What's behind the increased use of melatonin in children?
Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.
Melatonin is a hormone produced in our brains in response to darkness. And it helps with the timing of our circadian rhythms and sleep. Synthetic melatonin is also available as a dietary supplement sold over the counter and popular with people seeking sleep aids. But recently there's concern about the use of melatonin in children.
Here to explain is Dr. Vincent Calleo. He's the medical director of the Upstate New York Poison Center. Welcome back to "The Informed Patient," Dr. Calleo.
Vincent Calleo, MD: Thanks, Amber. It's great to be back
Host Amber Smith: A report from the Centers for Disease Control and Prevention noted more than a 500% increase in the number of pediatric ingestions of melatonin over 10 years, from 2012 to 2021.
And it said the increase was primarily because of an increase in unintentional melatonin ingestions in children under age 5, and I wonder, have you seen the same trend at the Upstate New York Poison Center?
Vincent Calleo, MD: We have been seeing a significant increase in the number of unintentional pediatric exposures to a number of different medications and substances.
But one of the ones that we have seen a pretty large increase in is the unintentional ingestion of melatonin in the children that fall into that age range. Now, if I'm taking a look at the exact percentages, I don't know if the ones that we've seen at the Upstate New York Poison Center have been quite as large as a 530-and-some-odd percent increase over the last several years, but that number certainly has gone up quite a bit.
Host Amber Smith: Why is there such an increase, then? Because I know there's an increase in the use of melatonin overall. Is it just that there's more of it out there in homes?
Vincent Calleo, MD: I don't know the exact answer to that question because I think there are probably a bunch of answers, but much like you alluded to, I think that one of the biggest reasons that there may be an increased number of exposures is simply because there's more of it around, right? It's just a law of statistics. The more that there is something around, the more likely it is that it could potentially be ingested by a small child.
And the other thing too, that I think people always need to remember, is that there are a lot of different formulations of melatonin out there. And some of them actually look like gummies. And for that reason, a lot of times children are more likely to seek something that looks like a common treat that they may have.
Host Amber Smith: So some of these are accidental. Are you seeing intentional ingestion of melatonin? Are parents giving younger kids, under age 5, melatonin to help them sleep?
Vincent Calleo, MD: We definitely do get calls, occasionally, when parents will give some of the medication to their children to help them sleep, if maybe they're concerned a child may have ingested an extra one. And I think melatonin certainly is used in the pediatric population, but normally that's done under the guidance of a pediatrician or a family medicine doctor who's helping to take care of the patients. Now, I can't say for sure that there aren't cases out there where parents are giving children melatonin without being told by their physician. But I think for the most part, most parents tend to err on the side of caution and at least ask a pediatrician or their family medicine provider, whether it's safe to give this medication to a child.
Host Amber Smith: Now I understand it's a small number, but some children who ingested melatonin required hospital intensive care. And some even died. What were the symptoms that they were in need of medical care? How would a parent recognize a bad reaction?
Vincent Calleo, MD: So when we start to think about that report that came out not too long ago, it was nice in that it looked at thousands and thousands of cases over the course of about nine to 10 years. And so I think from that end, we have a large number that we draw from, but Amber, much like you already spoke to, there were a few cases, sadly, of children that required some intensive hospitalization and a couple that even resulted in death.
Now, the problem with the study that was done is that it doesn't actually have the ability to take a look at the individual case reports for the children that had those more serious outcomes. So I really applaud the authors who put in a lot of work in order to get this data and, through no fault of their own, unfortunately, it sounds like it was a little bit unrealistic for them to get the exact case reports that take a look at the data as to, say, what may have caused the child to have a bad outcome, whether it was just the melatonin or whether the child may have been otherwise sick before that or had other medical problems that may have significantly led to their poor outcome.
In terms of answering your other question -- what can families watch out for? -- one of the things that melatonin can typically do is cause children to get more sleepy than normal. So if you start to see a child have a significant change in their mental status, where they're acting much different than normal, if you see the child, and it looks like they're having a harder time breathing or not breathing as much as they normally do, those are some of the more worrisome signs, and if families are ever concerned, I do urge them to seek immediate medical attention.
Host Amber Smith: I thought melatonin was considered safe for most people, especially if it's short-term use. But technically it's not a medication, so the FDA (Food and Drug Administration) doesn't have the same oversight that it would over, like, aspirin, right?
Vincent Calleo, MD: That's correct. So melatonin right now is considered to be a supplement, and as a supplement, the FDA doesn't have that same degree of, regulatory oversight that we see with other medications that are FDA approved. Overall, I think melatonin is a very safe medication, and we get many, many, many calls to the poison center every year for ingestions of only melatonin.
And in addition to that, melatonin along with other substances, and the vast majority of the time, people do tend to do pretty well with melatonin. So it is overall, I think, a relatively safe medication, but much like with any substance, including even things like water, too much of a good thing can result in something bad, right?
You know, in toxicology, one of the mantras that we live by is "the dose makes the poison." So if you take enough of anything, there's a chance that it could cause toxicity or significant harm. So normally though, in a therapeutic setting or one where it's taken at the recommended dose, normally it does tend to be a pretty safe medicine.
Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Dr. Vincent Calleo. He's the medical director for the Upstate New York Poison Center, and just a reminder that you can reach the poison center 24 hours a day at 800-222-1222.
Now, back to melatonin. Can you describe for me how melatonin works in the body? What does it do that helps us sleep?
Vincent Calleo, MD: Without getting, really technical with it, essentially, the way that melatonin works is your body naturally makes melatonin, and that does help to regulate your circadian rhythm and your sleep cycles. One of the reasons why we think that giving exogenous melatonin, or melatonin that you take by mouth, as a supplement is that if your body is running a little bit low in that hormone, taking extra melatonin may help to regulate that amount and raise it a little bit.
And by doing so may help to reestablish your ability to fall asleep a little bit more naturally and get into that induced sleep state. So that's the long and short of it. Unlike a lot of different medications that can affect your sleep cycle and develop some dependence, we don't think that, for the most part, the majority of people that take melatonin end up developing a dependence to it, just because of the way that it works a little bit differently than something like a benzodiazepine or some other medicines that people take more regularly. In fact, one of the things that melatonin is frequently touted as is a non-habit-forming sleep aid. And so by hopefully replacing the amount of melatonin in the body, you may be able to help regulate your circadian rhythm a little bit more.
And for that reason, it can help you to establish a better sleep pattern.
Host Amber Smith: So it might help you fall asleep. Does it help you stay asleep?
Vincent Calleo, MD: To be quite honest with you, Amber, I think it probably depends a little bit on the individual person. I think that there's a chance that it may help you to stay asleep some, but when I really start to think about it, the primary thing that I think about is helping to regulate getting you into a more healthy sleep cycle and help induce sleep a little bit more than staying asleep once you've already fallen asleep.
Host Amber Smith: What are the expected side effects? Does it make you feel drowsy, or is there a sensation that people will get from taking it?
Vincent Calleo, MD: Usually what'll happen is people will oftentimes describe feeling a little bit more relaxed in a wakeful state. And in theory, that's really what oftentimes helps people actually fall asleep from there.
When you start to think about taking too much of it, people will describe feeling maybe a little bit lightheaded or a little bit dizzy. They may feel a little bit drowsy, which, again, is not unexpected. When you start to think about some of the more severe side effects for taking far too much, sometimes you can see some more severe effects, like slurred speech, ataxia or, kind of walking around and bumping into things or having a decrease in your coordination. And some people have even described having hallucinations at larger amounts. Now, again, I think the number of people that have those more severe side effects are very, very low compared to the number of people that take the supplement. But at the same time, those are things that have been reported in the (medical) literature.
Host Amber Smith: Is it meant to be taken every day or every night, like a vitamin, or do you just take it if you're having trouble getting to sleep and you need some help sporadically?
Vincent Calleo, MD: I think that really depends on the individual person, and both for pediatric patients and for adults that take melatonin, I always recommend talking with your primary care provider in trying to establish a good trend, in order to help establish a better sleep cycle. Sleep is an incredibly complex field of study that, in all honesty, I don't think anyone has a great understanding of. There are some people that spend their entire career studying sleep and sleep cycles, and they still don't have all the answers.
So to go back to your original question, Amber, as to whether it's meant to be taken regularly or just on occasion, I think that really depends on the individual, and I would strongly encourage them to talk with their health care provider in order to help establish not just a safe, and effective treatment regimen with melatonin, but sometimes, and oftentimes even more importantly, establishing good sleep or healthy habits that can really help to optimize the ability to fall asleep without using any sort of medication and to help with that, too.
Host Amber Smith: Does melatonin interact with certain medications? Are there things, if you're taking them as a prescription, that you shouldn't take (with) melatonin?
Vincent Calleo, MD: I'm sure there are things out there that melatonin can interact with. And I would always recommend, particularly for elderly individuals or people who take other medications for things like anxiety or depression or for sleep, I would always recommend taking that at the recommendation of your primary care provider because I'm sure there probably are some medications where it could interact a little bit more strongly. When I start to think about the relative degree when I consider all the medications out there, it's not one of the ones that's higher on my list that I think has a high degree of very significant interactions with other medications.
But with that being said, always talking with your primary care provider, when you're thinking about whether you want to use this and looking at your medication list can help to decrease the likelihood of having a bad reaction or some sort of medication interaction between that and another substance.
Host Amber Smith: We started out talking about the use in children, particularly young children, under age 5, and, you talked about the importance of speaking with your pediatrician first. Are there special concerns about the use in senior citizens, older people?
Vincent Calleo, MD: When I look at age in the relative spectrum of caring for patients, I really think there are two different extremes.
On the one hand you have the young, pediatric patients. And on the other hand, you have the elderly, geriatric patients, both of whom tend to fall into slightly more unique categories than the majority of people that we think of as the traditional teenagers or early to mid-adulthood age ranges. So as the body starts to age, the way that different enzymes work does start to change, particularly as we're thinking about the way that the liver works, the way that the kidneys work and a number of different other functions in the body. Those things do change as people age.
So to answer your question as to whether we get a little bit more concerned regarding use in elderly patients, I'd say the answer is certainly yes. For one thing, like we just talked about before, there is always a potential for there to be a medication interaction with another substance. And as people age, the likelihood of them being on additional medications does go up pretty significantly. So I always worry that if we're adding in too many things, you end up to have that proverbial too many cooks in the kitchen type thing going on, where if you have extra medications that are being added in, sometimes it does get a little bit tricky to know exactly how each one is going to interact.
It's hard enough to sometimes figure out how two medicines will interact. And then when you go ahead and you have nine or 10, it makes it a lot more challenging. So, much like for the pediatric patients that we discussed earlier, I would say for anyone who's a geriatric patient in particular, they should be making sure they're speaking with their primary care provider or their geriatrician in order to help make sure that the medicine they're taking is not going to have an interaction with melatonin, should they choose to try and take it.
Host Amber Smith: What sorts of questions does the poison center get from callers about melatonin? Do you ever hear from people with questions?
Vincent Calleo, MD: Yeah, we certainly do. And one of the more common things that we see is in the pediatric patient population. Much like we talked about earlier in the interview, frequently families will call and say, "My child got into the melatonin gummies and took two or three extras. Is it going to be safe for my child to stay at home, or do they have to go to the emergency department?"
Now, in the majority of cases, most children are going to do pretty well at home, provided they don't take other medications and that they didn't get into any other substances and they're otherwise pretty healthy.
Every case we consider on an individual basis, so it's hard to make a blanket statement as to whether it's safe for any child to stay home under any circumstance after taking melatonin. But I'd say the majority of calls we get for home medication exposures to things like melatonin with young pediatric patients, we're normally able to keep them at home if the situation is appropriate.
And fortunately, we have a highly trained staff of specialists in poison information who've been trained for a long period of time as to how to "risk stratify" who's going to be safe to stay home and who needs to seek immediate medical attention.
So that's really, I think, probably the most common thing that we see, are the calls to the poison center regarding accidental exposures to home doses of melatonin from pediatric populations.
Host Amber Smith: Well, Dr. Calleo, I thank you for making time for this interview.
Vincent Calleo, MD: It's my pleasure. And Amber, if anyone ever has any questions for us, I always remind folks that we can be reached at the poison center toll free at that 1-800-222-1222 number, and we're there 24/7, 365 (days a year). We're safe. We're fast. We're confidential. And we strongly encourage anyone to call with any questions or concerns they may have.
Host Amber Smith: My guest has been Dr. Vincent Calleo. He's the medical director of the Upstate New York Poison Center. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed.
This is your host, Amber Smith, thanking you for listening.