Five things to know about melatonin for kids

Girl awake in bed with alarm clock

Your daughter’s lack of sleep is beginning to affect her school performance. You’ve tried to establish a consistent bedtime, to no avail. You’re half-crazy with sleep deprivation yourself tending to her insomnia.

You’ve heard melatonin — a hormone supplement — can help. Perhaps your pediatrician has already recommended it. But is it really beneficial, and can your child take it safely?

We checked in with Dr. Judith Owens, director of the Sleep Center at Boston Children’s Hospital, and her answer is: Probably. But we don’t really know for sure.

What is melatonin?

The melatonin available over the counter at drug and health food stores is a synthetic form of a hormone our brains naturally produce to help us fall asleep. Our own melatonin helps regulate the circadian clocks that control not only our sleep/wake cycles but virtually every function of our bodies.

Melatonin is normally released in the evening, stimulated by darkness. In the morning and during the day, it’s largely shut off.

Synthetic melatonin mimics the effects of our own melatonin. It has both a “hypnotic” (sleepiness-inducing) effect when given in larger doses (3 or 5 mg) shortly before bedtime and a “chronobiotic” (shifts the body’s circadian rhythms so that sleep occurs earlier) effect when given in much smaller doses (½ mg) earlier in the evening. A bedtime dose is typically recommended for children with difficulty falling asleep.

Studies suggest that use of synthetic melatonin does not suppress the body’s natural production of the hormone.

What you see may also not be what you get when it comes to melatonin. A recent study measured the actual amount of melatonin in 31 different brands and found a huge amount of variation from the melatonin content listed on the label, both significantly less than and greater than the claimed amount. This variability was found across brands and even from one lot to another within a given brand. For this reason, we strongly recommend use of “pharmaceutical grade melatonin” to produce reliable and consistent effects (this can be found online).

You should also be aware that many non-sleep products may contain melatonin as a secondary ingredient. Two examples are children’s “nighttime cough syrup” and “relaxation” drinks. Always check the label.

Can melatonin help my child sleep?

There is good scientific evidence melatonin can shorten the time to fall asleep in children with insomnia, including children with ADHD, autism and other neurodevelopmental disorders. While melatonin can be an effective short-term solution to address bedtime problems, children with neurodevelopmental disorders may benefit from longer-term use in some cases. It should be noted that the “immediate release” formulation does not help with difficulty staying asleep (melatonin levels in the blood peak at about 2 hours after it’s given). There is some evidence to suggest that extended-release melatonin may help with night awakenings in children, but there are far fewer studies to support this use, and the extended release formulations require the ability to swallow capsules.

There are many reasons why children may have trouble falling asleep: anxiety, restless legs symptoms (needing to move the legs at bedtime, often associated with uncomfortable feelings in the legs) or a too-early bedtime are just a few. Before considering melatonin, have your pediatrician conduct a thorough evaluation for other potential causes.

If after a thorough assessment, melatonin use seems appropriate in a given child with insomnia, it should never be a “stand alone” solution and should always be accompanied by behavioral interventions. These include temporarily delaying the bedtime to more closely match the actual fall asleep time, using “check ins” at bedtime and providing positive reinforcement for staying in bed. Paying attention to healthy sleep practices like having a regular bedtime and wake time seven days a week and having a regular bedtime routine is also key. Case in point: melatonin won’t help a child or teen who’s on their electronic device just before bed. These light-emitting devices actually suppress the body’s natural release of melatonin.

In general, melatonin should not be given to healthy, typically developing children under age 3, as difficulties falling and staying asleep in these children are almost always behavioral in nature.

Melatonin is also used as part of the treatment program for teens with a circadian rhythm disorder called “delayed sleep phase” in which the natural fall asleep and wake times are much later than normal (by three hours or more) and interfere with normal daily activities. Management usually includes gradually adjusting the sleep schedule and avoiding light exposure in the evening with increased light in the morning in addition to melatonin, and is best carried out by a sleep specialist.

Is melatonin safe for children?

It’s no wonder parents are uncertain about this. If you surf the web, you’re likely to get mixed messages:

  • “Australian experts called the increase in use among children ‘alarming’ and warned in 2015 that parents shouldn’t give it to their children.” WebMD
  • “Melatonin, according to more than 24 studies, is safe for children and has been used with little to no side effects.”
  • “Currently, we don’t have any evidence to say that taking melatonin on a daily basis in that sense is harmful, although there are no large-scale multicenter clinical trials to really test that.” Medscape

This last quote is probably closest to where we actually are. However, it is clear there has been a dramatic increase in use of melatonin in children in the past five years or so. For example, in England (where melatonin is only available by prescription), estimates have found a 25 percent increase in melatonin prescriptions in children under 18 between 2015-16 and 2017-18, and a 40 percent increase in the extended release forms during the same period. There are no similar statistics in the U.S. for over-the-counter melatonin, but it is now rare in our experience that children coming to the Boston Children’s Sleep Clinic with insomnia are not already on melatonin, usually recommended by their pediatrician. 

In general, melatonin seems to have relatively few side effects in children, most of them minor, such as headaches, increased bedwetting, nightmares, dizziness, mood changes and morning grogginess, and all of which disappear with discontinuation. However, there are ongoing concerns based on studies in animals showing melatonin can affect puberty-related hormones. While there is very little evidence to suggest this is true in humans, the reality is no long-term clinical trials, which would settle the question, have yet been conducted.

When should melatonin not be used?

As mentioned above, children lose sleep for many reasons. Avoid melatonin:

  • if the insomnia is situational (stemming from anxiety about a new school year, for example)
  • if the insomnia is short-term (caused by an ear infection, for example)
  • if the insomnia is due to an underlying physical cause (like sleep apnea or restless legs)
  • if your child is younger than 3

Melatonin should never substitute for healthy sleep practices: a regular, age-appropriate and consistent bedtime and bedtime routine, no caffeine, and no electronics or screens before bedtime.

What’s your bottom-line advice?

Consider melatonin only in consultation with a health care provider. Melatonin is likely to have the least risk and the most benefit if your child has significant difficulty falling asleep and when it is used in combination with behavioral interventions and healthy sleep practices.

Learn more about the Boston Children’s Sleep Center.

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