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Melatonin Wake Up Call · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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Music.
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For the busy pediatric practitioner. Today, a wake-up call about melatonin.
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Joining me here in the podcast studio is Dr. Karen Henschel-Franks.
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She's a fellow at the Academy of Pediatrics and also a fellow of the American
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Academy of Sleep Medicine.
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Dr. Franks, thank you so much for being here in the podcast studio today.
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Thank you very much. It's a pleasure. Sure.
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Karen, so what is the wake-up call?
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How big of an alarm is sounding when it comes to melatonin, which we know is so popular right now?
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Melatonin is incredibly important at this time.
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The CDC reports that there were 11,000 infants and children who visited the
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emergency room after accidentally taking melatonin.
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This is a wake-up call for all of us, and it should remind us that we need to
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educate parents, children,
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about the importance of how to take melatonin and how to actually sleep better at night.
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So, Karen, melatonin, it's a supplement. Yes.
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Melatonin is a supplement, but actually it's a natural hormone that helps us
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regulate our sleep-wake time, but it is now widely used as an over-the-counter
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and marketed as a sleep aid.
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Unfortunately, it is not regulated by the FDA as a medication.
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It is a dietary supplement, which is a problem at this point.
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There can be a variation in the the amount of melatonin found in the bottle.
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Symptoms of melatonin overdose can include headaches, dizziness, and irritability.
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How do you know if it's so severe that the child needs to go to the emergency room?
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It can be very difficult because they do have overdose symptoms that are headaches,
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dizziness, and irritability.
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And as they increase, parents may not realize that this is actually the melatonin
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causing these symptoms.
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And also, parents don't know the dose of melatonin. And there are no actual
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dose or guidelines by age or weight for melatonin.
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So some parents will use one pill, two pills, or continue to take as many as they think are needed.
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So it can cause even more issues.
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There's something specific to look for on each bottle of these if you are taking melatonin.
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Some of the bottles will have recommendations.
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Some will not. But however, like I said, there are no guidelines for dosing
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based on age or weight for when to give or how much to give for melatonin.
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Or is there something you were saying to look for that it shows that this bottle was checked out?
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Aaron should look for a product when they are selecting for melatonin.
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They should look for a USP verified mark.
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That'll show that the medication was checked and that you'll know that if it
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says three milligrams or five milligrams or one milligram,
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that it was verified how much milligrams were in each tablet.
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Do we know the long-term effects of melatonin. In children, there are no long-term
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studies at this time. So we just don't know.
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No, in children at this time, we don't know. Would you recommend that the pediatric
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practitioner not recommend melatonin across the board? Try other methods first?
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Pediatricians know the patient the best. Pediatricians need to look at the patient
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individually and then make the decision,
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but always start with sleep hygiene,
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with the patient behavioral interventions, and then my last step would be to use melatonin.
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Sleep hygiene, especially with the older kiddos, turning off screens.
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Taking the phone off at least an hour before bedtime, using black shades,
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not letting the kiddos stay up more than an hour past their bedtime on the weekend and vacations.
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Also addressing other medical problems such as snoring or asthma are all great things to start with.
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When is it time to refer out? If the parents or the pediatrician felt there
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were medical problems such as snoring and sleep apnea,
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if the parents and the pediatrician thought that behavioral interventions would help with insomnia,
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that would be a wonderful place to start.
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Do you Do you, in your clinic, do you prescribe melatonin?
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I do prescribe it, but not for a long term in normal patients that have no medical problems.
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So as a last resort, what I normally do is first start with sleep hygiene and
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behavioral interventions before I would go with medication.
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I talk with the family, get a good idea of what they're doing at night and see
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what problems they're having and address those problems.
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Right now at bedtime, there are many different things that are going on and
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it's hard for someone to go to bed.
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And I would address those issues first and then go to medications as a last resort.
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Because it should be considered a medication even though it's a supplement? Yes.
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Because it's affecting the brain. Yes.
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Any supplement such as melatonin, I still consider a medication.
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And that is usually one of the last things that I...
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Give to the patients. I usually will start off with sleep hygiene,
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what they do before they come to go to bed, how are they going to bed,
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what problems are they having.
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Let's address what's going on at home, what issues you are having or going to bed.
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And from there, let me hear what problems they're having.
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Let me have the kiddo talk to me and let me know what they're feeling.
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And then from there, I can one by one address the problem.
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And as a parent, when you think about bedtime, it's not, and with kids,
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it's not like, oh, this is the most relaxing time ever. It's usually stressful.
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And then that's not helping things too. You know that you want to I make it
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as relaxing as possible, but it's, I mean, why is it so hard to get kids to bed?
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Is it part of that end of the day? Everybody's kind of wound up.
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And then when the parent gets more frustrated, then that's not helping and it's
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causes more stress is, do you want to give us some advice there?
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It's a combination of everything they want.
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It's the end of the day. They have had a busy day and they want to do more things.
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The parents are tired. they're exhausted, they're busy as well.
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And you put the two together and it's hard to get everyone to go to sleep.
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Also, if the kids have other things they want to do, then it's difficult for them to go to sleep.
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Also, the iPhone, the iPad, it is very difficult to get rid of and then to have a child go to sleep.
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This is probably the easiest thing to give a patient after school,
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but it is the hardest thing to get rid of before they go to bed.
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And it is the hardest thing then to have them go to sleep.
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And so these are things we have to address with the parents and try to get them
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to do other things and try to get the child to do other things so that they can go to sleep.
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And even when they get home from school, if they can play outside or have some
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exercise, that's going to help. Yes.
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Going outside, playing, do other things other than video games,
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iPhones, watching TV, anything will help.
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And this, especially, and then on the iPhone or the iPads, our cell phone,
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a video call with friends, social media, all of that wakes us up, right?
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Yes. The light from the phone, from the video games, all tells your brain to
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stay up and to keep you up.
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The NPR recently had a story about the perils of melatonin and the situation sounds like it's dire.
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I mean, that it's being way overused.
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The pediatrician who was quoted in the story said she wouldn't like to see a
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kid use it more than once or twice a year.
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Would you say that that's accurate? I think with melatonin, once you start to
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use it, you have to then work with the patient to train them to get off of it.
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So that then they'll only having to use it less and less.
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So you may start them that they're using it a couple of days and then after
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that, slowly wean them off. I think that's the best thing to do.
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So it would be okay for a couple of days to get into a routine?
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Get into a routine and then once you get that
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patient back into a routine then to
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wean the melatonin off and is there
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something about sleeping pills in general where it can be
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you feel like you have to like there's this placebo effect too where now i'm
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going to sleep well or fall asleep because i took this but tomorrow night if
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i don't then i'm not going to yes recently i just saw a patient and they were
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finally got a good routine going they were sleeping well.
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And the patient was asking for a medication. And the mom said, why?
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And she said, well, because I normally take that. And the mom said,
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do you think you need it? And she said, no.
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And then when she went to bed without it, she realized, oh, I really don't need it.
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So I think a lot of times patients do think that they need it and they really
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don't. They need the confidence to believe they don't need it as well.
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And I mean, we've all been there where you lie down to sleep and then your mind starts going.
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Do you think for kids, do you recommend trying to introduce some sort of meditation
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before bed, a guided meditation or anything like that?
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There's multiple things you can do. One of the things I like to do is imagery,
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where you have the kid think of something that they like.
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It could be, for some patients, I have a girl who wants to dream of going to
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New York and shop on Fifth Avenue, and that's how she goes to sleep.
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Ooh, that sounds like a nice dream. I have another girl.
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She's never left Texas and she dreams of walking on the beach in Hawaii.
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And she could tell you every fish. She could tell you everything about Hawaii.
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I have another boy, he plays for the NBA, and he can tell you every team he's beat.
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So it all depends on imagery and how they think of what they're thinking before
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they go to bed. You need to change it.
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Because I find with my youngest daughter, she'll bring up the most stressful
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thing that happened that day or that's on her mind. It's usually as I'm tucking her into bed.
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Yes. It's very easy because it's quiet now. And in their head,
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everything that happened bad will come at that time.
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So another thing you can do is an hour before they go to sleep,
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whatever bad happened that you have them write down.
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And then you put it away and you tell them we're going to not think about any
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of these things until tomorrow.
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And then you give them something good that they can think about.
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And then that's how they decide. side.
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And then also the hour before they go to sleep, the parent will tell them good
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things that they did during the day.
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And all kids, you can find one or two good things that they did.
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When a patient comes in the room right away, I can always find one or two things.
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And I'll tell the parent, look at the patient did A, B, or C.
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And the mom will be like, wow. And the kid will look at me Like,
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you don't even know me, but I can find two or three good things about everybody.
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And I'll tell the parent that, okay, now you think about that before you go to bed.
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And I'll give them things so that they have something to think about other than that bad thought.
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I love it. Can you tell, like, what's an example? Like, how would you say that?
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Well, when I walk in and I see a kiddo and she has on a nice outfit or her hair
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is beautiful. And I'll say, oh, who did your hair?
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And she'll say, oh, I did it myself. I said, oh, I love it.
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Oh, who picked out your outfit? Oh, I did. And then that's what I'll bring up.
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And then I'll have another little boy who I saw and he was coloring and it was a great picture.
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And I'll say, that's a wonderful picture you did.
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And then I'll bring all that up. I try to find something when I walk in,
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something that they did wonderful or something that I think is good.
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And then I just point that out throughout when I'm talking to them.
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And then I try to give them confidence during the visit. And that's instantly...
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Reassuring, relaxing. Yes. The opposite of stressful.
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Yes. So once I find something that I think that they're going to feel confident
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about, then also I tell them, okay, before you go to bed, now I found something. You can try these.
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Or can you find something? Because sometimes when I'll ask a teenager,
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okay, where do you want to go? What would you do?
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And they're like, I don't know. And then once I start telling them,
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well, I like this, I like this that you do, and they're like,
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well, how did you figure that out? And then they're like, okay.
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And then they try to top me. And then they'll start saying, okay,
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what about, well, I like this.
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And then it goes on and on, and then we can have a good conversation. I love that, Dr.
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Franks. And as parents, if we're not intentional about it,
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it can be easy to point out stuff that's going wrong or to correct the child,
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but to really point out what's going great and what they're doing right and
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to vocalize that is important, sounds like. Yes.
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That's why whatever they did wrong, point out immediately after they came home
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from school, but that hour before school, before they go to bed.
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Find something good and let them know you love them.
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I love that. And then as adults, as we're trying to get to sleep,
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kind of everything we've talked about here applies to us. Yes.
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As an adult, you can do the same thing. Imagine something.
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Forget about your job. Forget about what you did, who did what, and how horrible it was.
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And imagine, you know, you won a million dollars.
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And where would you go? What would you do? You won a trip somewhere.
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Where would you go? What would you do? So it's kind of like that's the benefit
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of reading a story and imagine, you know, you're letting your imagination.
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Exactly. Except for the adult, you can make it more expensive.
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And then we won't have the credit card debt. Oh, no credit card debt. Don't think about that.
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You won the money and you can do whatever you want. Is it when we're imagining
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this or when we're reading before bed, is it better to do it in another area
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of the bed or in the chair in the bedroom?
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I've heard that. No, I would do everything in the bedroom and everything...
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Right before bed. That way, when you say goodnight, you walk out and then you
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shut the light and you say goodnight.
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And then when you, is it better for the child to be like on the other side of
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the bed when you're imagining?
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Like I've heard that too, like
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have the space be where you're actually going to go to sleep in the bed.
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Save that for when you're actually going to lie down. Or is that kind of too technical?
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No, I don't think they have to be as technical. Okay. It depends if they start
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getting really difficult to fall asleep, then you can get a little bit more technical.
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But in the beginning, I'm not as picky in the beginning.
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I'll get more picky as time goes on. I first start with them in the bed.
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And as long as I can get them in the bed and they'll go to sleep, then I'm happy.
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If I start having more issues in clinic, then I'll start to get a little more picky.
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So can you tell me about your clinic? Like, do you see patients at the clinic,
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at university hospital first?
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They'll come and see me first. And it's for various complaints.
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It could be for sleep apnea. It could be for insomnia.
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It could be for narcolepsy.
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And I'll address whatever concerns that they have at that time.
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Many times it's for a combination of several things where they'll say,
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well, I can't fall asleep, but I have horrible snoring. And then I'll say,
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okay, let's address that, your problem that you can't sleep.
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And then once I have them to the point where they're sleeping well,
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then the next couple of visits, then I'll start addressing, okay,
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now let's address the snoring.
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And then after a while, I've gotten several complaints.
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And then I've taken care of a couple of concerns with a couple of visits.
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And when you talk about before bedtime and what you say, are you role playing
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in the clinic or is that actually because you do studies where it's at a hotel
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where the child's asleep and you're measuring the sleep? Yes.
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When we do the sleep study, we're doing the actual sleep study that we would
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normally do in the hospital, but we're doing it in the hotel so it's a more
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comfortable place so that they don't hear what happens in the hospital.
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They are doing it now in the hotel, but it's the exact same study.
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Are you there doing that or is it someone from your team? No,
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it's somebody else. It's at night.
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From your team? Someone from our team is actually doing it. Anything else you
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want to say about melatonin?
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I think the pediatrician should ask the patient if they're taking it,
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what type of melatonin they're taking, and monitor how much they're using.
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And then as quickly as they put the patient on, try to wean them off.
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And I think from there, you'll get a good response.
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And so no more than two days? The daytime, it depends on the type of patient they have.
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It'll depend on the medical problems that they have, and I'll leave that to
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the pediatrician. But as long as they're monitoring it, from there, we can figure it on out.
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If we don't know what happens long term, that sounds kind of scary to me.
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Yes, it is very scary, and that's why I think the pediatricians should keep
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an eye on how much they're using the melatonin and not for kids that have normal medical problems,
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not keep it for a long period of time.
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And do you recommend not eating a few hours before bed or anything there you want to say?
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I would keep what you eat very light before bed. I wouldn't have a big meal before bed.
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I have a lot of patients that come and they have dinner and then they go straight
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to bed and they have stomach aches and then they're not eating afterwards.
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I try not to have anyone eat before they go to bed,
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but some kids may be very hungry if they played soccer right beforehand or if
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they did basketball and they may need a little snack beforehand before going
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to bed, and they usually will make that a light snack.
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But if it's a big dinner, have it at least a couple hours before that? Yes.
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Knowing what you know, and you have so much knowledge about sleep and melatonin,
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if you were having a hard time sleeping, would you take melatonin?
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No. The first thing that I would do if I'm having a hard time sleeping would
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be to look at what I'm doing at night.
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I would look at, am I getting enough sleep?
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What am I doing before I go to sleep? and what could I change?
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And then as a last resort, I would use melatonin.
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Is it okay to watch a show that's not stressful, like something you've seen
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before that's very relaxing if someone doesn't like to read books?
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TV, I don't think I would go for because that's the light from the TV and I
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think that may keep kiddos up.
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I would try to do things that don't have a lot of light,
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And I would stay away from the iPad, the iPhone, and I would look more into
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conversation, reading, and look into things that would try to get them a little more relaxed.
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Do you do the same routine before bed? I try to do the same thing before bed unless I get paged.
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Then you're not going to sleep. Yes. Do you like to read before bed or do you
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want to tell us a little bit about that? Usually before bed, I do read.
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And I pretty much have the same routine every night.
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I do talk to my teenage daughter.
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And I try to talk to at least one or two. I have one who's at home still.
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I have a son who's at A&M and I have a daughter who's in medical school.
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So each day I try to talk to at least one of them to make sure how they're doing before I go to bed.
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And then I'll read and I'll talk to my husband, of course. And then I go to sleep.
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Unfortunately, that can vary
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depending if I'm getting paged from somewhere. But usually after that.
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Sleep is usually not a hard thing for me to do. My husband is amazed how I can
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fall asleep pretty quick.
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And even though you're thinking about sleep issues a lot throughout the day,
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what do you do to unplug in your spare time?
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Now that my children are older and I don't have to go to soccer games anymore,
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I started running and walking and I just finished my first 10K at Disney World.
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That's awesome. Tell me about that.
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That was exciting. I actually went down to Disney World last week,
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and it started off at Epcot, and you started outside of Epcot.
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It was very early in the morning, though.
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And then you ended doing it, going all around Epcot, going through all the countries,
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and you had actually people from every country cheering you on, waving at you.
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You could take pictures with all the characters.
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And you actually had people taking pictures of you as you walked through,
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as you ran past countries.
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And it was exciting. And this is for the adults?
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Anyone over 10 could do it. That sounds wonderful.
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And you were telling me, and Disney also has events for adults or the pediatric
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practitioner listener who may be looking to get away for a good cause. Yes.
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I am also going to do another race and I want to be raising money for a charity as well.
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Nice. What inspired you to focus on sleep medicine?
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I was actually doing a fellowship in pulmonary, and when I was interviewing,
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the person who interviewed me said, you should look into sleep.
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You will like it. And I was like, are you sure?
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She says, yes, just do one rotation with us, and you will love it.
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And my first rotation was incredible. And then from there, I told my fellowship
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director, I said, this is what I want to do.
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Karen, is there anything else you want to mention that we didn't talk about
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today about melatonin or sleep or anything for the pediatric practitioner?
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It was a pleasure to do this. And that if the pediatricians have any questions,
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I am available always if they need any kind of help and that it is important sleep for pediatrics.
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I think sometimes it is neglected and the parents are not always.
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If the pediatrician doesn't ask, the parents don't know to tell them that it is a problem.
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So bring it up on every visit? Bring it up on your visits.
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That's a great point. Because there's so much to cover. It's hard to know.
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And that is hard as a pediatrician. I don't think people realize how much a
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pediatrician actually does and how busy a pediatrician is and how much work they really do.
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I am so impressed. it's amazing what they do.
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For our pediatric practitioner and listeners, we do have a new podcast called
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Pediatrics Now for the parent, for the busy parent, and that's health news in small bites.
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We will have this episode with information on sleep hygiene and melatonin.
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So you can tell your patients about Pediatrics Now for parents,
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and hopefully that will give a little bit more of an in-depth explanation and
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one, you know, save you a few minutes in the exam room, hopefully.
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So Dr. Karen Henschel-Franks with the University of Texas Health Science Center
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and University Hospital, thank you so much for being here today on Pediatrics Now.
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Thank you. You're going to sleep well tonight.
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Great job. Thank you. Karen, here on Pediatrics Now, as our listeners know,
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we love quotes. I love quotes.
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Do you have a favorite quote you'd like to share with us today?
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Yes. You are braver than you believe, stronger than you seem,
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and smarter than you think.
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It's from Disney's Christopher Robin.
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I love it. That might be a nice thing to say before tucking someone into bed.
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Thank you so much. Click on the link in this podcast for free credit that may
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include CME, MOC, or ethics credit, depending on our topic.
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Music.
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Podcast it's called pediatrics now for parents health news and small bites for the busy parent,
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here's a clip from an episode on vaccine hesitancy a
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lot of the diseases that pediatricians and the scientific community has been
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really successful at eradicating have become out of sight out of mind you know
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things like polio that the generation in front of us are two generations in
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front of us depending on the age of the parents who are listening to this you know grew up with as a as
28:44
a real world threat is something that they would see signs on the front of houses,
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signs on the front of stores.
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Those days are over and they're over because of the success of vaccination.
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So things like diphtheria, everyone knows the story of the Iditarod and the dog sled races.
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No one remembers why those dogs were doing that heroic effort.
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People don't remember the polio days. People don't really remember the measles or rubella days.
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Even I, you know, I'm in my mid forties and I, you know, That era is a dim memory
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at the beginning of my childhood of chickenpox and things like that.
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So as a result, when those aren't daily threats to our children,
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they sort of fade back to the back of our priorities, right?
29:27
We're trying to get kids to school.
29:28
We're trying to get all the shopping done. We're trying to make sure they're
29:31
staying safe online and make sure they're staying away from firearms.
29:35
It's not a clear and present danger like it was 20, 30, 40 years ago,
29:40
but But it can be and it will be again if our vaccine rates keep dropping.
29:45
And so even though it doesn't seem like it's the most immediate thing to worry about,
29:48
we have to, you know, unfortunately use outbreaks like this,
29:52
epidemics like this to remind ourselves that we're only a couple of,
29:55
you know, months or years of poor vaccination away from being right back in the mix again.
30:01
Our website is pediatricsnowpodcast.com. My email address is on there.
30:06
Please email me with episode ideas or comments.
30:11
Thank you so much for listening. I'll see you.
30:14
Music.