Safe and Informed Use of Melatonin in Pediatric Patients

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Transcript

Welcome CE And Rising Use

SPEAKER_00 0:00

Here on Game Changers, we're all about helping you stay ahead of pharmacy practice. But why stop at listening? You can earn CE credit for this episode and hundreds more by visiting CEimpact.com and logging into your account or creating a new one. Get credit, get inspired, and make your learning path. Hey CE Impact subscribers. Welcome to the Game Changers Clinical Update Podcast. I'm your host, Rachel Maynard. And today we're looking at the use of melatonin in children. That's because we're continuing to see a rise in melatonin use in children and adolescents, usually for sleep problems. And melatonin is often thought of as natural and safe, but that's not always the case. In fact, melatonin is the leading cause of accidental overdoses in young children up to age five in the U.S. So in today's episode, we'll skip through the latest evidence on the role of melatonin in pediatric patients and review some key safety considerations. So to help us navigate this tricky area. Thank you. So Monica, very excited to have you and thank you for taking time out of your busy schedule to chat with us today. Maybe you could share a little bit with our listeners about your background, your current role, and why you're interested in this topic.

SPEAKER_01 1:13

Yeah, absolutely. Again, thank you for having me on this. Uh, it's a really uh fun thing to share knowledge and just learn a little bit more about what you users are or the uh listeners are hoping to learn more about. So I'm a pediatric clinical pharmacist. I was trained at the University of Wisconsin-Madison, and then I did some residency training out at the West Coast at Stanford Children's Hospital. And I've now since returned to my roots in Wisconsin, where I've been practicing as a clinical pharmacist at the American Family Children's Hospital at UW Health for 17 years now. My barely practice areas are in pediatric critical care, but given our health system models, I have the opportunity to kind of dig my fingers in in all areas of patient care and the inpatient space.

Guest Background And Clinical Context

SPEAKER_00 1:59

Excellent. Well, I think you'll have some unique perspective to bring to our discussion today. I'm really looking forward to hearing your expertise on this topic because I think it is so difficult when we're thinking about supplements that are readily available and getting a lot of attention on social media. It can be difficult to help reconcile maybe some efficacy safety considerations with those and educating patients and parents about that. So very excited to have you. Thank you again for your time. Let's just start out with a review of melatonin in general, get us all on the same page. So if you could share a little bit about what melatonin is and how it's thought to work and why you see it used most often, or what are some of the most typical use cases for it?

SPEAKER_01 2:41

Yeah, absolutely. You know, when people think of melatonin, they most commonly think of sleep. And that's certainly one of the most common reasons that we use it in children. In pediatrics, melatonin is typically being used to help manage sleep onset insomnia. And that's really meaning where child children have a difficulty falling asleep at night. And it's also frequently used for circadian rhythm sleep disorders. So that's really particularly the delayed sleep phase syndrome. And that's where a child's natural sleep schedule is shifted later than desired. So kids, you expect that should be going to bed at seven, eight o'clock at night. Their bodies naturally say, Nope, I should be up at eight, nine, ten o'clock at night. So, goal and focus is to try to shift that to an earlier time in the evening. You know, and another group where melatonin is commonly used is with neurodevelopmental conditions. Uh, so things like autism spectrum disorder. There's a little data with patients in ADHD. And what's really interesting is that sleep disturbances are really common in those populations that are sometimes affecting more than 50 to 75% of children with autisms. So it really makes a lot of sense that clinicians are trying to turn to melatonin as a tool to help with this problem.

SPEAKER_00 3:57

And patients too, patients and parents, right? Yeah. Lots of interest in especially because sleep is often such a difficult issue for adults and children alike. And so trying to reach for something that seems readily accessible and safe potentially, I think is is often desired. But yeah, maybe you could speak a little bit more to those roles. And I I cut you off a little bit there. So I want to make sure you finish it.

Melatonin Mechanism And Sleep Disorders

SPEAKER_01 4:26

I mean, I think it's an excited thing, and and I'm someone that really loves learning about mechanisms and pharmacology. And so it's easy for me to keep on rambling about it because it's just so fascinating to me. But so one thing I think is always really important to consider anytime we're talking about medication supplements or whatever they are is just, you know, back to the basics of how these products work in the body. And so melatonin itself, right? We talked about that its uses most commonly for sleep disorders. But what actually is melatonin? So we think of it as a supplement, but we also have to recognize that melatonin itself is a natural occurring hormone that's produced in the body, specifically in the pineal gland in the brain. Um, and it's synthesized from serotonin, which we should remember serotonin and all the uses for that. So really plays a special role in regulating the body's circadian rhythm. And for us to like reorient ourselves, the circadian rhythm is really that natural clock that tells us when to go to sleep and when to wake up. And what I think is so fascinating about melatonin is that its production is directly tied to light exposure. And so when we think about what that means, like when it's time to sleep and when it's time to get up, well, when it's time to sleep is when it gets dark. So it's that darkness that really stimulates the release while the light is actually suppressing the release of it. So as you can kind of think about it, when we're thinking of sleep hygiene and things like that, that light exposure at time of bedtime can really interfere with sleep because it's going to suppress that natural rise in the melatonin production that's normally starting to occur in the evening when it's starting to get dark out. And so, even from like a pharmacologic perspective, the way melatonin works, it works by binding to two primarily two different receptors, the MT1 and MT2 receptors, that are within the brain space. And that's the area that's primarily regulating your circadian rhythm. So, activation of these receptors, so your MT1 or MT2 receptors, are really going to help what's going to promote that onset and can shift that timing of um of the body's circadian rhythm or circadium cycle. So, in other words, like melatonin's not actually going in to sedate a patient the way that we think some of the other sleep medications are working, but it's actually trying to signal the brain to say, hey, time to sleep.

SPEAKER_00 7:00

Okay, that's a really good clarification. So it's it's different than it's it's not a sedative per se, or like a Z drug or a benzo or even diphenhydramine. It doesn't necessarily have sedating effects. It's really more about resetting or helping to reset that sleep-wake cycle. Would you say that's fair to Yeah, absolutely?

SPEAKER_01 7:22

It's really it's it's trying to signal the body uh to naturally do what your body's meant to do. But as we know, there's all these external factors that can interrupt our natural body processes. And so melatonin's role is really trying to reset or keep you back on what your body's meant to do physiologically.

SPEAKER_00 7:42

Okay. And so for that reason, it would does it make sense for it to be used as sort of how how what how would it typically be used then in patients who may be looking for it for that sort of resetting sleep wake cycles or for sleep in general, sleep problems in general?

What Studies Show In Kids

SPEAKER_01 8:04

So, really when we look at the latest evidence and how it's meant to be used, right? So we think about again, it's those that onset of sleep or that kind of shifting of that circadian rhythm. And so, of course, we want to look at what the evidence is saying regarding that, particularly for that sleep onset and circadian rhythm disorders. And the meta-analysis or the data have really shown that it can mean meaningfully improve those sleep parameters for patients. Um, I think specifically one of the meta-analysis out there have shown that it can advance your onset sleep time by about 0.6 hours. So advanced, we kind of think of moving forward, but when we think about advancing that onset of sleep, it's actually moving your time backward. So if your body's saying, I am trying to go to sleep at 8 p.m., well, advancing it forward means it's going to try to set your body to sleep more before like a 7:30, which that can be pretty significant for a child or even an adult that's taking the supplement to have that onset of sleep happen a lot earlier in the evening. And then, of course, it can help with the decrease of sleep onset latency as compared to the placebos. So, similarly, we think about that that delayed sleep onset, and then of course, that the circadium rhythm disorders. So, in that delayed sleep phase syndrome, there's actually some studies that have shown an improvement in that sleep timing reductions by like 20 to 25 minutes. So it's actually helping to shift again that circadium rhythm naturally. So not only it helps you fall asleep faster, but also helps shift that circadium rhythm to be what would be more considered natural or normal. And again, with some of the biggest areas that kids see benefit are those children with those neurodevelopmental disorders. The trials with autism, as I kind of alluded to earlier, they're kind of mixed reviewed at this point in time, primarily because the evidence is still somewhat limited. Uh, the studies have been small, it's been a short-term evaluation of that data. And in general, it's the heterogeneous nature of those studies and the dosing strategies. So it's hard to discern a lot, but in general, results from those specific populations have shown some promising result and positive benefit when used according to their study design.

SPEAKER_00 10:32

Which is how do you translate that to in terms of talking with a patient or parent, for example? What how would you sort of summarize that in your elevator speech to them about the benefit of melatonin potentially in which patients and how it should be used if it is going to be used? And how would you sort of summarize that? Because you it does, it depends right on the data that you're looking at and what regimen is used. So how can we help patients come to a bottom line on that?

Start With Sleep Hygiene First

SPEAKER_01 11:02

You know, that's a really great push uh question on like how do we put it all together? So about like a parent that's concerned that their child isn't sleeping well, and so they enter a pharmacy or they're, you know, within a hospital system and they're talking about some of the challenges that they're having at home at home. And and the question comes up of you, you know, pharmacists, huh? What can you tell me? What do you recommend uh for a dose and how can I best use this in my child? And and we want to really think of one key thing before we just blurt out a dose, right? As pharmacists, we take pride in our knowledge of, oh, I know this dose. Let me tell you. Right, right, right. But oftentimes we have to think about wait a minute, what are we using this for? And is it really actually the appropriate thing to do in a case-by-case scenario? So, again, often when the parents are asking about melatonin, it's because their kids are having a hard time sleeping and they're really grasping at straws of like, what is it I can do? And sometimes they don't even realize some of the environmental factors are actually the problems that are protecting their children from sleeping. So we really want to be able to identify what are those underlying behaviors, what does that sleep environment look like, rather than thinking that's it's maybe a physiologic problem, which is commonly the reason that we should be using melatonin. So the first step that we really want to have pharmacists thinking about is having the conversation to identify like what are those sleep hygiene strategies, what is going on at home before we start any supplement, before we make any recommendation to a parent. So we need to think about things like your consistent bedtime routines. It's so important to limit screen exposure before bedtime. We talked about how melatonin, the signal that melatonin production starts naturally is darkness. Well, if I'm getting light right before bed, the body's saying, it's just not time to go to sleep. My melatonin production is being suppressed because I'm being inundated with light, light, and more in the light. And that usually means daytime to kind of get up and do something. It's so important to maintain those regular sleep schedules. I think sometimes during the week, especially in school-age children, it's easy to maintain that schedule. But then on weekends, we think, oh, it's okay, we can stay up a little later, or we don't have to pay as much focus because the kids can sleep in in the morning potentially. That's a great strategy in theory, but really it's so important again that they maintain a regular sleep schedule. And then, of course, I think adults can really relate to this as avoiding caffeine or avoiding any stimulating activities at nighttime. Um, that can also help kind of ease into natural sleep versus preventing that production. So, really, melatonin should ideally ideally be considered after all those behavioral interventions have been tried. And when we talk about what does a trial look like, it's not one day, two days. It's again having a consistent pattern of behavior, one week, two weeks, three weeks, even a month of trying to reset the patient naturally versus uh trying to have a supplement.

SPEAKER_00 14:10

Right, right. And I know that can be very challenging, especially with children, because it can be stressful, frustrating. Sleep schedules sound, consistent sleep schedules sound great in theory, but in practice, how does that actually happen? And so yeah, it's it is difficult. And it is one of those things that despite that still deserves reinforcing, I think, right? Because as you said, even though people may think of melatonin as an option in terms of the benefit, it's a pretty nuanced potential role. And first and foremost, we want to be thinking about those non-drug strategies and sleep hygiene.

SPEAKER_01 14:50

Yeah, and you know, when we think about drug versus non-drug, melatonin gets into that gray area because it's considered a supplement, which means it's not really considered a drug because it's not regulated like regular medications are in the United States. So it's supplement, dietary supplement. So there's no FDA approvals, there's no specific indications, manufacturers don't have to demonstrate safety, efficacy, or even consistent dosing in their products, as pharmaceuticals usually do. So that can in and of itself really lead to a lot of safety concerns for families, patients, and even providers that are recommending these supplements. Because when you really look down at some of that safety data, as particularly when it comes to, as we talked about, the overdose risks in patients, there's been studies that have found that melatonin supplements can really wild vary widely on their composition as compared to what on the label. And what's really interesting is some of the analyses are showing that there's a widespread of like negative 80% to all the way over to over 478% difference the in the actual composition of the product than what the label says. And what's even more concerning is some of the products that were analyzed actually had serotonin in it as a contaminant. Um, so and you think about from an overdose standpoint, if you're taking any medications that naturally support serotonin, so serotonin inhibitors or things like that, adding excess serotonin can always lead to those increased risks of adverse effects. Uh, specifically, you know, the offset chance that serotonin syndrome might occur. There's just a higher risk when you have these products used in combination with other medications. So by no means is it a benign supplement. Can't really call it a drug because it's not labeled specifically as one, but it's considered a natural product. However, there are side effects that can occur if not used properly or if um too much is given.

SPEAKER_00 17:06

Yeah. Yeah, I think you you summarized some of those concerns well because the fact that it's not regulated in the same way as prescription medications means it can have uh it can have, like you say, variety of different strengths of the uh the label may not match what's in the product, basically. There could be contaminants, there could be varying strengths of the product, there could be the labels aren't necessarily going to convey all of the information that the patient would need to know in terms of safety considerations. And so that is definitely a good counter to the idea that it's natural, so it's safe, but not necessarily because we we aren't regular those products are not regulated the same way as drugs, and so we don't have that data. Sometimes that happens after the fact that they're on the market, that some of the FDA actions can happen or supplements.

Supplement Quality And Overdose Risk

SPEAKER_01 17:53

So exactly. And so one of those big concerning trends we've seen in recent years is the increase in melatonin ingestions to the poison control centers. And so I think you had said earlier in our discussion that increased reports to poison control have been up over 500% between the years of 2012 and 2022. And that's particular in children less than five years of age. Fortunately, most of these cases have been asymptomatic, but some children have actually required hospitalization. And in rare cases, there have been patients that have been reported to need mechanical ventilation and potentially even death. The caveat to some of those pieces are we don't know what else is going on with those patients that have those really serious reactions or a concern of death. So we can't say that there is an association or a contribution to individual cases, but it's really like looking at that poison control data and what we know about it. So one of those big contributors that we think about again, it's an over-the-counter product, the way that it's marketed, we want to make it taste good, we want to make it look good because it tastes and look good. It's more likely to have folks purchasing it. And so it's it's those products that are sold as flavored gummies that look so similar to candy, or they taste like candy. So, of course, kids are going to think, well, yeah, I want more of this. There's open bottle counter. Of course, I'm going to have have my fingers into that. Right. So it even if it is appropriate for a child to have, we also have to think about appropriate storage and safety, right? Keeping out of reach of children and having it kind of locked in cabinets so those things don't happen in the home.

SPEAKER_00 19:37

Yeah, absolutely. I think that's a good distinction between the potential safety considerations with supplements generally, but then also this individualized sort of risk with overdose in this case, again, especially because there are so many appealing formulations in those gummies. As you said, I think it's one of the reasons that we're seeing those overdose cases and that that's been continuing to go up. But also because melatonin is the use is rising in general, and so it's in homes and therefore available for some of those potential risky situations. So um those are some risks, but what about any other side effects, concerns, interactions? What about what data do we have for long-term use with melatonin and then safety of that? Let's talk about some of the other safety considerations.

SPEAKER_01 20:21

Yeah, the one comment though, I wanted to state before we we go. You exactly have pointed out that we have increased utilization, increased purchasing of it. So it's really worth, I think, noting that their melatonin use has grown dramatically in the past decade. So, like sales alone in the United States have been reported at about$285 million in like 2016, so about 10 years ago. And then kind of post-pandemic, it's reported at over$800 million.

SPEAKER_00 20:50

Wow.

Side Effects Interactions And Unknowns

SPEAKER_01 20:51

So that's showing both a reflection in those sleep disturbances and of course the perception that melatonin is this natural and therefore safe option for families. And so getting into your question about the safety profile of it, what are our concerns? What are our long-term data releases? So, in general, yeah, melatonin is well tolerated when we're using it the way that we would expect to use it if package labeling is accurate and what it's saying the doses are, but of course, not completely free of side effects. So some of the things we think about are drowsiness and headaches, dizziness, it can cause some nausea. And in more extreme cases, it can actually cause some vivid dreams and nightmares in patients, which can be either further problematic and contributory to those um those poor sleep, those sleep nights or or issues with sleep itself. Um, and then of course, depending on the dosage that patients take, there's also some current concerns about the potential of next day's sedation or those disrupted sleep patterns as a result. Um an area of concern that has come up that I Think there's still some research is whether or not long-term use can affect puberty or hormonal development, right? It isn't hormone after all. So there's little we know about that long-term use in pediatric patients, especially as they're going through their stages of childhood into adolescence and their bodies are just developing and changing. Um, at this juncture, we have not seen any major effects on puberty development, which I think is great. However, the key takeaway really is there are not long-term studies. And so we don't really know globally what the use is going to look like or what the impact is. It's really interesting. Last fall, perhaps, um time escapes me. Uh, I don't know if you want there if that's that's a new problem. But I think it was last fall the um AHA at one of their conferences had put out an analysis of adult patients that looked at the use of melatonin for a five-term five-year study. And they essentially found some really interesting data that patients that had used melatonin long term actually had an association with worsening cardiac for their cardiac function. I'm not sure if you're familiar with this ring of bell. Yeah. And they basically found that there was an association, so not a causation. So we still have a lot more to learn about this. So don't go running and dumping all your melatonin down the drink just quite yet. But essentially what they found in that five-year analysis is that there was an association of increased risk of um of heart failure in those patients. And so that again, in adults that have other likely comorbid conditions, so association only not a causative factor, but further demonstrating that we think it's a safe and natural supplement, but certainly isn't without risk, uh, likely because of those reasons we had talked about is that these products aren't regulated by the FDA. We don't necessarily know what's in each specific supplement in terms of specific dose and in um how the product labeling is matching the composition of the product.

SPEAKER_00 24:08

So along those lines, what advice would you give to say you have discussed the sleep hygiene measures and they've tried a consistent sleep schedule and all of those non-drug options that we've wanted to reinforce? And there's a particular consideration for the use of melatonin in a given child. What advice would you give? Or the patient or parent is insistent perhaps on wanting to use it? How can we help them navigate that safely and minimize risk?

SPEAKER_01 24:41

Yeah. So some of those kind of key questions that come to mind for me are again, how long has your child been experiencing this problem? Um, what specific sleep problems is the child having? What are the current hygiene practices that are in place? And then, really importantly, as pharmacists, we think about every time we're recommending something new, what are the medications your child is currently taking? What potential do we have for interactions with these products? Melatonin is metabolized by um the liver. So specifically CYP1A, so CYP1A1, CYP1A2, uh, which is an important one we'll get to, and something that gets me really excited when we think about neonatal pharmacology. And then to a lesser extent, CYP2C19 and CYP2C9. So as a pharmacist, we should be thinking about let's evaluate what other medications this patient is taking. Is there a potential for drug interactions? Uh, reviewing all those questions I had just gone through. Does it make sense that we've already optimized our sleep hygiene schedules? We've optimized the darkness, we've optimized the temperature in the in the room. We're not, we're not too cold. And then we have to think about well, how do we ensure it's safe if the families are going to do it or administer it anyway? So we want to think about kind of that age of the child and the dosing recommendation because you actually really don't need a lot of melatonin to get the effects that you think you do. Um and so the body's naturally producing. Well, first, it's it's really interesting that um infants don't really start naturally producing consistent amounts of melatonin until about three months of age. And you think about the how that actually makes sense because babies aren't really sleeping through the night until they're after three months of age. And so so much of that is on just their development and how the brain is starting to create that natural substance to help facilitate that process. Um, babies potentially could even get melatonin through mother's milk, so that's another important factor of like there is transfer of melatonin through mother's milk, so something to think about with breastfeeding moms who might be taking it for themselves and that potential disruption to infant cycle as a result, but mom is ingesting. But in terms of what it is in terms of dosing, so your body doesn't really need a lot. Um, and so making sure that we're giving the lowest dose to start and titrating up after two weeks if it's not working is the really important consideration to have. So we think about patients that are less than three years old, you're really only needing a half up to one milligram of medication. And again, these are the kids that are we looking at screen use, are we looking at all these other factors? We want to try to correct those to prevent all this long-term exposure to medications. Kids that are three to six years old, they really should only be needing about one milligram. And again, that's based on what the body's naturally producing. Kids that are six to 12 years old, maybe about two milligrams is really the only dose that they should need. They shouldn't need a lot more. And then kids greater than 12 years of age, usually about three milligrams is what's needed. We talked earlier about the dosing and the safety, and that you can have that kind of daytime sleepiness as a residual. Some of the data shows that patients are taking like 10 milligrams or more, might actually have that kind of sleepiness that carries on into the day just as a result of that big dose that's lingering and still trying to be metabolized by the patient. So, how do we do it safely? We use that lowest dose possible and we try to be really considerate to the age of the child and again what their needs might be based on that and limiting that use. Um one, to limit exposure and making sure that we're promoting the sleep hygiene. And two, we don't want to have these extra costs incurred to families, right? Right. Thinking that it's going to be helpful or beneficial when we still don't know some of those long-term effects and we don't want to have that kind of residual sleep that's going to interfere with their day schedules, too.

unknown 28:58

Yeah.

SPEAKER_00 28:58

And Monica, you talked about interactions, but I think the other consideration for us as pharmacists is thinking about, as you said, get the med list and understand that. But are there timings of other medications that maybe could be affecting sleep also, like stimulants to close to bedtime as well for ADHD, perhaps, or other medications that could be affecting their sleep in other ways? So outside of even considering interactions, doing that med review and assessing for any factors that might be coming into play with sleep, I think it's also a really important reminder.

Dosing Storage And Stopping Plans

SPEAKER_01 29:27

Yeah, definitely. The other thing that comes to mind too is like beta one agenergic antagonists. So things like ethanol, emetoparol, ethanol, alcohol, or even medications like NSAIDs, those actually all will decrease the natural amount of melatonin that your body's producing. And so being mindful of timing of those drugs, right? Sometimes we take our beta blockers right before bed because they can make us sleepy. But at the same time of taking that, that can interfere with some of that natural production of your melatonin. So it might interrupt with your natural sleep cycle. So being a little bit more thoughtful about some of those medications and timing, I think is absolutely key to be successful when using the medication itself.

SPEAKER_00 30:11

And in your practice setting, you had mentioned that you often are when you see it, you may see people who are admitted, patients who are admitted, and maybe it's on their med list. And I that I think raises the question to me of how long people should be taking it if they even want to try it and follow some of those safe use precautions. But how is there a good thought process on when to reevaluate use, how often to try coming off of it, all of those kinds of questions? How long is too long?

SPEAKER_01 30:40

Yeah, I think we don't know the answer to how long is too long. But I think as pharmacists, so often we're associated that we want patients to have medications. Then what is what is their job going to be? I think sometimes my role as a pharmacist is to be that that goalie to prevent additional medications from come coming through and being exposed to patients. So I think I try really hard to try to work through like, is the problem still persisting? How can we safely get them off of a medication? So is it they've been on it for quote unquote years? Well, let's maybe first try to uh step back on the dosing and see if that makes an impact to the patient and their sleep schedule. Um, do that for a couple weeks and if family notices no different, take a further step back on the dosing or discontinue it altogether, or maybe just use it as needed to see if the child actually still needs it at all. Absolutely, one of the things that I do see when patients are in the hospital and we're we're talking to families during their admission time on what medications the child is using prior to admission, or if we're reviewing medications with the families prior to discharge, and that's kind of listed there. The question is one, on the when they're in the inpatient space, it looks like you use a specific gummy product. We don't have that in the hospital.

SPEAKER_02 31:58

Yeah.

SPEAKER_01 31:59

Either did you bring it in with you, which you know, there's rules and regulations per different institutions on whether or not supplements are allowed to be administered. Um, and if the answer is no, would it be acceptable to give the product that we've been using here? And if that answer is no, then we kind of have to go without it. And I can tell you more often than not, the kids that are not the neurovelopdevelopmental disorders, the kids that don't have underlying HDA or ADHD, the ones that are on it for more sleep hygiene issues that haven't been resolved, they usually do fine in the hospital from a sleep standpoint when they don't have it. So we do know even if kids have been on it for a long time, if we disrupt it for a weekend or a couple day hospital stay, um, it hasn't seemed to impact them too much. That's just anecdotal, not with sure, of course. So take that for what it is.

SPEAKER_00 32:53

Yeah. Yeah. Yeah. It's a good reason to have a holiday, a trial off and see if how they do without it. But I think I think that just reiterates that even if somebody wants to try it, following up and having those ongoing conversations around is it still needed? Have we retried those sleep hygiene measures? Have we retried the consistent schedule? Because situations change, life events change, you know, there's all kinds of reasons why people exactly. Absolutely. All right. Well, in terms of sort of summarizing where we're at, I think it sounds like we have some specific scenarios, patient populations where melatonin may be a consideration for short-term low dose potential use, but it's not a replacement for good sleep hygiene or a good bedtime routine. We want to emphasize those first and foremost, as always. If we are thinking about somebody who's going to be using it, reinforcing that low dose, looking for, I don't think we mentioned this, but again, something that comes to mind with the use of supplements for me is USP verified product, at least until you have the it it is more confident that you have what it says in the label, there's no risk of contaminants. So that's at least some quality check that you can help support patients and finding. But reinforcing that message, I think that just because it's a supplement or it's over the counter, that it's safe, is not is not true. And there's all kinds of reasons for that. And then again, reinforcing the point about if you're going to have it in the home, keep it up a way out of sight or locked cabinet, those sorts of things to prevent those accidents of poisonings. But anything else that we want to sort of summarize here and and remind our listeners about?

SPEAKER_01 34:41

Yeah, I I think really the the biggest things are let's just make sure first line approach is always consistent bedtime routines, limiting that light exposure. We are all guilty of this. Device is so accessible, but that's so important to prevent the suppression of the natural melatonin by getting rid of that light before bedtime, making sure that we have that cool, quiet sleep environment. So your body's able to do the natural things that it's meant to do, and avoiding any and all of those electronics before bedtime, which again I know is easier said than done, but those really be your first step approaches. And then, of course, if we were to need it, making sure that we're mindful of those lower dose regimens. Uh, we don't need to be doubling doses if it didn't work on night one. We don't need to be tripling doses because it seems like a low dose as compared to other things that we um on the good reminder.

Key Takeaway And CE Credit

SPEAKER_00 35:35

Yeah, yeah. Higher is not always better and could come with downsides. So that's absolutely a reminder. Yep. All right. Well, Monica, it is our game changers clinical update podcast. So we always wrap up with the game changer. And what do you think is the one takeaway that you'd want our listeners to walk away with when thinking about this topic in their practice or when working with patients? What is that game changer?

SPEAKER_01 35:59

Yeah, so melatonin, it isn't inherently harmless just because it's natural. And it can be a really helpful tool when used thoughtfully, but should be used strategically, really, at those low doses and ideally after all those sleep hygiene interventions have been optimized. And I think the biggest thing too is pharmacists have that really unique opportunity, given their accessibility, to guide those families towards that safe and evidence-based use.

SPEAKER_00 36:27

Absolutely. Yeah, I think you summarized it great. And we do. We are, regardless of what practice setting you're in, we're often in that position where we can provide that trusted advice and identify the use of supplements or medications that may or may not be appropriate and help guide through that. So excellent summary. Thank you so much, Monica, for your time. Really appreciate your insight on this topic. It's a tricky one, but important to get right because it is so commonly seen, I think, these days. Yeah, absolutely. I'm happy to be here. Thank you again for the opportunity. Fantastic. Thank you so much. So, listeners, be sure to claim your CE credit for this episode of Game Changers by logging in at CEimpact.com. And as always, have a great week and keep learning. I can't wait to dig into another game changing topic with you all next week.