Abstract Introduction Complex nocturnal visual hallucinations arise during sleep onset or nighttime awakenings and can be a significant source of anxiety for children and their caregivers. Although isolated reports have described successful treatment with melatonin in adults, its efficacy in pediatric patients has not been reported. Herein, we present the first known pediatric case of complex nocturnal visual hallucinations demonstrating a dramatic response to melatonin. Report of case(s) A 6-year-old female with no significant neurological comorbidities presented with frequent, intricate visual hallucinations associated with poor sleep quality and daytime fatigue. The hallucinations, occurring nightly for three weeks, involved seeing worms crawling over her body and bedroom during nocturnal awakenings to use the restroom. She was fully awake during the events, which lasted 1–2 hours, and had full recollection of events in the morning. Past history included transient nocturnal hallucinations several years prior during her father’s military deployment that self-resolved and a history of snoring but no sleep-disordered breathing on polysomnogram. She also endorsed symptoms of restless leg syndrome separate from her visual hallucinations and was started on oral iron therapy for sub-optimal ferritin levels. Standard sleep hygiene and behavioral interventions were ineffective. Evaluation with pediatric psychology identified symptoms of anxiety but did not identify any additional psychiatric disorders, psychological stressors, or underlying trauma. Family denied any prescribed or over-the-counter medications. There was no improvement in her nocturnal hallucinations with the introduction of iron. Following initiation of melatonin (3 mg, immediate-release, 30 minutes before bedtime), the frequency and intensity of hallucinations decreased markedly within several days, with complete resolution within one week. While she continues to wake up nightly to use the restroom, reported sleep onset latency and total sleep time also improved. No adverse effects were observed at 4-month follow-up with continued resolution with melatonin. Conclusion This is the first known reported case of pediatric melatonin-responsive complex nocturnal hallucinations to our knowledge and aligns with adult reports of melatonin-responsive nocturnal hallucinations. It highlights the potential therapeutic role of melatonin in this population. Further research is needed to clarify optimal dosing, indications, and underlying mechanisms for melatonin-responsive complex nocturnal hallucinations. Support (if any) None.
Lee et al. (Fri,) studied this question.