We recently covered some of the issues around sedation for transport, both within and outside the hospital. Whilst all of us are afraid of being stuck in front of an irate and agitated toddler for the duration of a long-haul flight, the trouble is not over for the parents when they land on the ground. Many of us have known the pain of having our children wide awake at 3AM when all you want to do is sleep. So is there anything we can do about jet lag in children?
Prior to departure initiate prescribed sleep scheduling
Circadian phase shifting with timed light exposure on arrival may reduce symptoms of jet lag
Consider circadian phase shifting with melatonin in the older child
Avoid sedatives such as benzodiazepines and other hypnotic agents
What is jetlag?
We all know the symptoms of jet lag:
- Difficulty initiating sleep in the new time zone (going east)
- Early awakening (going west)
- Fractured sleep patterns
- Increased fatigue and irritability
- Lack of interest in food
- Altered bowel habits
Why do we get jet lag?
If your natural circadian rhythm is out of sync with your external world, especially your exposure to natural light with the setting and rising of the sun, then jet lag occurs. Rapidly flying across multiple time zones makes it much more likely to occur than with slow, gradual shifts in time zone though children often have difficulty just adjusting to a single hour of Daylight Savings Time.
This easy to read paper, from Kolla and Auger (HT @emcrit), explains the competing homeostatic drives for sleep and wakefulness. Whilst some environmental factors have restricted the normal human circadian cycle to 24 hours in length, light exposure (or lack thereof) can quickly overwhelm the body’s natural tendencies. This biological clock resides in the hypothalamic supra-chiasmic nuclei.
West is best
We know that going west (say Melbourne to Dublin) is easier than travelling back east (Dublin to Melbourne) as you have to set your internal clock earlier rather than later.
What can we do to prevent jet lag?
Our core body temperature drops by a couple of degrees approximately two hours before our usual wake-up time. Exposure to bright light (especially sunlight) in the hours leading up to this resets our internal clock a little later. This is why the lights should be kept on in the Emergency Department overnight and why we should wear dark glasses on the drive home after a night shift. For more on this listen to Haney Mallemat at SMACC Chicago.
Before travel, it might be worth shifting the child’s bedtime. As they are used to routine children, somewhat surprisingly, suffer from jet lag a lot less than their carers.
Melatonin has been shown to be safe for use in preventing jet lag sleep disorder in adults. By starting it up to three days prior to departure (at a normal bedtime for the destination) and then for a further three days on arrival (at bedtime) symptoms may be reduced. As a chronobiotic agent, it acts on the biological clock. Endogenous melatonin is secreted during the hours of darkness to reinforce ‘darkness physiology’. It stands to reason then that taking exogenous melatonin might trick the body into thinking it is nighttime.
It has been used for a number of years to help children with sleep-wake disorders. However, there is no data regarding the use of melatonin in children for jet lag and so it should be avoided in anyone other than adolescents.
Hypnotic agents have been favoured by the international traveller but have not been widely studied in children. In an adult population, drugs such as zolpidem or zopiclone are probably as effective as melatonin (though with a much less complex dosing schedule) and may cause a number of side effects from nausea and vomiting to confusion and occasionally psychosis.
Every doctor’s best friend, caffeine, has also been studied, again in the adult population. It can reduce some of the feelings of sleepiness but this does not merit you giving a single shot of espresso to your two-year-old
How can parents look after themselves?
Long-haul flights with children can be tough so it is important to try and retain some sense of humour about the whole thing. If you are tired when they are wide awake then tempers will soon get frayed. One way to avoid this is to sleep when they sleep
If any of you have any great advice then please feel free to share in the comments section below.
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Kolla BP, Auger RR. Jet lag and shift work sleep disorders: how to help reset the internal clock. Cleve Clin J Med. 2011 Oct 1;78(10):675-84. Full text here
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Sack RL, Auckley D, Auger RR, Carskadon MA, Wright KP, Vitiello MV. Zhdanova IV. Circadian rhythm sleep disorders: Part I, basic principles, shift work and jet lag disorders. Sleep. 2007;30(11):1460-83. Full text here
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