Two experts offer strategies to address inadequate weight gain and poor sleep in kids taking ADHD medication

Prescriptions of stimulants for ADHD continue to climb in Australia.

While the role of assessment, diagnosis and prescription often falls outside the remit of a GP, GPs are increasingly becoming the first point of call for concerns around the side effects of ADHD stimulants on children.

Inadequate weight gain is the most concerning side effect followed by sleep, according to Sydney paediatrician, Dr Paul Joshua, and he says GPs can play a part in monitoring and treating both.

“Even though stimulants are one of the most efficacious medications that we have, it’s far from a diagnose-and-prescribe model of management,” Dr Joshua says.

“GPs have a key role to play in monitoring weight loss and sleep in stable patients with ADHD, especially in rural and regional areas where there are shortages in specialists.”

In her experience of working as a paediatric dietician for more than 15 years, Lauren Gladman says malnutrition rates among ADHD kids on stimulants is high. GPs may be reticent in asking about a child’s food intake. Mrs Gladman says GPs can direct the parents to food interventions that help the child to grow.

“Parents often struggle to know what the right goals are,” Mrs Gladman says.

“For a child who is underweight, you increase food opportunities to match the times they are hungry. If they are hungry at afternoon tea, for example, you encourage larger and more energy dense meals then.”

Foods that are high in protein, fat, and carbohydrates are best. Mrs Gladman says The Sydney Children’s Hospital Network’s guide on High Energy Eating for Children is an excellent handout for GPs to give to parents.

Mrs Gladman also recommends using nutritious drinks to improve weight gain, such as PediaSure, Nestle Sustagen Kids Essentials, A2 Smart Nutrition, IsoWhey Kids Complete, and AptaGrow.

“A child with ADHD is often someone who doesn’t like to sit down and take time to eat their meal. You can increase nutrition intake by focussing on making it easy for the child to consume their food,” she says.

To determine if a child is underweight, guidelines recently released by the Australian ADHD Professionals Association (AADPA) recommend plotting a child’s height and weight on a growth chart and to measure height every six months, and weight three and six months after initiating treatment, and then every six months thereon.

Mrs Gladman supports using an upper arm circumference measurement as an additional check on a child’s nutritional status. If weight drops significantly, or there are co-morbidities, like celiac disease, food allergies, vegan diets, or digestive issues, she advises GPs to refer the child or adolescent to a dietician.

Sleep is the other major side effect of ADHD stimulants where GPs can intervene. Dr Joshua points out that the challenge for kids on stimulants is falling asleep, rather than staying asleep.

“Onset of sleep is related to the length of action of the stimulant, but it can also be a delayed side effect. Even if the medication has worn off earlier in the day, kids can still have problems falling asleep later that evening,” he says.

Parents can assist by monitoring a child’s sleep hygiene. This includes ensuring the child has a dark and quiet room to sleep in, checking in about their child’s emotional state before sleep, limiting exposure to screens and caffeine before bed, and making sure the child is getting enough exercise.

“We know exercise has a role in learning and concentration and general health, but it is also one of the most effective things in helping ADHD kids on stimulants get to sleep without further medication,” Dr Joshua says.

If further medication is required, melatonin is more commonly prescribed to kids on stimulants than it was ten to twenty years ago, according to Dr Joshua. In his clinical experience, the immediate-release compound version of melatonin is best.

“Long acting or prolonged release melatonin gives kids an unnecessary dose which doesn’t work at the time of night when they need it most,” he says.

The other medication Dr Joshua sometimes uses in small doses to help with sleep onset is clonidine (Catapres), an antihypertensive medication.