Drug class | Examples | Bottom line |
Nonprescription medications | ||
Antihistamines |
| Consider for short-term situational and/or occasional use in younger children, especially those with comorbid atopic disease. |
Melatonin |
| Consider short-term use for children with sleep-onset insomnia, in combination with behavioral interventions. Most empiric evidence is in neurodiverse children (eg, autism). May also be used in patients (typically adolescents) with circadian phase delay. |
Prescription insomnia drugs | ||
Benzodiazepines |
| Limited utility in pediatric populations; other properties (eg, anxiolytic, muscle relaxant, anticonvulsant, long duration of action) may be useful in some neurodiverse patients. |
Nonbenzodiazepine receptor agonists |
| Lack of documented efficacy and significant sleep-related behavior side effects limit utility, except in older adolescents. |
Others |
| Ramelteon may be a reasonable choice for mild sleep-onset insomnia, especially with circadian component, but cost and lack of insurance coverage may limit use. Dual orexin receptor antagonism is a novel mechanism for sleep onset and maintenance insomnia. Doxepin is indicated for sleep maintenance insomnia in low doses. |
Drugs used off-label for insomnia | ||
Alpha-adrenergic agonists |
| These agents are commonly prescribed for childhood insomnia. Although there are few data to support this use, clinical experience suggests they are generally effective and well tolerated in ADHD. |
Antidepressants |
| Likely most useful in the setting of comorbid mood disorders and/or anxiety; little evidence to support the use of trazodone as drug of choice within this class*. |
ADHD: attention deficit hyperactivity disorder; ASD: autism spectrum disorder; SSRI: selective serotonin reuptake inhibitor.
* The American Academy of Sleep Medicine (AASM) practice guideline suggests against the use of trazodone for sleep-maintenance insomnia in adults with primary insomnia, based on paucity of data and the small effect sizes observed in the single randomized trial[1].