Studies have shown that modafinil can alleviate daytime sleepiness, with higher doses being more effective than lower ones. Split dosing may provide more sustained effects than a single dose (18). Research on pediatric narcolepsy indicates that the dosage range for children is similar to that for adults, ranging from 200 to 600 mg/day, usually administered in split doses to alleviate afternoon and evening drowsiness. Children taking modafinil did not report side effects such as headaches, nausea, or sweating in relevant cases (18–20).

Methylphenidate alleviates daytime sleepiness and is available in short-acting and long-acting formulations. The starting dose is 5 mg/day, slowly titrated to a maximum of 60 mg/day, with no single dose exceeding 25 mg (4).

The starting dose for amphetamines is 2.5 mg/day, with a slow titration of 2.5–5 mg/week, not exceeding a maximum of 40 mg/day.

Sodium oxybate is the only medication approved by the FDA and EMA for treating daytime sleepiness and cataplexy in children and adolescents aged 7 and older (4, 5). Common side effects include nausea, dizziness, sleepwalking, and headaches (21). The initial dose is 2.25 g at bedtime, followed by another 2.25 g 2.5–4 h later, gradually increasing by 1.5 g/week to an effective dose of 6–9 g per night.

Limited studies have reported that pitolisant can alleviate daytime sleepiness in children and adolescents, with a typical dose range of 4.5–36 mg/day. For children with low body weight, the dose can be halved. Side effects include insomnia, headaches, and hallucinations, with most, except insomnia, gradually subsiding (17, 21, 22).

Clomipramine is often used to alleviate cataplexy symptoms, with common side effects including dry mouth, drowsiness, orthostatic hypotension, and weight gain. Sudden discontinuation can worsen symptoms. The starting dose is 25 mg/day, adjusted weekly to a final dose of 3 mg/kg/day or 200 mg/day (17, 23). However, some literature suggests that clomipramine has limited efficacy for cataplexy (4). Other tricyclic antidepressants include imipramine and protriptyline.

Fluoxetine is commonly used to alleviate cataplexy symptoms, with side effects such as headaches, anxiety, nervousness, and personality changes. The starting dose is 10 mg/day, with a maximum dose of 20 mg/day (4). Other SSRIs include fluvoxamine.

Data on venlafaxine use in children are limited, with only two-year follow-up case studies available. It can alleviate cataplexy symptoms in narcolepsy, with side effects similar to those of SSRIs. The starting dose is 37.5 mg/day, with a maintenance dose of 75–300 mg/day (17). Clinicians often prefer SSRIs and SNRIs, but abrupt discontinuation can lead to rebound cataplexy (5).

Some studies suggest a connection between NT1 and autoimmune mechanisms, with intravenous immunoglobulin G (IVIG) potentially alleviating symptoms. However, research is limited and focused on early-stage treatment, with results remaining controversial. Further data is needed to exclude the possibility of spontaneous symptom remission in narcolepsy (6, 17, 23).

Children with narcolepsy often face numerous psychological issues, such as declining academic performance, reduced motivation, school aversion, and anxiety (24–26). Non-pharmacological treatments, as adjunctive or alternative therapies, are frequently used to alleviate daytime sleepiness. Some studies report that medication alone may not fully relieve daytime sleepiness, with only about 15% of narcolepsy patients relying solely on medication (27, 28). Over half of the patients require adjunctive non-pharmacological treatments (26). These include cognitive-behavioral therapy (CBT) and behavioral therapy, with clinical guidelines from various sleep medicine or neurology associations including recommendations such as regular napping, sleep hygiene, a balanced diet, and physical activity (29–32).

Studies suggest that scheduled naps at specific times during the day can alleviate daytime sleepiness (two to three short naps of 15–20 min each). Nap duration should be controlled to avoid sleep inertia from prolonged naps (33, 34). However, some studies found no significant difference between short and long naps in aspects such as reaction speed after waking (35).

Additionally, extending nighttime sleep can reduce daytime sleep pressure, alleviating daytime sleepiness. Physical activity can also reduce weight and alleviate daytime sleepiness without triggering cataplexy (36, 37). Other common behavioral strategies to alleviate daytime sleepiness include environmental management (e.g., keeping the environment dry and cool, enhancing ventilation), dietary management (e.g., avoiding overeating, consuming vitamin-rich foods), staying active (e.g., participating in activities, avoiding prolonged sitting), and using pain to stay awake (e.g., pinching oneself) (26, 28).

CBT has been more commonly applied to chronic insomnia, known as Cognitive-Behavioral Therapy for Insomnia (CBT-I). It has further developed into various forms, including Internet-based CBT for Insomnia (ICBT-I). Despite behavioral management being recommended for pediatric narcolepsy, research on the effectiveness of CBT for narcolepsy is limited (17). Researchers have developed a novel CBT for narcolepsy, involving online assessments and remote interventions through different modules (24).

CBT can be used as a non-pharmacological treatment to alleviate cataplexy, daytime sleepiness, and sleep-related hallucinations. The treatment mainly comprises three parts: (1) improving sleep disturbances through behavioral management; (2) altering beliefs, motivations, and emotions that play a significant role in maintaining narcolepsy through cognitive therapy; (3) educating patients about the disease, including its etiology, symptoms, and medication precautions. Specific methods include systematic desensitization, stimulus control, and imagery rehearsal therapy (37).

Some patients with narcolepsy also experience anxiety, depression, and other emotional issues, which can be alleviated through psychological counseling. Studies have shown that NT1 patients tend to use fewer active coping strategies when dealing with the symptoms of narcolepsy. Instead, they are more likely to exhibit mental and behavioral disconnection from real life, such as mentally distancing themselves from stressors or using passive and avoidant approaches to handle problems rather than actively attempting to resolve them (38). Research has also shown that when chronic illness leads to a decline in quality of life, peer support can help patients combat feelings of isolation, gain psychosocial support, boost their confidence in overcoming the illness, and alleviate negative emotions (1, 3, 39). Certain associations for narcolepsy, established either officially or privately, assist patients and their families by providing professional knowledge about the diagnosis and treatment of the disease and opportunities for narcolepsy patients to connect with each other (17, 40). Therefore, for the treatment of narcolepsy, relying solely on medication is insufficient; it requires supplemental behavioral and psychological therapies in addition to medication.

In summary, children suspected of having narcolepsy should be referred to a multidisciplinary sleep medicine center. For diagnosed pediatric narcolepsy patients, different treatment plans should be adopted based on their symptoms. For those without cataplexy, medication combined with behavioral management is recommended. For patients with cataplexy, or those whose quality of life is compromised, or who have anxiety and depression, medication combined with CBT is suggested. Currently, sodium oxybate is the only medication approved by the FDA for alleviating cataplexy. However, administering sodium oxybate before the patient goes to bed may pose a risk of nighttime falls. Additionally, a second dose is required 3–4 h after sleep onset, and there is a potential risk of side effects such as sleepwalking and enuresis. Other medications, including venlafaxine, atomoxetine, and fluoxetine, have been used in clinical practice, with careful monitoring of relevant test results being essential. Studies have shown that venlafaxine is highly effective in alleviating cataplexy and has been recommended as a first-line treatment for adult cataplexy. Furthermore, researchers have used venlafaxine in children and adolescents aged 7–14, finding it effective in relieving cataplexy without delayed effects (41, 42). Based on these findings, we opted for low-dose venlafaxine in this case. Future studies with larger sample sizes and control groups are warranted. Additionally, forming peer support groups can help patients and their families understand the disease better. Disease associations can provide education on medications and enhance patients' and families' medication adherence, ensuring safe pharmacological treatment (43).