Abstract
To The Editor:
S
Sleep terror is reported to affect ∼ 3% of children and <1% of adults, and is most commonly observed in toddlers and preschoolers (Robinson and Guilleminault 2003). Prevalence of the disorder decreases as the age increases; however, the colorful and scary images seen during sleep can adversely affect the functionality of the child and the family (DiMario and Emery 1987; Heussler et al. 2013).
The etiology of sleep terror is not fully understood, and there is, to date, no clearly defined treatment for it. Different therapeutic strategies have been proposed for sleep terror such as a behavioral approach, reinforcing age-appropriate sleep patterns, reassuring and guiding parents, and pharmacotherapy (Weissbluth 1984). The most commonly used medications in the pharmacological treatment of sleep terror are benzodiazepines and antidepressants (Howell 2012).
The purpose of this case report is to discuss the response of a 36-month-old male patient beginning treatment with melatonin after being diagnosed with sleep terror.
Case Report
A 36-month-old male patient was brought to the child psychiatry clinic by his parents with complaints of a sleep disorder exhibited by the child waking up frequently at night. It was understood from the interview with his parents that the patient had had sleep problems since his birth; he slept well for 30 minutes to 1 hour during the daytime, and his parents rocked him to sleep at ∼10
The mother described the patient as a warm-hearted child who shouted and insisted when he was angry. The patient had been taken care of by his babysitter during the daytime for the past 1.5 years; the 32-year-old university graduate mother described herself as a hot-tempered and intolerant person, and she stated that she received regular psychiatric support for manic-depressive disorder. The 32-year-old university graduate father had no psychiatric disorder, but had similar sleep problems when he was a child; the 8-year-old brother of the patient had short sleeping periods and had difficulty falling asleep.
During the psychiatric evaluation, it was observed that the patient was dressed appropriately for his age and sociocultural level, and that his verbal and nonverbal communication was normal and his cognitive functions were consistent with his age. Moreover, it was observed that he had a shy temperatment, and a mild level of articulation disorder. During the evaluation made using American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV-TR) diagnostic criteria, pervasive developmental disorder symptoms were not observed in the patient (American Psychiatric Association 2000). As a result of the application of Vineland Adaptive Behaviour Scale, it was determined that the patient's developmental level in all areas was similar to his peers'. A pediatric neurology consultation was requested for the patient and his electroencephalogram (EEG) was assessed as normal, and no neuropathology was detected. As a result of the psychiatric evaluation made using DSM-IV-TR diagnostic criteria, the patient was diagnosed with sleep terror and was followed up; his parents were informed about sleep terror, the follow-up, and the treatment process. Suggestions were given with relation to the sleep pattern and sleep hygiene of the child. After a 1 month follow-up process, no difference was observed in the duration and severity of the complaint; therefore, 1 mg melatonin treatment on a daily basis was started for the patient, and the patient was followed up for 6 months at regular intervals. The complaint completely disappeared 2 weeks after starting melatonin, no side effects were observed as a result of melatonin usage, and the patient tolerated the melatonin well.
Discussion
The most important role of the melatonin hormone, also known as N-acetyl-5-methoxytryptamine, is that it regulates the day–night and sleeping–awakening circles (Ozcelik et al. 2013). Melatonin has an effect on the suprachiasmatic nucleus, which is responsible for circadian rhythm, and melatonin release is regulated by transferring light information to the suprachiasmatic nucleus pineal gland (Stores 2003). The circadian rhythm of melatonin usually develops between the 2nd and 3rd months of life. Neonates and infants depend on their mothers' melatonin circadian rhythm through their milk (Touitou 2001). A sleep disorder, which began in infancy as in our case, may be associated with problems in the development of the circadian rhythm of melatonin.
Melatonin, which is very popular for use in insomnia treatment in children, ensures an effective treatment if taken in appropriate dosages. It has been indicated in studies that in addition to helping those with sleeping problems, melatonin is also effective in regulating start time of sleeping, the latency phase, and the sleep quality of children with autism spectrum disorder, mental retardation, and attention-deficit/hyperactivity disorder accompanied by sleeping problems (Pelayo and Yuen 2012).
In our case report, melatonin was used for the treatment of sleep terror occurring through stimulation at an early age, and there was an effective and reliable response to the treatment. In the literature, there is only one case report on this subject. Jan et al. reported that melatonin was used for the treatment of a 12-year-old male patient with Asperger syndrome and sleep terror and somnambulism complaints, and that the patient benefited from the treatment (Jan et al. 2004). However, our patient was very young, and our knowledge about the efficacy of melatonin usage at early ages is limited.
Studies in children using melatonin reported that melatonin use was not associated with any side effects even with >4 years of use (Jan and O'Donnel 1996). In our case, no side effects were observed as a result of melatonin use. Melatonin may be an option in the treatment of arousal disorders such as sleep terror. Controlled and comprehensive studies are required on the use of melatononin in children with disorders of arousal.