

Satapathy S, Swain R, Pandey V, Behera C. An Adolescent with Bestiality Behaviour: Psychological Evaluation and Community Health Concerns. Indian J Community Med. 2016 Jan-Mar;41(1):23-6.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital

What Are Complications of Cerumen?

Patient Presentation
A 17-year-old male went to an urgent care center with a 12 hour history of right ear pain that was not improving. The pain woke him up from sleep and he was able to return to sleep after some acetaminophen. The pain still woke him a few more times during the night, and was described as a constant, dull pain that was not improving over the rest of the day. He denied any discharge from the ear, popping sounds or acute hearing loss. He denied any trauma or placing anything into the ear. He did say that maybe he felt some water in the right ear. He was on his second day of vacation in Florida and had been swimming in the ocean and a pool the day before, and had not been scuba diving. The past medical history showed some acute ear infections as a young child. The review of systems was negative.

The pertinent physical exam showed a healthy male in no acute distress with normal vital signs. His left ear had moderate cerumen in the external canal and a normal tympanic membrane. The right ear was totally occluded with wax. The right ear was irrigated with warm water which returned a large amount of pelleted amber colored cerumen. Most of the pain immediately improved after irrigation. The external canal had some erythema near the tympanic membrane, but the tympanic membrane itself was not reddened and there was no middle ear effusion present. The diagnosis of cerumen impaction causing pressure along with mild otitis externa was made. The patient was prescribed ofloxacin otic drops and given instructions to use the drops until there was no pain but for at least 48 hours. He was also give instructions about how to prevent cerumen accumulation. He did endorse that he had used cotton-tipped swabs to try to self-clean his ears over the past several months during this discussion and was told not to do this.

Discussion
Cerumen or ear wax is produced in the outer third of the external auditory canal. It contains exfoliated squamous epithelium along with waxy substances. It is controlled by autosomal alleles and has two main phenotypes – “wet” cerumen which is dominant and common in Caucasian and African populations, and “dry” cerumen which is recessive and found more often in Asian populations. Cerumen protects the external canal and has some antibacterial and antifungal properties including against strains of Staphylococcus aureus, Pseudomonas aeroginosis, and Candida albicans. Staphylococcus aureus and Pseudomonas aeroginosis are the most common causes of otitis externa.

The external auditory canal is a self cleaning mechanism which is assisted by jaw movement. It helps to trap dirt and keep out water. When this self cleaning system fails, cerumen accumulation and potential impaction can occur. Cerumen impaction is defined as “…accumulation that causes symptoms and prevents the needed assessment of the ear canal/tympanic membrane or audiovestibular system or both.” Cerumen impaction is common in children,the elderly and also in developmentally disabled populations.

Treatment is by use of cerumenolytics, aural irrigation or manual removal.

  • “Cerumenolytics work by hydrating the desquamated sheets of keratinocytes and by inducing keratinolysis causing disintegration of the cerumen.”
    A Cochrane Collaboration review found that cerumenolytics were better than no treatment for cerumen impaction but no particular product was recommended over another. A meta-analysis of two high quality trials found a statistical difference in favor of using triethanolamine polypeptide drops over saline though.
    Cerumenolytics usually need several treatments to be successful and should never be used if there is any suspicion that the tympanic membrane is perforated.

  • Aural irrigation with warm water or saline is often used. Sometimes it is used after a cerumenolytic. Problems can occur because of pain or irritation with the irrigations.
    Irrigation should not be attempted if there is any concern for tympanic membrane perforation.

  • Manual removal by curette, suction or other instrumentation is also used frequently. This requires a cooperative patient so as not to cause trauma.
    Studies have found that manual removal does not increase the risk of otitis externa.

Cerumen impaction can be prevented by not placing anything into the canal and also by various ceruminolytics.

Learning Point

Cerumen build up and even impaction usually do not cause problems but they can occur. The cerumen in this patient probably absorbed water while swimming and therefore he developed pain because of the expanded mass. A mild otitis externa also appeared to be developing and was treated.

Complications of cerumen can include conductive hearing loss, irritation, infection (otitis externa), itching, pain, ear fullness, tinnitus, dizziness, and vertigo, and has been associated with chronic cough.

An overview of otitis externa can be found here and complications of otitis media can be found here.

Questions for Further Discussion
1. What organisms cause otitis media?

2. What causes acute hearing loss? A differential diagnosis can be found here.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Ear Disorders and Ear Infections.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Dimmitt P. Cerumen removal products. J Pediatr Health Care. 2005 Sep-Oct;19(5):332-6.

Saloranta K, Westermarck T. Prevention of cerumen impaction by treatment of ear canal skin. A pilot randomized controlled study. Clin Otolaryngol. 2005 Apr;30(2):112-4.

Lum CL, Jeyanthi S, Prepageran N, Vadivelu J, Raman R. Antibacterial and antifungal properties of human cerumen.
J Laryngol Otol. 2009 Apr;123(4):375-8.

Burton MJ, Doree C. Ear drops for the removal of ear wax.
Cochrane Database Syst Rev. 2009 Jan 21;(1):CD004326.

Guidi JL, Wetmore RF, Sobol SE. Risk of otitis externa following manual cerumen removal. Ann Otol Rhinol Laryngol. 2014 Jul;123(7):482-4.

Soy FK, Ozbay C, Kulduk E, Dundar R, Yazıcı H, Sakarya EU. A new approach for cerumenolytic treatment in children: In vivo and in vitro study. Int J Pediatr Otorhinolaryngol. 2015 Jul;79(7):1096-100.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital