Empirical research evaluating the effects of non-traditional approaches to enhancing sleep in typical and clinical children and young people

Summary

This paper examines the effects of non-traditional (non-behavioural and non-prescription pharmaceutical) approaches to sleep in children and young people (0–18 y). A systematic search identified 79 studies that met inclusion criteria. Seventeen percent of the studies were rated as having a conclusive level of evidence, forty-two percent with preponderant evidence and forty-one percent with only suggestive evidence. There were promising indications, with certain populations only, for aromatherapy, ketogenic diets, an elimination diet (few foods diet), elimination of cow's milk, avoidance of caffeine, tryptophan with adenosine and uridine, omega-3 and omega-6, valerian, music, osteopathic manipulation and white noise. Bright light therapy and massage returned some positive results. All of these interventions warrant further, more rigorous research. There was limited or no evidence to support acupressure or acupuncture, other diets or dietary supplements, exercise or weighted blankets.

Caution is needed in interpreting some studies because poorer quality studies were more likely to return positive results. Suggestions are made for the improvement of large and smaller scale research, especially conceptualization around multiple physiological measures of sleep and the adoption of research methods which are of use in clinical settings.

Introduction

Prevalence studies into sleep problems in children and young people regularly remark on the low frequency of consultation with medical practitioners such as paediatricians [1]. Given this, it is likely that parents make their own decisions regarding treatment and access non-traditional remedies which are not reliant on contact with health professionals. But do these approaches work and what is the quality of evidence available to answer this question?

Generally such approaches are referred to as complementary and alternative medicine (CAM) but what comprises CAM is sometimes unclear. Most studies exclude psychological treatments as being mainstream and well researched [2] while other models [3] of CAM treatments include cognitive behaviour therapy. Similarly, some studies include melatonin as a CAM, while it is a prescribed medicine in some jurisdictions and is excluded in some reviews [2]. Complementary and alternative medicines are used by 20–40% of typical and more than 50% of chronically ill children [3]. Although regularly used by adults with sleep problems [2], overviews of their use with children scarcely mention sleep [3]. This review poses the question – do such remedies and approaches have an effect on sleep problems, or even an effect on sleep per se in children and young people?

This review adopts the term “non-traditional (i.e., specifically non-prescription pharmacological and non-behavioural) approaches” and investigates their use with both sleep and sleep problems in both typical and atypical children and young people (0–18 y). This descriptor is used instead of CAM, and omits the word “medicine” to reflect the information accessed by families outside of the health professions; to reflect that approaches, such as exercise, are difficult to categorise as “medicine”; and to expand the investigation beyond medically diagnosable sleep problems to include their effects on sleep per se.

Even with adults, there are few studies employing randomized controlled trials (RCTs) to investigate this topic. A previous review into the use of CAM in insomnia by Sarris and Byrne [2], found only 20 studies, over eight (of 16) therapeutic approaches, reaching their standards of rigour. Their studies predominantly addressed adult and geriatric populations, so at this point in time, rigorous criteria may function to render the use with children, and some specific approaches, invisible in reviews. So, restricting the inclusion of articles to those using RCTs or similarly rigorous approaches seemed counterproductive. Instead, we catalogue what research has been done in this area, together with the quality of the research involved, in order to demonstrate just what the evidence-base is for these approaches. This may allow researchers to remedy the systematic problems which beleaguer research with such interventions [2]. We therefore seek to ascertain 1) the evidence that any non-traditional approaches affect sleep per se, or sleep problems, and 2) the quality of the research addressing these questions.