Sleep and Its Disorders in Children

Timothy F. Hoban, MD

Disclosures

Semin Neurol. 2004;24(3) 

In This Article

NREM Arousal Parasomnias in Children

Sleepwalking, confusional arousals, and night terrors are the major childhood parasomnias that are thought to result from incomplete arousal from sleep ( Table 1 ). Such arousals, usually arising from deep NREM sleep, may cause a spectrum of nocturnal behaviors ranging from quiet sitting or ambulation to violent degrees of agitation. Partial arousal parasomnias tend to occur during the first third of nighttime sleep, during the time of predominant slow-wave sleep, and may increase in frequency as a result of sleep deprivation or other stressors. It is usually difficult to alert or awaken a child during these events, and affected children typically demonstrate little or no independent recollection of these episodes the following day. There is a family history of partial arousals in up to 60% of cases, suggesting strong genetic influences on this family of parasomnias.[50,51]

Episodes of sleepwalking in children usually consist of quiet, nonagitated ambulation lasting several minutes. Sleepwalking is often difficult to distinguish from drowsy wakefulness, and semipurposeful activity such as voiding next to the toilet is sometimes observed. Occasional sleepwalking is very common in children, with an overall prevalence of 40% in one large series of 6- to 16-year-olds, although only 2 to 3% of patients in this series exhibited more than one episode monthly. The prevalence of sleepwalking declines after age 10, although 3.3% of 13-year-olds still exhibited some degree of sleepwalking in another large series.[52]

Although the terms "confusional arousal" and "night terror" are sometimes used synonymously to describe agitated partial arousals in children, some authors have suggested a distinction between the two conditions.[50,53] Confusional arousals are most commonly seen in toddlers and early school-age children. Episodes often evolve gradually, commencing with crying or calling out to parents followed by overt confusion or inconsolable agitation that may last 30 minutes or more. In contrast, night terrors are characterized by precipitous onset of screaming or extreme agitation, usually in older children or adolescents. Night terrors typically last only a few minutes, but may be accompanied by thrashing movements, running, or other potentially hazardous motor activity. Events are usually accompanied by visible signs of "sympathetic storm" including significant tachycardia or diaphoresis. Agitated arousals of all types are common in children, affecting 17.3% of children between 3 and 13 years of age in one large recent Canadian study.[52]

Treatment of NREM arousal parasomnias has received little formal study in children. Despite this, the obvious potential for sleepwalking or night terrors to cause injury necessitates that the families of affected children take measures to safeguard the sleeper's environment. This can usually be accomplished via a combination of parental watchfulness and other safety measures designed to limit a sleepwalker's access to balconies, exterior doors, and other potentially hazardous areas inside and outside the household. Use of alarms or deadbolt locks on exterior doors is sometimes appropriate but must be implemented in a fashion that does not compromise safety and rapid egress in case of emergencies. Families should also be instructed to maintain a safe environment when affected children are sleeping away from home. In addition to appropriate safety measures, use of scheduled awakenings may be an effective treatment for childhood sleepwalking and night terrors.[54,55] In particularly severe cases, use of low-dose clonazepam or tricyclic antidepressants may be appropriate and effective.[50,56,57]

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