Abstract

Introduction
Children with autistic spectrum conditions commonly experience sleep difficulties and are less likely to respond to behavioural sleep measures alone [1]. Melatonin is thought to improve sleep in this population [2], however little is known about what factors influence prescribers’ decision-making.
Aim
To explore factors influencing melatonin prescribing decisions for paediatric patients diagnosed with autistic spectrum conditions and sleep difficulties.
Methodology
All children diagnosed with ASC at one centre over a 12-month period were identified through outpatient coding (SNOMED). Electronic records were reviewed and thematically analysed to identify factors influencing prescribing decisions by one author (CH) and reviewed by others (AT, APR). Descriptive and inferential statistics (Mann-Whitney U test and Fisher Exact test) were used to identify and analyse prescribing patterns (CH). Ethical approval was not required as this was a retrospective evaluation.
Results
One hundred and ninety-three children were diagnosed with ASC between Oct 2019 and Sep 2020 and seen by 13 different clinicians. The sample included more males than females (male: female ratio 2.7:1) with an age range between 2–16 years age, and mean length follow-up of 126 weeks. Approximately 42% of children (n = 82) had reported sleep difficulties recorded in their electronic records, whilst 65% (n = 53) had melatonin prescribed. Melatonin prescribing varied between clinicians, with seven clinicians always prescribing melatonin when sleeping problems were reported, four prescribing between 50 and 100% of the time and one clinician only prescribing melatonin for 10% of patients reporting sleeping problems. The median age of children with sleep difficulties prescribed melatonin was 4.52 compared with 5.4 years for children who were not prescribed melatonin. Clinicians who prescribed the least melatonin recorded information about sleep less often compared to clinicians who prescribed the most melatonin (6% vs 53%). Clinicians who prescribed the least melatonin were also more likely to discharge at diagnosis (median follow-up 0 vs 223 weeks). Melatonin was more commonly prescribed if information about parents being separated was recorded (p<0.05). Factors which did not lead to significant differences in melatonin prescribing included records of a sibling with a disability; a child protection plan; parental disability or sibling with ASC.
Discussion
Melatonin prescribing decisions vary considerably for paediatric patients diagnosed with autistic spectrum conditions and sleep difficulties. Melatonin prescribing behaviour of clinicians may be influenced by what information about sleep is identified during consultations, the length of follow-up and family circumstances. The findings align to FIP Development Goal 13, 15 and 18. Further work is needed to explore clinician prescribing decisions to standardised melatonin prescribing policies, ensure person-centred care and equitable access to medicines. A limitation of the study is prescribers may not always document factors influencing their prescribing decisions and so factors may have been missed. Further work is needed to understand why decisions to prescribe melatonin vary for patients with ASC and sleep difficulties.