Termination of short term melatonin treatment in children with delayed Dim Light Melatonin Onset: Effects on sleep, health, behavior problems, and parenting stress

Abstract

Objective

To investigate the effects of termination of short term melatonin treatment on sleep, health, behavior, and parenting stress in children with delayed Dim Light Melatonin Onset.

Methods

Forty-one children (24 boys, 17 girls; mean age = 9.43 years) entered melatonin treatment for 3 weeks and then discontinued treatment by first taking a half dose for 1 week and then stopping completely for another week. Sleep was measured with sleep diaries filled in by parents and with actometers worn by children. Analyses were conducted with linear mixed models.

Results

Sleep latency was longer during the stop week compared to the treatment weeks. Sleep start was later and actual sleep time was shorter during the half dose and stop weeks compared to the treatment weeks. Sleep efficiency deteriorated in the stop week. Dim Light Melatonin Onset was earlier after treatment, but this effect disappeared after the stop week. In addition to the effects on sleep, results from questionnaires completed by parents showed that melatonin treatment also had positive effects on children’s health and behavior problems and parenting stress. While health deteriorated after treatment discontinuation, the effects on behavior problems and parenting stress remained. Behavior problems at baseline did not influence the effect of melatonin treatment.

Conclusions

This study showed that complete termination of treatment after 4 weeks of melatonin use was too early. However, clinicians may advise a lower dose after a successful treatment trial of several weeks.

Introduction

Sleep onset problems are common among children. Different studies report prevalence rates varying from 11% [1] to 30% [2] or even 40% [3] of school age children who have problems falling asleep. Considering the negative consequences of sleep problems on health, interpersonal relations, psychological functioning, daily activities [4], [5], and school functioning [6], [7] it is important to treat these problems.

The pineal hormone melatonin plays a central role in the synchronization of circadian rhythms, especially the sleep–wake rhythm. Its secretion is inhibited during the day, but increases at night [8]. In some children endogenous melatonin secretion is delayed, which causes them to be unable to fall asleep at an appropriate time. This delay in melatonin secretion might be associated with a Per3 polymorphism in rare cases [9]. Exogenous melatonin, if well timed and administered in the right dose, can phase-shift the melatonin and sleep–wake rhythm [10].

Although many studies have shown that melatonin treatment has direct positive effects on sleep onset and health [11], [12], [13], optimal treatment duration has not yet been established and is mostly patient dependent. Consequently, melatonin is often used for an indefinite time and patients are advised to stop every now and then to see whether sleep problems return [14], [15]. Although several studies presented results after a relatively short treatment time [11], [12], [13], information concerning discontinuation of treatment is missing. Because more knowledge about the effects of treatment discontinuation in different phases of treatment (short, medium, long) can help to find optimal times for treatment termination, we explored the effects of short term treatment. An additional reason for examining short term treatment effects is that there is a (theoretical) risk that delayed puberty onset is related to long melatonin use [16].

There is only one study [17] that examined the effects of termination of short term (3 weeks) melatonin treatment on sleep, health and behavioral variables. In this pilot study, the positive effects of melatonin disappeared almost completely after abrupt treatment discontinuation. As the abrupt discontinuation of melatonin might have diminished the effects of melatonin on sleep, in the present study we examined the effects of half-dose treatment and thereafter complete discontinuation of melatonin. An additional advantage of half-dose treatment is that we could also investigate whether a lower dose was still effective. To our knowledge, this study is the first to investigate the effects of half dose and discontinued short term melatonin treatment on children.

In addition to the chronobiotic (phase-advance) and hypnotic (sleep promoting) effect, we also examined the effects of termination of melatonin on health, behavior problems and parenting stress. Sleep, health, behavior problems and parenting stress appear strongly related [4], [5], [18], [19], [20]. Therefore, we hypothesized that melatonin treatment would not only have positive effects on sleep, but also on these other variables. We expected the positive effects on health, behavior problems and parenting stress to remain after melatonin discontinuation only in cases where the positive effects on sleep remained. The question whether behavior problems influence the effects of melatonin treatment and melatonin termination was also examined in the present study.