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<jats:title>Abstract</jats:title><jats:p>This was a prospective, randomized, double‐blind, single‐center placebo‐controlled trial to assess the efficacy and safety of melatonin as an add‐on treatment for infantile epileptic spasms syndrome (IESS). Participants aged 3 months to 2 years with a primary diagnosis of IESS were recruited and assigned to two groups in a 1:1 ratio. Both treatment groups received a combination of adrenocorticotrophic hormone (ACTH) and magnesium sulfate (MgSO<jats:sub>4</jats:sub>) for 2 weeks, and the treatment group also received melatonin (3 mg) between 20:00 and 21:00 daily, 0.5–1 h before bedtime. The study's primary endpoint was the average reduction rate in spasm frequency assessed by seizure diaries. Secondary endpoints included assessment of the response rate, EEG hypsarrhythmia (Kramer score), and psychomotor development (Denver Developmental Screening Test, DDST). Sleep quality was assessed by using the Brief Infant Sleep Questionnaire (BISQ), the Infant Sleep Assessment Scale (ISAS), and actigraphy. Safety parameters were also evaluated. Statistical analyses were conducted on intention‐to‐treat and per‐protocol populations. The trial is registered at <jats:ext-link xmlns:xlink="http://www.w3.org/1999/xlink" xlink:href="http://Clinicaltrials.gov">Clinicaltrials.gov</jats:ext-link> (ChiCTR2000036208). Out of 119 screened patients, 70 were randomized and 66 completed treatments. In the intention‐to‐treat population, there were no significant differences in the average percentage reduction of spasm frequency (median [interquartile range, IQR: Q3–Q1], 100% [46.7%] vs. 66.7% [55.3%], <jats:italic>p</jats:italic> = .288), the 3‐day response rate (51.4% vs. 37.1%, <jats:italic>p</jats:italic> = .229), the 28‐day response rate (42.9% vs. 28.6%, <jats:italic>p</jats:italic> = .212), EEG Kramer scores (2 [3.5] vs. 2 [3], <jats:italic>p</jats:italic> = .853), or DDST comprehensive months (5 [2.5] vs. 6 [6], <jats:italic>p</jats:italic> = .239) between the melatonin (<jats:italic>n</jats:italic> = 35) and placebo (<jats:italic>n</jats:italic> = 35) groups. However, caregivers reported improved sleep quality after melatonin treatment, with 85.7% reporting regular sleep compared to 42.9% with placebo (42.9%, <jats:italic>p</jats:italic> &lt; .001). The melatonin group had lower ISAS scores in 4–11‐month‐old patients compared to the placebo (mean ± SD, 29.3 ± 4.4 vs. 35.2 ± 5.9, <jats:italic>p</jats:italic> &lt; .001). Moreover, the median (IQR) value of sleep‐onset latency was shortened by 6.0 (24.5) min after melatonin treatment, while that in the placebo group was extended by 3.0 (22.0) min (<jats:italic>p</jats:italic> = .030). The serum melatonin (6:00 h) level (pg/mL) of the children in the melatonin group after treatment was significantly higher than in the placebo group (median [IQR], 84.8 [142] vs. 17.5 [37.6], <jats:italic>p</jats:italic> &lt; .001). No adverse effects related to melatonin were observed in the study, and there were no significant differences in adverse effects between the melatonin and placebo groups. Although not statistically significant, the results of this randomized clinical trial proved that melatonin supplementation, as an add‐on treatment, can improve spasm control rate in the treatment of IESS. For IESS children treated with ACTH, the addition of melatonin was found to improve sleep quality, shorten sleep onset latency, and increase blood melatonin levels. Moreover, it was observed to be a safe treatment option.</jats:p>