Melatonin Use and Poisoning Reports Surge in Children

Written by Marina Zhang on December 11, 2023. Posted in Current News

Insomnia and melatonin supplements aren’t words that one would often associate with children

About one-fifth of U.S. children use melatonin for sleep, and some parents begin administering it to their children at the early age of 1, the authors wrote.

The United States has seen a rapid rise in pediatric melatonin use because of sleep problems. Some clinicians attribute these sleep problems to an increase in mental illness and screen use.

The JAMA Pediatrics study authors compared this finding to their own research results, reporting that the current data indicate a rise in use of about 20 percent. Parents surveyed also reported that their children take the supplement on average two to five days per week, and many take it daily.

The common use of melatonin has also contributed to a surge in melatonin poisoning. From 2012 to 2021, poison control centers in the United States have seen a 530 percent increase in melatonin ingestion reports among children, some of which resulted in hospitalization and death, according to research published in the U.S. CDC’s Morbidity and Mortality Weekly Report (MMWR) publication.

Kids have always had sleeping problems, and these don’t differ much from those of adults.

Just as stress, anxiety, and depression can cause insomnia in adults, the same can occur in children who have different worries from day to day. These may include schoolwork, pressure from peers, and social media interactions.

Many teenagers are also over-committed in their school activities, which impacts their ability to get to bed on time.

Additionally, homeschooling during the COVID-19 pandemic increased children’s screen time. Screens are highly stimulating; their light can suppress and disrupt the sleep cycle.

There’s a significant problem with electronics in general, “to the point that some parents really have lost control,” Dr. Perry said. Kids may get up in the middle of the night or early in the morning before school to get on their tablets or phones or to play video games.

Pediatrician Dr. Derek Husmann said he believes screen use is the main problem causing disordered sleeping in children.

Supplements for children are accessible, unregulated, and can be bought without a prescription. Available in the form of gummies and liquids, they’re also appealing to young children.

“The majority of parents that come into my clinic have at least tried melatonin, or the child is already on melatonin—either per recommendation from a general pediatrician or on their own,” Dr. Perry said.

From 2016 to 2020, sales of melatonin supplements increased by about 150 percent, according to the CDC’s Morbidity and Mortality Weekly Report.

Melatonin is a natural hormone that the body produces to, among other things, regulate the sleep-wake cycle. Light suppresses, while darkness stimulates, the release of melatonin from the pineal gland.

Generally, melatonin supplements are advised to be taken one to two hours before bedtime to mimic the natural cycle.

Melatonin’s effects last only about two hours. “It’s going to facilitate falling asleep quicker, but it’s not going to be around long enough to impact sleep quality,” Dr. Perry said. While parents typically report a short-term benefit when administering melatonin, as time passes, the supplements may not work as well, and the dose may need to be increased.

Dr. Husmann has seen this happen in his patients.

“It used to bother me a lot when I came across those patients that have been on it for months and months. I asked them to try to wean their kids off. … but there are some cases where they try, and it’s not particularly successful,” he said.

Yet there have been numerous cases of melatonin use in infants and toddlers.

High melatonin levels have also been detected in deceased children.

One case involved a 3-month-old girl routinely given eight to 10 daily doses of 5 milligrams of melatonin supplements as a sleep aid. Such a dosage is well above what’s recommended for a child of any age. The child’s cause of death was inconclusive.

Doctors still don’t know why melatonin supplementation may be associated with death, given its assumed high safety profile. It should also be noted that deaths from melatonin supplements make up only a very small percentage of all melatonin poisoning reports.

Dr. Perry said she has never had a patient die from melatonin and expects that because melatonin is an endogenous hormone—meaning it naturally occurs in the body—it should have a wide safety margin.

Dr. Husmann agreed.

“I don’t see a lot of downsides other than I wish so many kids didn’t need it in the first place,” he said.

However, Dr. Rishi argued that melatonin is a drug, meaning that it changes a person’s mental or physical state, and therefore, it should be treated as such.

Long-term side effects are still unknown because there have been no long-term safety studies. One concern is that melatonin supplements may delay puberty, because melatonin levels in the blood typically start to decrease prior to the onset of puberty.

“When going through the literature, we found that there is a general underreporting on safety and that the certainty of evidence is low,” Ms. Edemann Callesen wrote regarding melatonin.

The current evidence shows that children and adolescents are likely to experience nonserious adverse events instead of serious ones, “yet we don’t know the actual extent of this.”

Because melatonin is sold as a supplement, it doesn’t have the same regulatory oversight from the U.S. Food and Drug Administration (FDA) as other over-the-counter medications, Dr. Rishi wrote via email. Contamination and variability in dosage are rampant.

Children require only a very low dose of melatonin—about 0.05 to 3 milligrams—but doses from supplements can vary, even in the same batch.

Even among supplements of the same lot, differences could vary by as much as 465 percent. Among these, chewable tablets had the highest content variation.

In addition, about a quarter of the supplements were also contaminated with serotonin.

In contrast to melatonin, which is generally assumed to have a high safety profile, serotonin is known to cause neurological effects, including seizures, tremors, and even death at toxic levels.

“If those supplements were high in serotonin, you could theoretically say that perhaps that could have led to death,” Dr. Perry reasoned.

Therefore, ensuring a standard dosage of melatonin can be important. Dr. Perry recommends pharmaceutical-grade melatonin for short-term use.

Unlike store-bought supplements, pharmaceutical-grade melatonin is held to the same standard as FDA-regulated drugs. Under U.S. Pharmacopeia (USP) standards, this grade of melatonin must exceed 99 percent purity and not contain any fillers, binders, dyes, or inactive additives. The risk of contamination is, therefore, low.

There are also differences between taking melatonin supplements and letting the body regulate its own melatonin levels.

Research has also shown that melatonin supplements cause a higher peak in melatonin levels than natural nocturnal melatonin levels in the body.

Fixing the Root Problem

For children, insomnia is very much a behavioral problem driven by poor sleep habits, said Dr. Perry, who has more than 30 years of experience as a sleep specialist.

“The majority of children have behavioral insomnia or restless legs,” she said. Restless leg syndrome is often related to iron deficiency, and supplementation with iron can help.

Behavioral insomnia includes sleep-association insomnia and limit-setting insomnia.

Limit-setting insomnia occurs when parents are unable to set limits because of giving in to the child’s bedtime-opposing tactics. These tactics could include sobbing, outbursts, asking numerous questions, throwing objects, making unnecessarily frequent trips to the bathroom, asking for drinks and extra hugs, and claiming to have important things to say.

Sleep-association insomnia occurs when the child needs a parent to lie beside him or her in bed to sleep. It also refers to when a child wakes in the night and needs a parent to return to bed with him or her to fall asleep.

However, by starting a regular bedtime routine as a family and setting good boundaries, children and parents can get a good night’s sleep.

Screen addiction can also lead to insomnia, and parents are often unaware that screens impact their children’s sleep. “[Parents] have no idea that the children are getting up to get the tablet or doing things under the cover,” Dr. Perry said.

“Some parents have had to turn off the internet” to remove the child’s incentive to get up at night, she said.

Parents set a very important example in modeling sleep habits for their children. Often, changing a child’s sleep behavior involves the entire family changing its behavior.

Beginning in the 2010s, Dr. Husmann started noticing upticks in later bedtimes for children. It goes on in households where “plenty of people are mostly nocturnal” and their habits include too much screen use. In such cases, the kids follow along, particularly the younger ones, he said.

“It’s very similar to obesity. So to address obesity in children, you have to address obesity in the entire family,” Dr. Perry said. “Sometimes, it’s very difficult for me to even get parents to want to change their own behavior, let alone do it for their children.”

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