May 16, 2024 • 30 mins
Episode 35: Melatonin Wake Up Call
Link for CME credit
https://cmetracker.net/UTHSCSA/Publisher?page=pubOpen#/getCertificate/10095855
FACULTY:
Karen Hentschel-Franks, DO is an associate professor in Pediatrics-Neurology at UT Health San Antonio.
OVERVIEW:
Pediatrics Now host an executive producer, Holly Wayment and sleep expert Dr. Karen Hentschel-Franks discuss growing concerns over the use of melatonin in children and the importance of sleep hygiene.
Dr. Franks, a recognized expert in the pediatric and sleep medicine field, underscores the need for educating children and parents about the potential dangers, emphasizing possible side effects such as headaches, dizziness, and irritability. Furthermore, she warns about the lack of regulatory control over melatonin, pushing for awareness in selecting only those products with a USP verified mark as a last resort.
The discussion delves into the uncharted territories of melatonin’s long-term effects. Reinforcing the mantra of patient-centric care, Dr. Franks suggests thorough patient evaluation and implementing sleep hygiene, along with behavioral interventions, before resorting to sleep aids like melatonin.
She lays out practical sleep hygiene strategies, including limiting screen time before bedtime, maintaining consistent routines, and addressing medical concerns related to sleep. You'll also learn about innovative techniques Dr. Franks uses to cultivate effective sleep routines in her patients, such as imagination exercises and positive reassurances.
Dr. Franks encourages a holistic approach to children’s sleep problems, highlighting the importance of addressing potential behavioral and environmental factors over relying on supplements.
You will not only learn about the nuances of sleep but also gain intriguing insights into maintaining work-life equilibrium in a demanding field like sleep medicine. Explore Dr. Franks' favorite relaxation activities and get a sneak peek into her clinic's day-to-day activities!
Wrapping up the conversation is an inspiring quote from Christopher Robin that embodies the spirit of strength and resilience. Tune in for an exceptional blend of science, wisdom, and charm centered around better sleep health.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Music.
(00:05):
For the busy pediatric practitioner. Today, a wake-up call about melatonin.
Joining me here in the podcast studio is Dr. Karen Henschel-Franks.
She's a fellow at the Academy of Pediatrics and also a fellow of the American
Academy of Sleep Medicine.
Dr. Franks, thank you so much for being here in the podcast studio today.
(00:27):
Thank you very much. It's a pleasure. Sure.
Karen, so what is the wake-up call?
How big of an alarm is sounding when it comes to melatonin, which we know is so popular right now?
Melatonin is incredibly important at this time.
The CDC reports that there were 11,000 infants and children who visited the
(00:53):
emergency room after accidentally taking melatonin.
This is a wake-up call for all of us, and it should remind us that we need to
educate parents, children,
about the importance of how to take melatonin and how to actually sleep better at night.
(01:16):
So, Karen, melatonin, it's a supplement. Yes.
Melatonin is a supplement, but actually it's a natural hormone that helps us
regulate our sleep-wake time, but it is now widely used as an over-the-counter
and marketed as a sleep aid.
Unfortunately, it is not regulated by the FDA as a medication.
(01:39):
It is a dietary supplement, which is a problem at this point.
There can be a variation in the the amount of melatonin found in the bottle.
Symptoms of melatonin overdose can include headaches, dizziness, and irritability.
(02:02):
How do you know if it's so severe that the child needs to go to the emergency room?
It can be very difficult because they do have overdose symptoms that are headaches,
dizziness, and irritability.
And as they increase, parents may not realize that this is actually the melatonin
causing these symptoms.
(02:24):
And also, parents don't know the dose of melatonin. And there are no actual
dose or guidelines by age or weight for melatonin.
So some parents will use one pill, two pills, or continue to take as many as they think are needed.
(02:44):
So it can cause even more issues.
There's something specific to look for on each bottle of these if you are taking melatonin.
Some of the bottles will have recommendations.
Some will not. But however, like I said, there are no guidelines for dosing
(03:07):
based on age or weight for when to give or how much to give for melatonin.
Or is there something you were saying to look for that it shows that this bottle was checked out?
Aaron should look for a product when they are selecting for melatonin.
They should look for a USP verified mark.
That'll show that the medication was checked and that you'll know that if it
(03:34):
says three milligrams or five milligrams or one milligram,
that it was verified how much milligrams were in each tablet.
Do we know the long-term effects of melatonin. In children, there are no long-term
studies at this time. So we just don't know.
(03:55):
No, in children at this time, we don't know. Would you recommend that the pediatric
practitioner not recommend melatonin across the board? Try other methods first?
Pediatricians know the patient the best. Pediatricians need to look at the patient
individually and then make the decision,
(04:17):
but always start with sleep hygiene,
with the patient behavioral interventions, and then my last step would be to use melatonin.
Sleep hygiene, especially with the older kiddos, turning off screens.
Taking the phone off at least an hour before bedtime, using black shades,
(04:46):
not letting the kiddos stay up more than an hour past their bedtime on the weekend and vacations.
Also addressing other medical problems such as snoring or asthma are all great things to start with.
When is it time to refer out? If the parents or the pediatrician felt there
(05:06):
were medical problems such as snoring and sleep apnea,
if the parents and the pediatrician thought that behavioral interventions would help with insomnia,
that would be a wonderful place to start.
Do you Do you, in your clinic, do you prescribe melatonin?
(05:26):
I do prescribe it, but not for a long term in normal patients that have no medical problems.
So as a last resort, what I normally do is first start with sleep hygiene and
behavioral interventions before I would go with medication.
(05:48):
I talk with the family, get a good idea of what they're doing at night and see
what problems they're having and address those problems.
Right now at bedtime, there are many different things that are going on and
it's hard for someone to go to bed.
And I would address those issues first and then go to medications as a last resort.
(06:13):
Because it should be considered a medication even though it's a supplement? Yes.
Because it's affecting the brain. Yes.
Any supplement such as melatonin, I still consider a medication.
And that is usually one of the last things that I...
Give to the patients. I usually will start off with sleep hygiene,
(06:37):
what they do before they come to go to bed, how are they going to bed,
what problems are they having.
Let's address what's going on at home, what issues you are having or going to bed.
And from there, let me hear what problems they're having.
(06:58):
Let me have the kiddo talk to me and let me know what they're feeling.
And then from there, I can one by one address the problem.
And as a parent, when you think about bedtime, it's not, and with kids,
it's not like, oh, this is the most relaxing time ever. It's usually stressful.
(07:18):
And then that's not helping things too. You know that you want to I make it
as relaxing as possible, but it's, I mean, why is it so hard to get kids to bed?
Is it part of that end of the day? Everybody's kind of wound up.
And then when the parent gets more frustrated, then that's not helping and it's
causes more stress is, do you want to give us some advice there?
(07:40):
It's a combination of everything they want.
It's the end of the day. They have had a busy day and they want to do more things.
The parents are tired. they're exhausted, they're busy as well.
And you put the two together and it's hard to get everyone to go to sleep.
Also, if the kids have other things they want to do, then it's difficult for them to go to sleep.
(08:08):
Also, the iPhone, the iPad, it is very difficult to get rid of and then to have a child go to sleep.
This is probably the easiest thing to give a patient after school,
but it is the hardest thing to get rid of before they go to bed.
(08:30):
And it is the hardest thing then to have them go to sleep.
And so these are things we have to address with the parents and try to get them
to do other things and try to get the child to do other things so that they can go to sleep.
And even when they get home from school, if they can play outside or have some
(08:51):
exercise, that's going to help. Yes.
Going outside, playing, do other things other than video games,
iPhones, watching TV, anything will help.
And this, especially, and then on the iPhone or the iPads, our cell phone,
a video call with friends, social media, all of that wakes us up, right?
(09:16):
Yes. The light from the phone, from the video games, all tells your brain to
stay up and to keep you up.
The NPR recently had a story about the perils of melatonin and the situation sounds like it's dire.
I mean, that it's being way overused.
(09:39):
The pediatrician who was quoted in the story said she wouldn't like to see a
kid use it more than once or twice a year.
Would you say that that's accurate? I think with melatonin, once you start to
use it, you have to then work with the patient to train them to get off of it.
(10:00):
So that then they'll only having to use it less and less.
So you may start them that they're using it a couple of days and then after
that, slowly wean them off. I think that's the best thing to do.
So it would be okay for a couple of days to get into a routine?
Get into a routine and then once you get that
patient back into a routine then to
(10:23):
wean the melatonin off and is there
something about sleeping pills in general where it can be
you feel like you have to like there's this placebo effect too where now i'm
going to sleep well or fall asleep because i took this but tomorrow night if
i don't then i'm not going to yes recently i just saw a patient and they were
(10:43):
finally got a good routine going they were sleeping well.
And the patient was asking for a medication. And the mom said, why?
And she said, well, because I normally take that. And the mom said,
do you think you need it? And she said, no.
And then when she went to bed without it, she realized, oh, I really don't need it.
(11:07):
So I think a lot of times patients do think that they need it and they really
don't. They need the confidence to believe they don't need it as well.
And I mean, we've all been there where you lie down to sleep and then your mind starts going.
Do you think for kids, do you recommend trying to introduce some sort of meditation
(11:31):
before bed, a guided meditation or anything like that?
There's multiple things you can do. One of the things I like to do is imagery,
where you have the kid think of something that they like.
It could be, for some patients, I have a girl who wants to dream of going to
(11:51):
New York and shop on Fifth Avenue, and that's how she goes to sleep.
Ooh, that sounds like a nice dream. I have another girl.
She's never left Texas and she dreams of walking on the beach in Hawaii.
And she could tell you every fish. She could tell you everything about Hawaii.
I have another boy, he plays for the NBA, and he can tell you every team he's beat.
(12:17):
So it all depends on imagery and how they think of what they're thinking before
they go to bed. You need to change it.
Because I find with my youngest daughter, she'll bring up the most stressful
thing that happened that day or that's on her mind. It's usually as I'm tucking her into bed.
Yes. It's very easy because it's quiet now. And in their head,
(12:42):
everything that happened bad will come at that time.
So another thing you can do is an hour before they go to sleep,
whatever bad happened that you have them write down.
And then you put it away and you tell them we're going to not think about any
of these things until tomorrow.
And then you give them something good that they can think about.
(13:06):
And then that's how they decide. side.
And then also the hour before they go to sleep, the parent will tell them good
things that they did during the day.
And all kids, you can find one or two good things that they did.
When a patient comes in the room right away, I can always find one or two things.
(13:30):
And I'll tell the parent, look at the patient did A, B, or C.
And the mom will be like, wow. And the kid will look at me Like,
you don't even know me, but I can find two or three good things about everybody.
And I'll tell the parent that, okay, now you think about that before you go to bed.
And I'll give them things so that they have something to think about other than that bad thought.
(13:54):
I love it. Can you tell, like, what's an example? Like, how would you say that?
Well, when I walk in and I see a kiddo and she has on a nice outfit or her hair
is beautiful. And I'll say, oh, who did your hair?
And she'll say, oh, I did it myself. I said, oh, I love it.
Oh, who picked out your outfit? Oh, I did. And then that's what I'll bring up.
(14:15):
And then I'll have another little boy who I saw and he was coloring and it was a great picture.
And I'll say, that's a wonderful picture you did.
And then I'll bring all that up. I try to find something when I walk in,
something that they did wonderful or something that I think is good.
(14:37):
And then I just point that out throughout when I'm talking to them.
And then I try to give them confidence during the visit. And that's instantly...
Reassuring, relaxing. Yes. The opposite of stressful.
Yes. So once I find something that I think that they're going to feel confident
(14:58):
about, then also I tell them, okay, before you go to bed, now I found something. You can try these.
Or can you find something? Because sometimes when I'll ask a teenager,
okay, where do you want to go? What would you do?
And they're like, I don't know. And then once I start telling them,
well, I like this, I like this that you do, and they're like,
(15:21):
well, how did you figure that out? And then they're like, okay.
And then they try to top me. And then they'll start saying, okay,
what about, well, I like this.
And then it goes on and on, and then we can have a good conversation. I love that, Dr.
Franks. And as parents, if we're not intentional about it,
it can be easy to point out stuff that's going wrong or to correct the child,
(15:45):
but to really point out what's going great and what they're doing right and
to vocalize that is important, sounds like. Yes.
That's why whatever they did wrong, point out immediately after they came home
from school, but that hour before school, before they go to bed.
(16:05):
Find something good and let them know you love them.
I love that. And then as adults, as we're trying to get to sleep,
kind of everything we've talked about here applies to us. Yes.
As an adult, you can do the same thing. Imagine something.
Forget about your job. Forget about what you did, who did what, and how horrible it was.
(16:33):
And imagine, you know, you won a million dollars.
And where would you go? What would you do? You won a trip somewhere.
Where would you go? What would you do? So it's kind of like that's the benefit
of reading a story and imagine, you know, you're letting your imagination.
(16:53):
Exactly. Except for the adult, you can make it more expensive.
And then we won't have the credit card debt. Oh, no credit card debt. Don't think about that.
You won the money and you can do whatever you want. Is it when we're imagining
this or when we're reading before bed, is it better to do it in another area
of the bed or in the chair in the bedroom?
(17:13):
I've heard that. No, I would do everything in the bedroom and everything...
Right before bed. That way, when you say goodnight, you walk out and then you
shut the light and you say goodnight.
And then when you, is it better for the child to be like on the other side of
the bed when you're imagining?
(17:34):
Like I've heard that too, like
have the space be where you're actually going to go to sleep in the bed.
Save that for when you're actually going to lie down. Or is that kind of too technical?
No, I don't think they have to be as technical. Okay. It depends if they start
getting really difficult to fall asleep, then you can get a little bit more technical.
But in the beginning, I'm not as picky in the beginning.
(17:58):
I'll get more picky as time goes on. I first start with them in the bed.
And as long as I can get them in the bed and they'll go to sleep, then I'm happy.
If I start having more issues in clinic, then I'll start to get a little more picky.
So can you tell me about your clinic? Like, do you see patients at the clinic,
at university hospital first?
(18:20):
They'll come and see me first. And it's for various complaints.
It could be for sleep apnea. It could be for insomnia.
It could be for narcolepsy.
And I'll address whatever concerns that they have at that time.
Many times it's for a combination of several things where they'll say,
well, I can't fall asleep, but I have horrible snoring. And then I'll say,
(18:42):
okay, let's address that, your problem that you can't sleep.
And then once I have them to the point where they're sleeping well,
then the next couple of visits, then I'll start addressing, okay,
now let's address the snoring.
And then after a while, I've gotten several complaints.
And then I've taken care of a couple of concerns with a couple of visits.
(19:03):
And when you talk about before bedtime and what you say, are you role playing
in the clinic or is that actually because you do studies where it's at a hotel
where the child's asleep and you're measuring the sleep? Yes.
When we do the sleep study, we're doing the actual sleep study that we would
normally do in the hospital, but we're doing it in the hotel so it's a more
(19:26):
comfortable place so that they don't hear what happens in the hospital.
They are doing it now in the hotel, but it's the exact same study.
Are you there doing that or is it someone from your team? No,
it's somebody else. It's at night.
From your team? Someone from our team is actually doing it. Anything else you
want to say about melatonin?
(19:46):
I think the pediatrician should ask the patient if they're taking it,
what type of melatonin they're taking, and monitor how much they're using.
And then as quickly as they put the patient on, try to wean them off.
And I think from there, you'll get a good response.
(20:08):
And so no more than two days? The daytime, it depends on the type of patient they have.
It'll depend on the medical problems that they have, and I'll leave that to
the pediatrician. But as long as they're monitoring it, from there, we can figure it on out.
If we don't know what happens long term, that sounds kind of scary to me.
(20:33):
Yes, it is very scary, and that's why I think the pediatricians should keep
an eye on how much they're using the melatonin and not for kids that have normal medical problems,
not keep it for a long period of time.
And do you recommend not eating a few hours before bed or anything there you want to say?
(20:57):
I would keep what you eat very light before bed. I wouldn't have a big meal before bed.
I have a lot of patients that come and they have dinner and then they go straight
to bed and they have stomach aches and then they're not eating afterwards.
I try not to have anyone eat before they go to bed,
but some kids may be very hungry if they played soccer right beforehand or if
(21:23):
they did basketball and they may need a little snack beforehand before going
to bed, and they usually will make that a light snack.
But if it's a big dinner, have it at least a couple hours before that? Yes.
Knowing what you know, and you have so much knowledge about sleep and melatonin,
if you were having a hard time sleeping, would you take melatonin?
(21:44):
No. The first thing that I would do if I'm having a hard time sleeping would
be to look at what I'm doing at night.
I would look at, am I getting enough sleep?
What am I doing before I go to sleep? and what could I change?
And then as a last resort, I would use melatonin.
(22:08):
Is it okay to watch a show that's not stressful, like something you've seen
before that's very relaxing if someone doesn't like to read books?
TV, I don't think I would go for because that's the light from the TV and I
think that may keep kiddos up.
I would try to do things that don't have a lot of light,
(22:28):
And I would stay away from the iPad, the iPhone, and I would look more into
conversation, reading, and look into things that would try to get them a little more relaxed.
Do you do the same routine before bed? I try to do the same thing before bed unless I get paged.
(22:52):
Then you're not going to sleep. Yes. Do you like to read before bed or do you
want to tell us a little bit about that? Usually before bed, I do read.
And I pretty much have the same routine every night.
I do talk to my teenage daughter.
And I try to talk to at least one or two. I have one who's at home still.
(23:16):
I have a son who's at A&M and I have a daughter who's in medical school.
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.
And then I'll read and I'll talk to my husband, of course. And then I go to sleep.
Unfortunately, that can vary
(23:37):
depending if I'm getting paged from somewhere. But usually after that.
Sleep is usually not a hard thing for me to do. My husband is amazed how I can
fall asleep pretty quick.
And even though you're thinking about sleep issues a lot throughout the day,
what do you do to unplug in your spare time?
(23:59):
Now that my children are older and I don't have to go to soccer games anymore,
I started running and walking and I just finished my first 10K at Disney World.
That's awesome. Tell me about that.
That was exciting. I actually went down to Disney World last week,
(24:20):
and it started off at Epcot, and you started outside of Epcot.
It was very early in the morning, though.
And then you ended doing it, going all around Epcot, going through all the countries,
and you had actually people from every country cheering you on, waving at you.
(24:43):
You could take pictures with all the characters.
And you actually had people taking pictures of you as you walked through,
as you ran past countries.
And it was exciting. And this is for the adults?
Anyone over 10 could do it. That sounds wonderful.
And you were telling me, and Disney also has events for adults or the pediatric
(25:07):
practitioner listener who may be looking to get away for a good cause. Yes.
I am also going to do another race and I want to be raising money for a charity as well.
Nice. What inspired you to focus on sleep medicine?
I was actually doing a fellowship in pulmonary, and when I was interviewing,
(25:29):
the person who interviewed me said, you should look into sleep.
You will like it. And I was like, are you sure?
She says, yes, just do one rotation with us, and you will love it.
And my first rotation was incredible. And then from there, I told my fellowship
director, I said, this is what I want to do.
(25:51):
Karen, is there anything else you want to mention that we didn't talk about
today about melatonin or sleep or anything for the pediatric practitioner?
It was a pleasure to do this. And that if the pediatricians have any questions,
I am available always if they need any kind of help and that it is important sleep for pediatrics.
(26:13):
I think sometimes it is neglected and the parents are not always.
If the pediatrician doesn't ask, the parents don't know to tell them that it is a problem.
So bring it up on every visit? Bring it up on your visits.
That's a great point. Because there's so much to cover. It's hard to know.
(26:34):
And that is hard as a pediatrician. I don't think people realize how much a
pediatrician actually does and how busy a pediatrician is and how much work they really do.
I am so impressed. it's amazing what they do.
For our pediatric practitioner and listeners, we do have a new podcast called
Pediatrics Now for the parent, for the busy parent, and that's health news in small bites.
(26:58):
We will have this episode with information on sleep hygiene and melatonin.
So you can tell your patients about Pediatrics Now for parents,
and hopefully that will give a little bit more of an in-depth explanation and
one, you know, save you a few minutes in the exam room, hopefully.
So Dr. Karen Henschel-Franks with the University of Texas Health Science Center
(27:21):
and University Hospital, thank you so much for being here today on Pediatrics Now.
Thank you. You're going to sleep well tonight.
Great job. Thank you. Karen, here on Pediatrics Now, as our listeners know,
we love quotes. I love quotes.
Do you have a favorite quote you'd like to share with us today?
(27:41):
Yes. You are braver than you believe, stronger than you seem,
and smarter than you think.
It's from Disney's Christopher Robin.
I love it. That might be a nice thing to say before tucking someone into bed.
Thank you so much. Click on the link in this podcast for free credit that may
(28:01):
include CME, MOC, or ethics credit, depending on our topic.
Music.
Podcast it's called pediatrics now for parents health news and small bites for the busy parent,
(28:23):
here's a clip from an episode on vaccine hesitancy a
lot of the diseases that pediatricians and the scientific community has been
really successful at eradicating have become out of sight out of mind you know
things like polio that the generation in front of us are two generations in
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,
signs on the front of stores.
Those days are over and they're over because of the success of vaccination.
So things like diphtheria, everyone knows the story of the Iditarod and the dog sled races.
No one remembers why those dogs were doing that heroic effort.
(29:05):
People don't remember the polio days. People don't really remember the measles or rubella days.
Even I, you know, I'm in my mid forties and I, you know, That era is a dim memory
at the beginning of my childhood of chickenpox and things like that.
So as a result, when those aren't daily threats to our children,
they sort of fade back to the back of our priorities, right?
(29:27):
We're trying to get kids to school.
We're trying to get all the shopping done. We're trying to make sure they're
staying safe online and make sure they're staying away from firearms.
It's not a clear and present danger like it was 20, 30, 40 years ago,
but But it can be and it will be again if our vaccine rates keep dropping.
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,
epidemics like this to remind ourselves that we're only a couple of,
you know, months or years of poor vaccination away from being right back in the mix again.
Our website is pediatricsnowpodcast.com. My email address is on there.
Please email me with episode ideas or comments.
(30:11):
Thank you so much for listening. I'll see you.
Music.
Music.
(00:05):
For the busy pediatric practitioner. Today, a wake-up call about melatonin.
Joining me here in the podcast studio is Dr. Karen Henschel-Franks.
She's a fellow at the Academy of Pediatrics and also a fellow of the American
Academy of Sleep Medicine.
Dr. Franks, thank you so much for being here in the podcast studio today.
(00:27):
Thank you very much. It's a pleasure. Sure.
Karen, so what is the wake-up call?
How big of an alarm is sounding when it comes to melatonin, which we know is so popular right now?
Melatonin is incredibly important at this time.
The CDC reports that there were 11,000 infants and children who visited the
(00:53):
emergency room after accidentally taking melatonin.
This is a wake-up call for all of us, and it should remind us that we need to
educate parents, children,
about the importance of how to take melatonin and how to actually sleep better at night.
(01:16):
So, Karen, melatonin, it's a supplement. Yes.
Melatonin is a supplement, but actually it's a natural hormone that helps us
regulate our sleep-wake time, but it is now widely used as an over-the-counter
and marketed as a sleep aid.
Unfortunately, it is not regulated by the FDA as a medication.
(01:39):
It is a dietary supplement, which is a problem at this point.
There can be a variation in the the amount of melatonin found in the bottle.
Symptoms of melatonin overdose can include headaches, dizziness, and irritability.
(02:02):
How do you know if it's so severe that the child needs to go to the emergency room?
It can be very difficult because they do have overdose symptoms that are headaches,
dizziness, and irritability.
And as they increase, parents may not realize that this is actually the melatonin
causing these symptoms.
(02:24):
And also, parents don't know the dose of melatonin. And there are no actual
dose or guidelines by age or weight for melatonin.
So some parents will use one pill, two pills, or continue to take as many as they think are needed.
(02:44):
So it can cause even more issues.
There's something specific to look for on each bottle of these if you are taking melatonin.
Some of the bottles will have recommendations.
Some will not. But however, like I said, there are no guidelines for dosing
(03:07):
based on age or weight for when to give or how much to give for melatonin.
Or is there something you were saying to look for that it shows that this bottle was checked out?
Aaron should look for a product when they are selecting for melatonin.
They should look for a USP verified mark.
That'll show that the medication was checked and that you'll know that if it
(03:34):
says three milligrams or five milligrams or one milligram,
that it was verified how much milligrams were in each tablet.
Do we know the long-term effects of melatonin. In children, there are no long-term
studies at this time. So we just don't know.
(03:55):
No, in children at this time, we don't know. Would you recommend that the pediatric
practitioner not recommend melatonin across the board? Try other methods first?
Pediatricians know the patient the best. Pediatricians need to look at the patient
individually and then make the decision,
(04:17):
but always start with sleep hygiene,
with the patient behavioral interventions, and then my last step would be to use melatonin.
Sleep hygiene, especially with the older kiddos, turning off screens.
Taking the phone off at least an hour before bedtime, using black shades,
(04:46):
not letting the kiddos stay up more than an hour past their bedtime on the weekend and vacations.
Also addressing other medical problems such as snoring or asthma are all great things to start with.
When is it time to refer out? If the parents or the pediatrician felt there
(05:06):
were medical problems such as snoring and sleep apnea,
if the parents and the pediatrician thought that behavioral interventions would help with insomnia,
that would be a wonderful place to start.
Do you Do you, in your clinic, do you prescribe melatonin?
(05:26):
I do prescribe it, but not for a long term in normal patients that have no medical problems.
So as a last resort, what I normally do is first start with sleep hygiene and
behavioral interventions before I would go with medication.
(05:48):
I talk with the family, get a good idea of what they're doing at night and see
what problems they're having and address those problems.
Right now at bedtime, there are many different things that are going on and
it's hard for someone to go to bed.
And I would address those issues first and then go to medications as a last resort.
(06:13):
Because it should be considered a medication even though it's a supplement? Yes.
Because it's affecting the brain. Yes.
Any supplement such as melatonin, I still consider a medication.
And that is usually one of the last things that I...
Give to the patients. I usually will start off with sleep hygiene,
(06:37):
what they do before they come to go to bed, how are they going to bed,
what problems are they having.
Let's address what's going on at home, what issues you are having or going to bed.
And from there, let me hear what problems they're having.
(06:58):
Let me have the kiddo talk to me and let me know what they're feeling.
And then from there, I can one by one address the problem.
And as a parent, when you think about bedtime, it's not, and with kids,
it's not like, oh, this is the most relaxing time ever. It's usually stressful.
(07:18):
And then that's not helping things too. You know that you want to I make it
as relaxing as possible, but it's, I mean, why is it so hard to get kids to bed?
Is it part of that end of the day? Everybody's kind of wound up.
And then when the parent gets more frustrated, then that's not helping and it's
causes more stress is, do you want to give us some advice there?
(07:40):
It's a combination of everything they want.
It's the end of the day. They have had a busy day and they want to do more things.
The parents are tired. they're exhausted, they're busy as well.
And you put the two together and it's hard to get everyone to go to sleep.
Also, if the kids have other things they want to do, then it's difficult for them to go to sleep.
(08:08):
Also, the iPhone, the iPad, it is very difficult to get rid of and then to have a child go to sleep.
This is probably the easiest thing to give a patient after school,
but it is the hardest thing to get rid of before they go to bed.
(08:30):
And it is the hardest thing then to have them go to sleep.
And so these are things we have to address with the parents and try to get them
to do other things and try to get the child to do other things so that they can go to sleep.
And even when they get home from school, if they can play outside or have some
(08:51):
exercise, that's going to help. Yes.
Going outside, playing, do other things other than video games,
iPhones, watching TV, anything will help.
And this, especially, and then on the iPhone or the iPads, our cell phone,
a video call with friends, social media, all of that wakes us up, right?
(09:16):
Yes. The light from the phone, from the video games, all tells your brain to
stay up and to keep you up.
The NPR recently had a story about the perils of melatonin and the situation sounds like it's dire.
I mean, that it's being way overused.
(09:39):
The pediatrician who was quoted in the story said she wouldn't like to see a
kid use it more than once or twice a year.
Would you say that that's accurate? I think with melatonin, once you start to
use it, you have to then work with the patient to train them to get off of it.
(10:00):
So that then they'll only having to use it less and less.
So you may start them that they're using it a couple of days and then after
that, slowly wean them off. I think that's the best thing to do.
So it would be okay for a couple of days to get into a routine?
Get into a routine and then once you get that
patient back into a routine then to
(10:23):
wean the melatonin off and is there
something about sleeping pills in general where it can be
you feel like you have to like there's this placebo effect too where now i'm
going to sleep well or fall asleep because i took this but tomorrow night if
i don't then i'm not going to yes recently i just saw a patient and they were
(10:43):
finally got a good routine going they were sleeping well.
And the patient was asking for a medication. And the mom said, why?
And she said, well, because I normally take that. And the mom said,
do you think you need it? And she said, no.
And then when she went to bed without it, she realized, oh, I really don't need it.
(11:07):
So I think a lot of times patients do think that they need it and they really
don't. They need the confidence to believe they don't need it as well.
And I mean, we've all been there where you lie down to sleep and then your mind starts going.
Do you think for kids, do you recommend trying to introduce some sort of meditation
(11:31):
before bed, a guided meditation or anything like that?
There's multiple things you can do. One of the things I like to do is imagery,
where you have the kid think of something that they like.
It could be, for some patients, I have a girl who wants to dream of going to
(11:51):
New York and shop on Fifth Avenue, and that's how she goes to sleep.
Ooh, that sounds like a nice dream. I have another girl.
She's never left Texas and she dreams of walking on the beach in Hawaii.
And she could tell you every fish. She could tell you everything about Hawaii.
I have another boy, he plays for the NBA, and he can tell you every team he's beat.
(12:17):
So it all depends on imagery and how they think of what they're thinking before
they go to bed. You need to change it.
Because I find with my youngest daughter, she'll bring up the most stressful
thing that happened that day or that's on her mind. It's usually as I'm tucking her into bed.
Yes. It's very easy because it's quiet now. And in their head,
(12:42):
everything that happened bad will come at that time.
So another thing you can do is an hour before they go to sleep,
whatever bad happened that you have them write down.
And then you put it away and you tell them we're going to not think about any
of these things until tomorrow.
And then you give them something good that they can think about.
(13:06):
And then that's how they decide. side.
And then also the hour before they go to sleep, the parent will tell them good
things that they did during the day.
And all kids, you can find one or two good things that they did.
When a patient comes in the room right away, I can always find one or two things.
(13:30):
And I'll tell the parent, look at the patient did A, B, or C.
And the mom will be like, wow. And the kid will look at me Like,
you don't even know me, but I can find two or three good things about everybody.
And I'll tell the parent that, okay, now you think about that before you go to bed.
And I'll give them things so that they have something to think about other than that bad thought.
(13:54):
I love it. Can you tell, like, what's an example? Like, how would you say that?
Well, when I walk in and I see a kiddo and she has on a nice outfit or her hair
is beautiful. And I'll say, oh, who did your hair?
And she'll say, oh, I did it myself. I said, oh, I love it.
Oh, who picked out your outfit? Oh, I did. And then that's what I'll bring up.
(14:15):
And then I'll have another little boy who I saw and he was coloring and it was a great picture.
And I'll say, that's a wonderful picture you did.
And then I'll bring all that up. I try to find something when I walk in,
something that they did wonderful or something that I think is good.
(14:37):
And then I just point that out throughout when I'm talking to them.
And then I try to give them confidence during the visit. And that's instantly...
Reassuring, relaxing. Yes. The opposite of stressful.
Yes. So once I find something that I think that they're going to feel confident
(14:58):
about, then also I tell them, okay, before you go to bed, now I found something. You can try these.
Or can you find something? Because sometimes when I'll ask a teenager,
okay, where do you want to go? What would you do?
And they're like, I don't know. And then once I start telling them,
well, I like this, I like this that you do, and they're like,
(15:21):
well, how did you figure that out? And then they're like, okay.
And then they try to top me. And then they'll start saying, okay,
what about, well, I like this.
And then it goes on and on, and then we can have a good conversation. I love that, Dr.
Franks. And as parents, if we're not intentional about it,
it can be easy to point out stuff that's going wrong or to correct the child,
(15:45):
but to really point out what's going great and what they're doing right and
to vocalize that is important, sounds like. Yes.
That's why whatever they did wrong, point out immediately after they came home
from school, but that hour before school, before they go to bed.
(16:05):
Find something good and let them know you love them.
I love that. And then as adults, as we're trying to get to sleep,
kind of everything we've talked about here applies to us. Yes.
As an adult, you can do the same thing. Imagine something.
Forget about your job. Forget about what you did, who did what, and how horrible it was.
(16:33):
And imagine, you know, you won a million dollars.
And where would you go? What would you do? You won a trip somewhere.
Where would you go? What would you do? So it's kind of like that's the benefit
of reading a story and imagine, you know, you're letting your imagination.
(16:53):
Exactly. Except for the adult, you can make it more expensive.
And then we won't have the credit card debt. Oh, no credit card debt. Don't think about that.
You won the money and you can do whatever you want. Is it when we're imagining
this or when we're reading before bed, is it better to do it in another area
of the bed or in the chair in the bedroom?
(17:13):
I've heard that. No, I would do everything in the bedroom and everything...
Right before bed. That way, when you say goodnight, you walk out and then you
shut the light and you say goodnight.
And then when you, is it better for the child to be like on the other side of
the bed when you're imagining?
(17:34):
Like I've heard that too, like
have the space be where you're actually going to go to sleep in the bed.
Save that for when you're actually going to lie down. Or is that kind of too technical?
No, I don't think they have to be as technical. Okay. It depends if they start
getting really difficult to fall asleep, then you can get a little bit more technical.
But in the beginning, I'm not as picky in the beginning.
(17:58):
I'll get more picky as time goes on. I first start with them in the bed.
And as long as I can get them in the bed and they'll go to sleep, then I'm happy.
If I start having more issues in clinic, then I'll start to get a little more picky.
So can you tell me about your clinic? Like, do you see patients at the clinic,
at university hospital first?
(18:20):
They'll come and see me first. And it's for various complaints.
It could be for sleep apnea. It could be for insomnia.
It could be for narcolepsy.
And I'll address whatever concerns that they have at that time.
Many times it's for a combination of several things where they'll say,
well, I can't fall asleep, but I have horrible snoring. And then I'll say,
(18:42):
okay, let's address that, your problem that you can't sleep.
And then once I have them to the point where they're sleeping well,
then the next couple of visits, then I'll start addressing, okay,
now let's address the snoring.
And then after a while, I've gotten several complaints.
And then I've taken care of a couple of concerns with a couple of visits.
(19:03):
And when you talk about before bedtime and what you say, are you role playing
in the clinic or is that actually because you do studies where it's at a hotel
where the child's asleep and you're measuring the sleep? Yes.
When we do the sleep study, we're doing the actual sleep study that we would
normally do in the hospital, but we're doing it in the hotel so it's a more
(19:26):
comfortable place so that they don't hear what happens in the hospital.
They are doing it now in the hotel, but it's the exact same study.
Are you there doing that or is it someone from your team? No,
it's somebody else. It's at night.
From your team? Someone from our team is actually doing it. Anything else you
want to say about melatonin?
(19:46):
I think the pediatrician should ask the patient if they're taking it,
what type of melatonin they're taking, and monitor how much they're using.
And then as quickly as they put the patient on, try to wean them off.
And I think from there, you'll get a good response.
(20:08):
And so no more than two days? The daytime, it depends on the type of patient they have.
It'll depend on the medical problems that they have, and I'll leave that to
the pediatrician. But as long as they're monitoring it, from there, we can figure it on out.
If we don't know what happens long term, that sounds kind of scary to me.
(20:33):
Yes, it is very scary, and that's why I think the pediatricians should keep
an eye on how much they're using the melatonin and not for kids that have normal medical problems,
not keep it for a long period of time.
And do you recommend not eating a few hours before bed or anything there you want to say?
(20:57):
I would keep what you eat very light before bed. I wouldn't have a big meal before bed.
I have a lot of patients that come and they have dinner and then they go straight
to bed and they have stomach aches and then they're not eating afterwards.
I try not to have anyone eat before they go to bed,
but some kids may be very hungry if they played soccer right beforehand or if
(21:23):
they did basketball and they may need a little snack beforehand before going
to bed, and they usually will make that a light snack.
But if it's a big dinner, have it at least a couple hours before that? Yes.
Knowing what you know, and you have so much knowledge about sleep and melatonin,
if you were having a hard time sleeping, would you take melatonin?
(21:44):
No. The first thing that I would do if I'm having a hard time sleeping would
be to look at what I'm doing at night.
I would look at, am I getting enough sleep?
What am I doing before I go to sleep? and what could I change?
And then as a last resort, I would use melatonin.
(22:08):
Is it okay to watch a show that's not stressful, like something you've seen
before that's very relaxing if someone doesn't like to read books?
TV, I don't think I would go for because that's the light from the TV and I
think that may keep kiddos up.
I would try to do things that don't have a lot of light,
(22:28):
And I would stay away from the iPad, the iPhone, and I would look more into
conversation, reading, and look into things that would try to get them a little more relaxed.
Do you do the same routine before bed? I try to do the same thing before bed unless I get paged.
(22:52):
Then you're not going to sleep. Yes. Do you like to read before bed or do you
want to tell us a little bit about that? Usually before bed, I do read.
And I pretty much have the same routine every night.
I do talk to my teenage daughter.
And I try to talk to at least one or two. I have one who's at home still.
(23:16):
I have a son who's at A&M and I have a daughter who's in medical school.
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.
And then I'll read and I'll talk to my husband, of course. And then I go to sleep.
Unfortunately, that can vary
(23:37):
depending if I'm getting paged from somewhere. But usually after that.
Sleep is usually not a hard thing for me to do. My husband is amazed how I can
fall asleep pretty quick.
And even though you're thinking about sleep issues a lot throughout the day,
what do you do to unplug in your spare time?
(23:59):
Now that my children are older and I don't have to go to soccer games anymore,
I started running and walking and I just finished my first 10K at Disney World.
That's awesome. Tell me about that.
That was exciting. I actually went down to Disney World last week,
(24:20):
and it started off at Epcot, and you started outside of Epcot.
It was very early in the morning, though.
And then you ended doing it, going all around Epcot, going through all the countries,
and you had actually people from every country cheering you on, waving at you.
(24:43):
You could take pictures with all the characters.
And you actually had people taking pictures of you as you walked through,
as you ran past countries.
And it was exciting. And this is for the adults?
Anyone over 10 could do it. That sounds wonderful.
And you were telling me, and Disney also has events for adults or the pediatric
(25:07):
practitioner listener who may be looking to get away for a good cause. Yes.
I am also going to do another race and I want to be raising money for a charity as well.
Nice. What inspired you to focus on sleep medicine?
I was actually doing a fellowship in pulmonary, and when I was interviewing,
(25:29):
the person who interviewed me said, you should look into sleep.
You will like it. And I was like, are you sure?
She says, yes, just do one rotation with us, and you will love it.
And my first rotation was incredible. And then from there, I told my fellowship
director, I said, this is what I want to do.
(25:51):
Karen, is there anything else you want to mention that we didn't talk about
today about melatonin or sleep or anything for the pediatric practitioner?
It was a pleasure to do this. And that if the pediatricians have any questions,
I am available always if they need any kind of help and that it is important sleep for pediatrics.
(26:13):
I think sometimes it is neglected and the parents are not always.
If the pediatrician doesn't ask, the parents don't know to tell them that it is a problem.
So bring it up on every visit? Bring it up on your visits.
That's a great point. Because there's so much to cover. It's hard to know.
(26:34):
And that is hard as a pediatrician. I don't think people realize how much a
pediatrician actually does and how busy a pediatrician is and how much work they really do.
I am so impressed. it's amazing what they do.
For our pediatric practitioner and listeners, we do have a new podcast called
Pediatrics Now for the parent, for the busy parent, and that's health news in small bites.
(26:58):
We will have this episode with information on sleep hygiene and melatonin.
So you can tell your patients about Pediatrics Now for parents,
and hopefully that will give a little bit more of an in-depth explanation and
one, you know, save you a few minutes in the exam room, hopefully.
So Dr. Karen Henschel-Franks with the University of Texas Health Science Center
(27:21):
and University Hospital, thank you so much for being here today on Pediatrics Now.
Thank you. You're going to sleep well tonight.
Great job. Thank you. Karen, here on Pediatrics Now, as our listeners know,
we love quotes. I love quotes.
Do you have a favorite quote you'd like to share with us today?
(27:41):
Yes. You are braver than you believe, stronger than you seem,
and smarter than you think.
It's from Disney's Christopher Robin.
I love it. That might be a nice thing to say before tucking someone into bed.
Thank you so much. Click on the link in this podcast for free credit that may
(28:01):
include CME, MOC, or ethics credit, depending on our topic.
Music.
Podcast it's called pediatrics now for parents health news and small bites for the busy parent,
(28:23):
here's a clip from an episode on vaccine hesitancy a
lot of the diseases that pediatricians and the scientific community has been
really successful at eradicating have become out of sight out of mind you know
things like polio that the generation in front of us are two generations in
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,
signs on the front of stores.
Those days are over and they're over because of the success of vaccination.
So things like diphtheria, everyone knows the story of the Iditarod and the dog sled races.
No one remembers why those dogs were doing that heroic effort.
(29:05):
People don't remember the polio days. People don't really remember the measles or rubella days.
Even I, you know, I'm in my mid forties and I, you know, That era is a dim memory
at the beginning of my childhood of chickenpox and things like that.
So as a result, when those aren't daily threats to our children,
they sort of fade back to the back of our priorities, right?
(29:27):
We're trying to get kids to school.
We're trying to get all the shopping done. We're trying to make sure they're
staying safe online and make sure they're staying away from firearms.
It's not a clear and present danger like it was 20, 30, 40 years ago,
but But it can be and it will be again if our vaccine rates keep dropping.
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,
epidemics like this to remind ourselves that we're only a couple of,
you know, months or years of poor vaccination away from being right back in the mix again.
Our website is pediatricsnowpodcast.com. My email address is on there.
Please email me with episode ideas or comments.
(30:11):
Thank you so much for listening. I'll see you.
Music.
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