Pediatric Primary Care Case Studies (20 page)

Medications

There is little scientific evidence for best approaches to pharmacologic treatment of sleep problems in children and adolescents. Most medications used to treat sleep problems are prescribed without Food and Drug Administration (FDA) approval, also known as off label use (Pelayo & Dubik, 2008). Most teens do not require medications, but pharmacologic therapies should be considered in cases where there is significant trouble initiating or maintaining sleep. Because prescription hypnotics are not indicated for use in children younger than 18 years, primary care therapies for insomnia should be used for only brief periods and should focus on use of two types of medications: antihistamines and melatonin.

The first generation antihistamines are known for causing drowsiness. Diphenhydramine is the most common ingredient in over-the-counter sleep aids and has been shown to decrease time to sleep and number of night-time awakenings when taken shortly before sleep (Pelayo & Dubik, 2008). Peak blood levels typically occur within 2 hours of dosing, and average duration of activity is 4 to 6 hours (Pelayo & Dubik). Normal adult doses are 25 to 50 milligrams. Common side effects include dizziness and daytime drowsiness, although significant side effects are rare and diphenhydramine is considered to have a good safety profile. A small but significant number of children will actually have paradoxical arousal from this medication, so caution should be used with the first dose.

Melatonin is available over the counter and is given to mimic the normal secretion of melatonin by the pineal gland. Melatonin levels cycle in a circadian rhythm and are generally highest at night and lowest during the day (Pelayo & Dubik, 2008). Blood levels typically increase 1 to 2 hours prior to bedtime and are considered to be the final trigger for sleep (Wagner, Wagner, & Hening, 1998). Melatonin is indicated for use in jet lag, in blindness-induced circadian rhythm disturbances, and in delayed sleep patterns (Mindell & Owens, 2003). Adult doses of melatonin are 1 to 3 mg and demonstrate best response when taken 2 hours prior to sleep (Pelayo & Dubik). There are two important issues to consider with melatonin. First, it is considered a diet supplement and therefore is not regulated by the FDA for safety, purity, or efficacy (Wagner et al.). Second, the National Sleep Foundation warns against melatonin use in individuals with immunodeficiencies, lymphoproliferative disease, and those taking corticosteroids or immunosuppressants because of its effect of enhancing immune function (Toitu, 2001). Side effects include nausea, headache, and lightheadedness (Mindell & Owens).

How would you manage Jennifer at this time?

Patient Education

The cornerstone of treatment for inadequate sleep is patient and family education about sleep needs and good sleep hygiene. Parents and adolescents must
be taught that teens need 9 to 9½ hours sleep at night and that naps, when taken, should be brief (no longer than 30 to 45 minutes). Naps should only take place in the early afternoon. Sleep hygiene instruction should focus on developing good sleep schedules, making the bedroom “sleep friendly,” encouraging health habits, promoting bedtime routines, and avoiding sleep disturbances (
Table 5-3
).

You help Jennifer recognize that her sleep patterns are the most likely cause of her fatigue. Your education begins by talking to Jennifer about ways she might make her bedroom more sleep friendly. You teach her to turn off her cell phone and computer before going to bed. You suggest that she only go to bed when sleepy and that she listen to music before getting into bed. Jennifer agrees to go to bed once she feels sleepy and to not try to “fight” her sleep. She agrees to set routine sleep and awake times and to not deviate more than one hour from these times. You review healthy nutrition and suggest a routine exercise program in the mid to late afternoon. Jennifer’s mother commits to making sure she does not schedule evening activities and promises to help Jennifer wake up in the morning.

Once school starts, she will no longer work her lifeguard job. When babysitting, Jennifer decides to make phone calls and work on homework after her neighbor’s children go to sleep so that she can go to bed within 30 minutes of arriving home.

Lastly, you decide to have her try melatonin 3 mg PO at bedtime for the next week until her sleep routines are better regulated.

Is there anything else you would add to the plan at this time?

Jennifer may need to make some adjustments in the time she spends with friends and the hours in which she talks with them. You and Jennifer need to agree upon a plan to inform her mother of the diagnosis and the plan that has been established.

When do you want Jennifer to follow up with you?

Follow-Up Parameters and Expected Outcomes

Adolescents with fatigue should be followed closely until a cause of their fatigue is found. Parents and adolescents should be asked to keep in close contact with the healthcare provider and should return for re-evaluation if symptoms change or worsen. Most critical for prompt evaluation is the development of fever, activity intolerance, abnormal bleeding or bruising, or fatigue that suddenly worsens or persists beyond a few weeks. Psychiatric referral for evaluation is indicated for fatigue that lasts more than 3 months in afebrile adolescents with normal physical findings and laboratory results (Feins, 1999). Referral to sleep specialists is indicated for failure to respond within 1 month of establishing sleep routines, if primary care pharmacologic intervention fails or if prolonged pharmacologic treatment is required (Howard, 2001; Mindell & Owens, 2003).

You call Jennifer 2 weeks after her recheck appointment. She informs you that her fatigue is significantly decreased and she is no longer using the melatonin. She eliminated caffeine after 6:00 p.m. and implemented the sleep hygiene plan you created with her. You schedule a well examination in 3 months and tell her to call you if her symptoms recur or if she has questions or concerns.

Key Points from the Case

1. Fatigue is a complex symptom that is influenced by a number of factors.

2. Fatigue is a universal complaint that is especially common during adolescence.

3. It is essential that the evaluation of fatigue focuses on the diagnosis of underlying medical conditions that result in fatigue.

4. The most common cause of adolescent fatigue is insufficient sleep and poor sleep hygiene.

5. Adolescent sleep problems are best managed with behavioral modification and the development of good sleep habits. Medications should not be used in most cases and should be limited to use of antihistamines and melatonin in primary care settings.

6. The management plan needs to consider the adolescent’s developmental level and milestones currently being achieved in order to support those important activities of their age.

REFERENCES

American Academy of Child and Adolescent Psychiatry. (2004).
Depression in children and adolescents
. Washington, DC: American Academy of Child and Adolescent Psychiatry.

Carter, B. D., Kronenberger, W. G., Edwards, J. F., Michalczyk, L., & Marshall, G. S. (1996). Differential diagnosis of chronic fatigue in children: Behavioral and emotional dimensions.
Developmental and Behavioral Pediatrics, 17
(1), 16–21.

Feins, A. (1999). Fatigue. In R. A. Dershewitz (Ed.),
Ambulatory pediatric care
(3rd ed., pp. 913–915). Philadelphia: Lippincott-Raven.

Ghandour, R. M., Overpeck, M. D., Huang, Z. J., Kogan, M. D., & Scheidt, P. C. (2004). Headache, stomachache, backache, and morning fatigue among adolescent girls in the United States.
Archives of Pediatric and Adolescent Medicine, 158
, 797–803.

Giger, J. N., & Davidhizer, R. E. (2004).
Transcultural nursing: Assessment and intervention
(4th ed.). St. Louis, MO: Mosby.

Green, M. (1998).
Pediatric diagnosis: Interpretation of symptoms and signs in children and adolescents
. Philadelphia: WB Saunders.