Melatonin And Promethazine Treating Insomnia

Introduction

Studies suggest that sleep disorders are prevalent in children with neurodevelopmental delay and is approximately 80 percent [6] among them. Melatonin is an indoleamine hormone synthesized and secreted from the pineal gland. That is, the retinal photoreceptors transmit photic information to the pineal gland through the suprachiasmatic nucleus of the hypothalamus and the sympathetic nervous system Van et al [14]. During the day the photoreceptors cells are hyperpolarized hence inhibit melatonin secretion in contrast the receptors activate the retino-hypothalamic-pineal system and secrete melatonin, which induces sleep at night, hence contributes to the sleep-wake cycle of a normal person. On the other hand, Promethazine; an anti-histamine drug induces quicker sleep onset and improve sleep quality as a side-effect of its medicinal actions [4] [9] [10]. The anti-histamine blocks histamine H1 receptors in the brain and relax neurotransmitters thus enhance drowsiness [12]. In this regard, this paper appraises the prescription of these drugs in a case study, where a seven year old girl, Aurora, has an underlying neurodevelopmental delays and is also under treatment of epilepsy. The need for an appropriate treatment of her insomnia that does not make her epileptic treatment unstable and also does not worsen her neurodevelopment is very crucial. In this appraisal melatonin and promethazine have to be assed if they are suitable and better options offered if not.

Melatonin secretions occur primarily at night and relate to a decrease in core body temperature and increased sleepiness levels. Several studies have recommended oral administration of melatonin drugs to young children who experience sleep disorders [13] so as to help rectify their sleep-wake cycle. In addition, these research literatures have reported positive effects of melatonin administration like decreased sleep latency and increased sleep efficiency with doses ranging between 0.3mg to 75.0 mg while others have claimed little or no effect Bruni et al [1]. For instance, observed an increase in total sleep duration with no effect on sleep-onset latency in children aged 6-12 years with developmental disabilities [7]. Melatonin has also been reported to decrease epileptic seizure frequency with very few long term effects. Nevertheless, a meta-analysis on the effects of melatonin in sleep disorders for all age groups failed to document fundamental and clinical effects of exogenous melatonin on sleep latency, quality, and efficiency [8]. Melatonin has also proven to have a number of side effect such as daytime sleepiness, anxiety and dizziness which would not encourage neurological development.

Promethazine is a type of sedative that works very fast due to the ability of this antihistamine to cross the blood brain barrier and block histamine neurotransmitter quickly. Medical researchers tend to hypothesize the side effects of Promethazine like fatigue and drowsiness as treatments for patients with insomnia. However a study claims that 25mg dosage of Promethazine taken an hour before bedtime causes quicker sleep onset but lower sleep quality [4] [12] . Further research applies the Friedman non-parametric analysis of variance to determine sleep latency in children with disorders. This drug is also rarely prescribed especially to children due to its effect of reducing daytime behavior and increasing the probability of impairment in cognitive and psychomotor functions which still contributes to neurodevelopment delay. In conclusion, study literatures disapprove prescription of promethazine in treatment of sleep disorders due to its high prevalence in causing respiratory depressions, direct effects on the brain, and seizures in extreme cases [13], this is not compatible with and epileptic child and may lead to severe medical conditions.

Evidence Critique

Aurora’s case study is quite vague in relation to her diagnosis. Sleeping patterns in developing children with mental disorders requires crucial attention since various disabilities show varying types of sleep disorders [2]. Also, children with underlying neurological disorder may prove problematic to treat using the International Classification of Sleep Disorders (ICSD). Furthermore, Promethazine may increase incidences of seizures in cases of epilepsy [6]. Although melatonin s useful in reducing epileptic seizures, long term use suppresses neuronal activity and causes delayed puberty [3]. Aurora’s doctor hardly considers her young age and medical history and recommends the two drugs for her sleep disorder. In this essence, Aurora’s prescription is likely to affect her instead of increasing her sleep duration and sleep quality. To be able to come up with this paper, medical databases on clinical trials had to be used to gather information in sites such as NCBI. This was not as efficient because response to the drug was not well specified for each age bracket. Randomized control trials was also an option however most patients with epilepsy and neurodevelopment delay were not as cooperative to share information because they were shy.

Recommendation

The two drugs suggested by the doctor for treatment of insomnia may not be compatible with Aurora’s medical condition because Melatonin helps with epilepsy seizures but not neurodevelopment delay while promethazine is bad for both of her conditions. Medical scientists often recommend application of the behavioral sleep patterns especially in children with neurodevelopmental delay as in Aurora’s case study. The treatment involves understanding normal sleep designs and control of sleep through the homeostatic and circadian drive [5]. The time dependent homeostatic drive proves that the longer a child is awake the greater their tiredness and tendency to sleep [4] while the intrinsic circadian drive is biologically controlled [11].

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