Melatonin linked to improved brain function in paediatric concussion

Concussions in young people account for 90% of all traumatic brain injuries, with one in five children experiencing a concussion by the age of 10.
 
Symptoms can vary and evolve over time, fatigue and sleep disturbance among them.
 
But new research into the use of melatonin as a sleep promoting agent has brought some hope.
 
The study involved 62 children with mild traumatic brain injuries, one month post-injury, who reported persistent concussion symptoms. These included sleep disturbance, fatigue, and issues with memory, attention and concentration at school.
 
In a randomised clinical trial, participants aged between eight and 18 were split into three cohorts. Over the course of 28 days, they were either given one tablet of 3 mg or 10 mg of melatonin to take orally each night, or a placebo.
 
To assess brain activity, each participant underwent a magnetic resonance imaging (MRI) scan before and after the trial, which showed significant improvement in whole-brain function and grey matter among those who received the melatonin.
 
‘What we basically found was that the higher doses of melatonin actually improved their sleep quality, and that was actually linked to some key brain functions related to sleep control and also attention and memory,’ Dr Kartik Iyer, lead researcher from the Child Health Research Centre at the University of Queensland, told newsGP.
 
‘When we looked at the MRI scans again, we noticed that a lot of their brain functions improved, and specifically their grey matter, which is a great sign.’
 
The MRI scans enabled the team to rapidly assess millions of neural connections, and to identify a specific network of brain connections that positively responded to treatment.
 
‘These key regions talk to each other, and this network is actually really active when we’re daydreaming or when we’re washing our dishes or doing sort of menial tasks,’ Dr Iyer said.
 
‘This network’s actually damaged when they have a brain injury. But what we found is that melatonin gets this network back to normal so that we can actually go back to daydreaming.
 
‘It sounds funny to say, but daydreaming is actually really, really essential to us being able to switch on and switch off to tasks, and that’s something that we found that these kids can’t quite do as well.’
 
The evidence points towards melatonin being a useful neuroprotective agent to get people’s circadian rhythm back to normal.
 
‘So promoting that idea of getting a sleep time around about evenings to just produce melatonin in the brain, so that allows us to get into a sleep cycle,’ Dr Iyer said. 
 
But what happens when you take the supplemental melatonin away? It remains up for debate, according to Dr Iyer.
 
‘Our working theory behind this is that once you take away the melatonin, some kids are going to have this kind of neuroplasticity effect [where] they’re going to be able to control their sleep better without the actual medication,’ he said.
 
‘Other kids are potentially going to struggle without it, and that just might be related to their brain maturity or their overall development.’
 
While the study showed positive effects, it also highlighted that solving sleep problems is only part of the answer in aiding recovery.
 
That does not surprise Professor Gary Browne.
 
An expert in children’s brain injuries caused by sporting accidents, he said the study’s findings are of great interest, but agrees they do not represent a cure-all.
 
‘It was very exciting because it actually showed that melatonin does change brain wiring,’ Professor Browne told newsGP.
 
‘Melatonin probably has some very minimal anti-inflammatory effects … which can be a very important bridge to actually allowing you to get a child that has a lot of very high symptom burden to actually start accepting some basic rehabilitation interventions, which if they can have that intervention much earlier, they’ll do much better.
 
‘But I think that’s all it is. It’s a bridge – it’s not a panacea.’
 
With melatonin a largely safe drug, Dr Iyer says it could be a beneficial option in the days and weeks following a head injury.
 
‘One of the things that GPs can look into, even on a short-term basis, is whether melatonin does help. It’s almost like a quick fix just to see whether a child will respond,’ he said.
 
Dr Iyer hypothesises that the benefits may be even greater with a longer course of treatment as advised by a GP or neurologist.
 
‘So instead of four weeks, trialling it in an eight week course to really try to get that net benefit of not only sleep quality, but also once you have a really good control over sleep it rolls over into other things like improved attention and improved memory,’ he said.
 
Professor Browne disagrees with this approach.
 
Having used melatonin in his own practice for almost five years and, pursuing his own study on use of the hormone, he says anecdotally the benefits are largely dependent on the type of sleep disturbance.
 
‘Yes, it has an impact on sleep, but what type of sleep? Post-concussion insomnia is the big problem mostly with adolescents, but a lot of adolescents phase-shift and phase-shifting isn’t really going to be impacted by melatonin,’ Professor Browne said.
 
‘So you need to select the patient to use it wisely and carefully, and you can get very good results.
 
‘Sleep is important for brain healing, but there’s many different ways of encouraging sleep, from sleep hygiene through to cognitive therapy, which has actually been proven to be much more effective.’
 
Professor Browne says the most important step to improving concussion recovery is for GPs to recognise the differences between simple and complex cases, and to educate parents.
 
‘The literature is very clear – there must now be 100 papers showing that the common theme for prolonged recovery is that a kid gets concussed, it’s not recognised, they play on, and then suddenly three or four days later they’ve got overwhelming florid concussion symptoms because it just wasn’t recognised and they overstressed the physiology and their neural networks are just going crazy. I see this all the time,’ he said.
 
‘Parents need to know how to recognise the child’s concussed and to make sure that the parent pulls the child immediately away from activity and that they stay away from activity until they see their GP, and their GP can clear them.
 
‘Then it’s just weeding out the ones with simple concussion. And GPs will know, their gut will tell them, “It just keeps getting better and the parents are happy and things seem to be going along well”, or “This kid’s not quite right and they probably need to refer them on”.
 
‘So I think giving out melatonin willy-nilly because they’ve got sleep problems is like saying, someone has a breathing problem, give them some Ventolin because we assume it’s asthma. It may be, but it may not be.’
 
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