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Parasomnias of childhood, including sleepwalking

Parasomnias of childhood, including sleepwalking
Authors:
Anne Marie Morse, DO
Suresh Kotagal, MD
Section Editor:
Ronald D Chervin, MD, MS
Deputy Editor:
Laurie Wilkie, MD, MS
Literature review current through: Dec 2022. | This topic last updated: Oct 20, 2021.

INTRODUCTION — Parasomnias are episodic behaviors that intrude onto sleep and often lead to significant worry for the parents/caregivers or the patient. The events are most common in preschool-aged children and gradually decrease in frequency over the first decade of life [1]. The events may mimic sleep-related epileptic seizures; thus, it is important to understand their clinical and sleep laboratory diagnostic features. Sometimes, parasomnias are isolated symptoms in an otherwise healthy child, while on other occasions, they coexist with neurologic, psychiatric, or medical disorders. This article provides an overview of common parasomnias of childhood.

Parasomnias involve relatively complex behaviors. Simpler and stereotyped movements are categorized as sleep-related movement disorders. These include restless legs syndrome (RLS), periodic limb movements of sleep, sleep-related bruxism, and sleep-related rhythmic movement disorder and are discussed in separate topic reviews. (See "Sleep-related movement disorders in childhood" and "Restless legs syndrome and periodic limb movement disorder in children" and "Assessment of sleep disorders in children".)

EPIDEMIOLOGY — Most studies of parasomnias in childhood have provided cross-sectional data. There are few longitudinal studies.

Young children (aged 2.5 to 6 years) were evaluated in a large study in Quebec, Canada [2]. Parasomnias were ubiquitous: 88 percent of the cohort manifested at least one parasomnia during the study period. Parasomnias or other sleep-related movements were noted at the following frequencies:

Sleep terrors – 40 percent

Sleepwalking – 15 percent

Sleep enuresis – 25 percent

Bruxism (teeth grinding) – 46 percent

Rhythmic movement disorder (eg, head banging) – 9 percent

Older children (aged 6 to 11 years) were evaluated as part of the Tucson Children's Assessment of Sleep Apnea study (TuCASA) [1]. Each parasomnia was noted by parents with the following frequency at baseline and remission rate approximately five years later:

Sleep terrors – 0.6 percent at baseline, 100 percent resolved

Sleepwalking – 6 percent at baseline, 65 percent resolved

Sleep talking – 1 percent at baseline, 50 percent resolved

Sleep enuresis – 0.3 percent at baseline, 71 percent resolved

One limitation in estimates of incidence and prevalence of parasomnias during childhood is that they are based mainly on parental recall. Another is that mild and infrequent parasomnias, such as a confusional arousal with no vocalization, may not even come to parental attention. There does not seem to be a sex predisposition for any specific parasomnia. Some parasomnias show a familial predisposition. Additionally, the presence of a parasomnia in childhood predicts a predisposition for development of other types of parasomnias in the future. For example, a study found that one-third of children with night terrors subsequently developed sleepwalking [2].

CLASSIFICATION OF PARASOMNIAS BY TYPE OF SLEEP — Sleep can be broadly segmented into rapid eye movement (REM) sleep and non-rapid eye movement (NREM) sleep. NREM sleep is divided into stages ranging from N1 (the lightest and often initial stage of sleep) to N3 (deep NREM sleep with a high arousal threshold). These sleep states occur in cycles throughout the night, typically with an increasing percentage of REM sleep and decreasing percentage of N3 sleep in each cycle as sleep progresses.

Infants enter REM at sleep onset and have relatively rapid sleep cycles (50 to 60 minutes). With maturation, children initially enter NREM at sleep onset, with the largest percentage of N3 sleep typically occurring in the beginning of the night and the initial REM sleep stage occurring 90 to 140 minutes later. As night sleep progresses, the proportion of REM sleep gradually increases. (See "Sleep physiology in children", section on 'Maturation of sleep architecture'.)

Most parasomnias are associated with either REM or NREM sleep. This characteristic is used in the classification scheme outlined in the International Classification of Sleep Disorders, third edition (ICSD-3) [3]. Because of the characteristic association with type of sleep, the occurrence of parasomnias tends to reflect the changes in sleep throughout the night. Parasomnias that are associated with arousal from NREM sleep are more common in the first one-third of the night, when deep NREM (N3) sleep is most abundant, whereas REM sleep-associated parasomnias are more common in the last one-third of the night, when REM sleep is more prominent.

Common parasomnias and other behaviors during sleep are outlined in the table (table 1) and detailed below.

DISORDERS OF AROUSAL FROM NON-RAPID EYE MOVEMENT SLEEP

Confusional arousals, sleep terrors, and sleepwalking are the most significant parasomnias associated with non-rapid eye movement (NREM) sleep. They are also termed disorders of partial arousal as they result from incomplete arousal from NREM sleep. Typically, they occur at the transition from deep NREM (stage N3) sleep into the lighter stages of NREM sleep (N1 or N2) or into the awake state. They are most likely to arise during the first one-third of nocturnal sleep because N3 sleep is most prevalent at this time of the night [4].

Pathophysiology — The abovementioned three parasomnias that occur on arousal from NREM sleep have similar predisposing characteristics and triggers (table 2), suggesting common pathophysiology:

Genetic predisposition – A familial predilection to parasomnias is suggested by several studies [5-8]. In a study of 323 pairs of twins (199 monozygotic, 124 dizygotic), the pair-wise concordance for sleepwalking was six times higher in the monozygotic twins than in the dizygotic twins [6,7]. Another study found that sleepwalking was twice as common in children whose parents had exhibited sleepwalking (47.4 percent) compared with children whose parents did not (22.5 percent) [5].

Increased arousal from sleep – Disorders that increase arousals from sleep such as obstructive sleep apnea (OSA), restless legs syndrome (RLS), periodic limb movement of sleep, or gastroesophageal reflux are common triggers for arousal parasomnias. In a study of 84 children with recurrent or chronic sleepwalking, 58 percent had a history suggestive of OSA, the treatment of which frequently led to resolution of sleepwalking [9]. In a study of 30 children with RLS and NREM parasomnias, the correction of iron deficiency led to resolution of the parasomnias in 40 percent [10]. Separation anxiety also may be a predisposing factor for both sleep terrors and sleepwalking [2].

Other triggers – Sleep deprivation and fever are common triggers for NREM parasomnias, possibly because they cause increased N3 sleep.

Age – Vulnerability to these parasomnias is also influenced by age; these disorders are most common in childhood and gradually resolve by adolescence.

Electroencephalogram (EEG) – Arousal parasomnias are associated with increased frequency of cyclic alternating patterns on sleep EEG. These are repeated, spontaneous high-voltage patterns that recur at regular intervals of up to one minute [11]. They are a reliable marker of unstable sleep and are increased during the slow-wave sleep of children with sleep terrors [11].

Clinical features — Confusional arousals, sleep terrors, and sleepwalking are typically seen in toddlers and school-aged children. Sometimes, more than one of these parasomnias may be seen in the same child. When there are no underlying triggers (primary or with familial predisposition), patients show gradual, spontaneous resolution of the events over months to years, although sleepwalking is somewhat more likely to persist into adolescence compared with sleep terrors or confusional arousals. Those with identifiable triggers such as OSA, RLS, or anxiety tend to improve when these conditions are addressed. (See 'Epidemiology' above.)

Confusional arousals — Confusional arousals are most commonly reported in toddlers and usually diminish in frequency after five years of age. In a population-based study, the prevalence in children 3 to 13 years of age was 17.3 percent [3]. The onset of symptoms is typically within two to three hours of sleep onset but also may occur upon attempted awakening from sleep during the night or in the morning. The child will typically sit up in bed, whimper, cry, or moan and may utter words like "no" or "go away," appear distressed, and remain inconsolable regardless of all effort at soothing [4]. There is generally no sweating, flushing of the face, or stereotypic motor behavior. The child may remain sitting in the bed. The duration is 5 to 30 minutes. A simultaneously recorded EEG may show generalized, high-amplitude rhythmic delta or theta activity. The following morning, the patient awakens, feeling alert and refreshed, and has no recollection of the event whatsoever. Although these events are benign, they often cause parents or caregivers to be concerned or puzzled about the nature of the events and how to deal with them.

Sleep terrors — Sleep terrors (often called night terrors) typically occur between 4 and 12 years of age. The events occur during the first one-third of nocturnal sleep. The child awakens abruptly from sleep with a loud scream, is agitated, and has a flushed face, sweating, and tachycardia. The child may jump out of bed as if running away from an unseen threat [12], is usually unresponsive, and, paradoxically, may become even more agitated by the parent/caregiver's efforts at calming. The child usually does not remember the episode later.

A simultaneously obtained EEG may show high-amplitude rhythmic delta or theta activity. There is a strong genetic predisposition.

Sleepwalking — Sleepwalking, like the other parasomnias associated with NREM sleep, occurs in approximately 15 percent of children, peaking between age 8 and 12 years [3,5]. Mild episodes, in which a toddler sits up and crawls around the bed or walks up quietly to stand by the bed of the parents, may initially go unnoticed [4,12,13]. Other children may become agitated and run around the house or have confused, inappropriate behaviors. Some patients have injured themselves by unconsciously carrying out dangerous behaviors like leaving the house on cold, wintry nights and have had consequences like accidental hypothermia. Autonomic dysfunction may coexist in the form of sweating and flushing of the face. Some patients exhibit a combination of sleep terrors and sleepwalking, though one type may predominate.

Differential diagnosis

Nocturnal seizures – Nocturnal seizures can mimic sleepwalking, confusional arousals, or sleep terrors. Disorganized bodily movements, staring, unresponsiveness, vocalizations, and confused behavior are common to both seizures and parasomnias [14-17]. A number of features including age of onset and ictal pattern help distinguish parasomnias from seizures (table 3). Sleep-related hypermotor epilepsy (SHE; previously named autosomal dominant nocturnal frontal lobe epilepsy) can be sporadic or familial. It may be related to mutations in the CHRNA2, CHRNA4, or CHRNB2 genes that regulate the expression of nicotinic acetyl choline receptors [18-20]. For investigation of any nocturnal events that are suspected to be seizures, a 16- to 18-channel EEG montage should be routinely incorporated into the polysomnogram (PSG). Correlating the event to the sleep stage can help to distinguish between seizures and parasomnias: Sleep-related seizures more commonly arise from N1 or N2 sleep, while NREM parasomnias more typically arise from N3 sleep. However, in clinical practice, it may be difficult to distinguish NREM parasomnias from nocturnal seizures. One reason is that conditions that cause partial arousals and sleep fragmentation (eg, OSA, RLS, or anxiety) can predispose to either NREM parasomnias or nocturnal seizures. Home video recordings of the spells made by the parents can help in this regard because they capture the features of the nocturnal events in the natural home environment, which may not recur in the artificial environment of the sleep laboratory. Sleep-related epilepsy syndromes and the clinical features that help distinguish nocturnal epileptic seizures from parasomnias are discussed separately. (See "Sleep-related epilepsy syndromes" and "Nonepileptic paroxysmal disorders in children", section on 'Sleep disorders'.)

Gastroesophageal reflux – Gastroesophageal reflux can lead to episodes of abrupt arousal from sleep in association with crying or tonic extension of the trunk and extremities. It can also exacerbate sleep-disordered breathing. A simultaneously obtained EEG fails to reveal epileptiform abnormalities. There may be an associated cough. Reflux episodes may also occur during wakefulness. The suspicion of reflux can be supported by esophageal pH monitoring (obtained after consultation with a pediatric gastroenterologist), but a firm association between reflux and the arousal is difficult to establish unless the events are captured simultaneously during the pH monitoring study.

Panic attacks – Panic attacks are characterized by an abrupt awakening from NREM sleep with a sensation of choking or tightness in the chest [21]. The EEG remains normal. The events may last a few minutes and then subside. Daytime episodes of anxiety also may occur. The patient typically can recount the uncomfortable sensation the following day.

REM sleep behavior disorder (RBD) – RBD is characterized by aggressive motor behavior as part of dream enactment, resulting from loss of the physiologic muscle atonia of REM sleep. RBD events typically occur during the early morning hours when REM sleep is more abundant. RBD occurs rarely in children and is more common in adults. (See 'Rapid eye movement sleep behavior disorder' below.)

Management — Most healthy children presenting with sleepwalking, confusional arousals, or night terrors require only a focused history and physical examination for diagnosis (see "Assessment of sleep disorders in children"). Parasomnias that are infrequent (one to two times per month) or that have typical triggers such as sleep deprivation or fever generally do not require further investigation, especially if there is a family history of childhood parasomnias.

Investigations — In children with frequent parasomnias, indications for nocturnal PSG (sleep study) include [22]:

Habitual snoring, observed apneas, and/or daytime somnolence; behavioral problem or mood disturbance, suggesting underlying OSA as a potential trigger [23,24].

Leg discomfort or involuntary jerking movements during sleep, suggesting restless leg syndrome or periodic limb movements of sleep. (See "Restless legs syndrome and periodic limb movement disorder in children".)

Safety concerns because of dangerous behaviors during the parasomnia, excessive disruption of the family members' sleep, or if pharmacotherapy is contemplated.

Atypical features that raise concern for nocturnal seizures, including daytime neurologic symptoms, highly stereotyped behaviors, older age group, multiple occurrences on a single night, and/or very frequent occurrences (eg, several nights each week) (table 3 and table 4). In this case, the PSG should include a 16- to 18-channel EEG [23]. (See 'Differential diagnosis' above.)

Presence of excessive daytime sleepiness and/or features concerning for RBD. Children with these features should be evaluated with a PSG and a next-day multiple sleep latency test to evaluate for narcolepsy. (See "Clinical features and diagnosis of narcolepsy in children".)

If the PSG shows greater than five periodic limb movements per hour of sleep or if there is a history of RLS, the serum ferritin level should be measured. A low serum ferritin (eg, below 50 micrograms/L) is a marker for iron deficiency, which is present in up to 80 percent of children with RLS [25]. Restless sleep disorder, a newly described sleep disorder that is characterized by large-amplitude, excessive movements of the arms, legs, trunk, or head without excessive periodic limb movements, also may be associated with iron deficiency. (See "Restless legs syndrome and periodic limb movement disorder in children".)

OSA is suggested if the PSG reveals more than one obstructive apnea or hypopnea per hour of sleep (apnea-hypopnea index ≥1), increased respiratory event-related arousals, or increased levels of end-tidal carbon dioxide. The interpretation of the PSG features of sleep apnea is discussed separately. (See "Evaluation of suspected obstructive sleep apnea in children", section on 'Diagnosis'.)

General strategies — Infrequently occurring (one to two times per month) confusional arousals, sleep terrors, and sleepwalking may not need to be treated. Parents should be informed about the benign and self-limiting nature of the disturbance and that the symptoms usually will resolve spontaneously over one to two years. However, if they identify an increase in frequency or severity of events, they should seek reevaluation. Increased frequency or severity can be a sign of poor quality or inadequate sleep. Reinforcement of good sleep hygiene and age-appropriate hours of sleep is recommended. Toddlers should be given adequate time to nap during the day because sleep deprivation may be a trigger for the parasomnia.

In the case of sleepwalking or parasomnia behaviors resulting in the child leaving the bed or room, the clinician should discuss environmental safety issues with the parent(s), such as ensuring that the child is not able to leave the house or otherwise injure him- or herself while sleepwalking. Safety measures are critical to avoid injury during the parasomnia event. Unless the child is in a position to get injured, parents should be advised to not restrain or awaken the child, as this may exacerbate the disturbance.

Safety recommendations should include the following steps, as needed:

Clearing the bedroom of obstructions

Securing doors and windows

Placing the child's mattress on the floor

If the child sleeps on the upper levels of the home, consider having the child sleep on the first floor of the home to avoid falling down stairs

Consider installing locks and/or alarms on windows and doors

Consider covering windows with heavy curtains to reduce light that may cause awakenings

Medical/surgical strategies — If no specific underlying triggers are found and the parasomnias remain problematic, we suggest a low dose of a benzodiazepine (eg, clonazepam in a dose of 0.125 to 0.5 mg at bedtime). Alternative treatment options that have been suggested for the treatment of parasomnias include tricyclic antidepressants, melatonin, and selective serotonin reuptake inhibitors [26].

If the serum ferritin level is below 50 micrograms/L in a child with RLS or periodic limb movements of sleep, we suggest oral iron therapy 2 to 3 mg/kg per day with orange juice or vitamin C for four to six months [27]. The objective is to raise the serum ferritin level to 50 to 100 micrograms/L. This is because the parasomnia may be triggered by RLS, as described above. (See 'Investigations' above.)

If the PSG indicates mild OSA (eg, an apnea hypopnea index between one and three events per hour), and if there are no symptoms suggestive of more severe sleep apnea, it is reasonable to do a trial of treatment with nasal corticosteroids (one puff twice a day) combined with saline nasal spray (one spray two to three times a day). If this treatment fails to resolve the parasomnia, or if the PSG shows moderate to severe OSA (apnea-hypopnea index ≥3 events per hour), a referral should be made to a pediatric otolaryngologist to evaluate the child for possible adenotonsillectomy. (See "Management of obstructive sleep apnea in children".)

Behavioral measures — Ensure that the patient is achieving the age-appropriate number of hours per sleep per day (figure 1) and has age-appropriate consolidation of sleep. In addition, sleep hygiene measures should be reviewed and all patients should be encouraged to maintain a regular sleep schedule seven days a week.

Anticipatory awakening (scheduled awakening) is a behavioral technique that can be utilized to prevent these parasomnias [28-30]. Because these events generally occur during the first one-third of the night, momentary awakening of the child by the parent approximately 15 to 20 minutes prior to the usual time of occurrence may alter the sleep state and abort the event. During the scheduled awakening attempt, the parent comforts the child and generally behaves as they would during a spontaneous awakening. In one report of three children with frequent sleepwalking, nightly anticipatory awakenings for one month led to near-resolution of the symptom and the improvement continued at follow-up six months later [30]. Anecdotal reports from the children's parents suggest that the scheduled awakenings may have conditioned the children to self-arouse prior to transitioning from slow-wave sleep, but this hypothesis has not been further examined.

Although the efficacy of scheduled awakenings has not been well tested in clinical studies, the technique may be worth trying when the family is reluctant to administer medications and is inclined towards nonpharmacologic management. It has the potential drawback of actually triggering a parasomnia by the awakening procedure.

PARASOMNIAS USUALLY ASSOCIATED WITH RAPID EYE MOVEMENT SLEEP

Nightmare disorders

Clinical features — Nightmares are disturbing dreams that awaken the dreamer. They are also referred to as dream anxiety attacks. The International Classification of Sleep Disorders, third edition (ICSD-3) defines nightmares as "an internally generated conscious experience or dream sequence that seems vivid and real. They have a tendency to become increasingly more disturbing as they unfold. Emotions are characteristically negative and most frequently involve anxiety, fear, or terror but may also involve anger, rage, embarrassment, and disgust" [3]. Full alertness generally returns immediately upon awakening after a nightmare, and recall of the dream experience remains intact. Since rapid eye movement (REM) sleep predominates during the final one-third of the night, nightmares generally occur in the early hours of the morning.

The recall of dream content is good in children who are verbal. The description of dreams in preschool-age children may be simple but more elaborate in older children. Nightmares are more common in children with post-traumatic stress disorder, and their dream content may be particularly distressing, with themes of inflicted violence, death, or separation from close family members.

Bodily movement during nightmares is infrequent because muscle tone and mobility are actively inhibited during REM sleep. Autonomic manifestations like sweating and flushing of the face also do not occur. Mild tachycardia may occur. The duration of the event is generally brief. After waking up, the child may find it hard to fall back asleep.

The association between anxiety symptoms and nightmares was explored in a group of 610 children who were evaluated at the ages of 13 and 16 years [31]. Anxiety symptoms were classified based on the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-3) criteria for separation anxiety, overanxious disorder, and generalized anxiety disorder. As compared with boys, girls were more likely to report disturbing dreams, and the symptom tended to increase over time. The frequent occurrence of disturbing dreams at age 13 years was associated with generalized anxiety disorder, separation anxiety, or overanxious disorder at age 16 years for both boys and girls.

Management — Polysomnography is not routinely indicated for the investigation of nightmares. When nightmares are recurrent and problematic, psychological evaluation is indicated to assess for anxiety and determine its underlying causes.

Medications are rarely indicated for treatment of nightmares. Triggers for nightmares include certain medications, including antidepressants, antihypertensives, and antihistamines. Behavioral techniques to manage nightmares in children are based on observations from small, nonrandomized case series and include the following:

Reassurance – Some nightmares may subside simply with reassurance.

Rescripting – Rescripting or imagery rehearsal therapy are techniques in which children are taught to create new, more pleasant endings to recurring nightmares may lessen their distress.

Desensitization – Desensitization techniques may also help alleviate the fear of nightmares [32]. Some therapists have found it useful to encourage the child to write down the content of the nightmare or draw pictures of the object(s), which may help make the experience less scary. Parents or caregivers may be able to help a child process negative experiences by discussing them with the child; this approach has been suggested but not proven as an intervention for nightmares [33].

Hypnotherapy – A small case series suggested that one or two sessions of hypnotherapy will help adults and children with nightmares, with 5 of 7 (71 percent) remaining free of nightmares or much improved at 18 months follow-up and 4 of 6 (67 percent) remaining free of nightmares after five years [34].

Cognitive-behavioral therapy (CBT) – CBT may be of value in cases of intense, disturbing nightmares but is not well studied in children or adults [35]. Techniques include imagery rehearsal therapy [36].

Rapid eye movement sleep behavior disorder

Clinical manifestations – REM sleep behavior disorder (RBD) is characterized by aggressive motor behavior as part of dream enactment, resulting from loss of muscle atonia during REM sleep and often leading to injury of the patient or bed partner. At the end of an episode, the dreamer typically awakens quickly and is able to recall the dream content, which tends to correspond to the observed sleep behaviors [3]. In contrast with the non-rapid eye movement (NREM) arousal parasomnias discussed above, RBD tends to occur during the later part of the night, when REM sleep predominates. In contrast to sleep terrors, in which there is no recollection of the event the following morning, patients with RBD may exhibit vivid dream recall. They also tend to remain in bed rather than jump out of bed and move about, as in sleep terrors or sleepwalking. (See 'Disorders of arousal from non-rapid eye movement sleep' above.)

Epidemiology and comorbidities – RBD is infrequently recognized in children. The main exceptions occur in childhood narcolepsy, neurodevelopmental disorders, and use of certain medications [37,38].

RBD has been reported in one-third of children with narcolepsy type 1 and may occur during sleep or during an episode of daytime cataplexy (status cataplecticus) [38]. In narcolepsy type 1, the central nervous system orexin (hypocretin) deficiency predisposes to reduced suppression of the pontine "REM off" neurons during REM sleep. This can, in turn, predispose to motor dream enactment [39]. Case reports describe two girls aged seven and nine years with combined RBD and narcolepsy-cataplexy [40]. A reasonably large series of children with RBD (n = 15) found a preponderance of narcolepsy, neurodevelopmental disorders such as autism, Smith-Magenis syndrome and Rett syndrome, structural brainstem abnormalities such as Chiari type I malformation, a medication effect from selective serotonin reuptake inhibitors (SSRIs), or withdrawal from barbiturates or alcohol [37]. (See "Clinical features and diagnosis of narcolepsy in children", section on 'Awakenings and movements during sleep'.)

The long-term outcome of childhood RBD is not known, but the clinical course may differ from that of adults with this disorder because there does not seem to be an association with neurodegeneration involving synuclein.

RBD is somewhat more common in adults. The clinical features and associations with narcolepsy and neurodegenerative diseases in adults are discussed separately. (See "Rapid eye movement sleep behavior disorder".)

Evaluation – RBD may be suspected from the history, especially in children with underlying neurodevelopmental disorders, narcolepsy, or medications that can provoke REM sleep without atonia or RBD. Home video observations are helpful in diagnosis and often document yelling, agitation, or flailing of the limbs, although these behaviors may be absent when sleep is recorded in a sleep laboratory. These aggressive motor behaviors help to distinguish RBD from sleepwalking and other parasomnias (which are far more common). The nocturnal polysomnogram (PSG) demonstrates a lack of the chin muscle atonia that normally characterizes physiologic REM sleep. This is known as REM sleep without atonia and is a neurophysiologic correlate of RBD, even in the absence of RBD episodes [41]. Excessive twitching and movement of the limbs during REM sleep also may occur.

Management – Treatment recommendations for RBD are based on small case series in adults and anecdotal experience in children. If the patient is taking medications known to exacerbate RBD (which include SSRIs), discontinuation of the medication (when possible) may lead to improvement or resolution of the RBD. As in adults, RBD in children responds promptly to treatment with benzodiazepines like clonazepam, 0.125 to 0.5 mg at bedtime. High-dose melatonin also appears to be useful for adults with RBD [42,43]; in children, we have used a dose of 1 to 3 mg at bedtime with some success. Sodium oxybate may be effective in children with narcolepsy type 1, from the standpoint of reducing RBD and REM sleep without atonia [44]. (See "Rapid eye movement sleep behavior disorder", section on 'Management'.)

Patients with compressive brainstem lesions such as Chiari malformation require treatment measures directed specifically to these disorders. The same applies to neurodevelopmental disabilities like Smith-Magenis syndrome. (See "Chiari malformations" and "Microdeletion syndromes (chromosomes 12 to 22)", section on '17p11.2 deletion syndrome (Smith-Magenis syndrome)'.)

Parasomnia overlap disorder – Parasomnia overlap disorder consists of RBD and another parasomnia (sleepwalking, sleep terrors, confusional arousals), or rhythmic movement disorder occurring in the same patient, and has been reported in adults and children [3]. Like RBD, many of the cases are associated with underlying neurologic disease. Obstructive sleep apnea (OSA) or other causes of partial arousal from both NREM and REM sleep should also be considered. However, idiopathic disease also occurs and is more common among patients presenting with parasomnia overlap disorder at a younger age [45]. (See "Rapid eye movement sleep behavior disorder".)

Isolated sleep paralysis — Muscle atonia and transient skeletal muscle paralysis are physiologic properties of REM sleep. These phenomena may, however, sometimes intrude onto wakefulness around the time of sleep onset or at the time of waking up from sleep. The resulting transient inability to move the body is called sleep paralysis. Recurrent sleep paralysis is often associated with narcolepsy. If it is not associated with narcolepsy, it is known as isolated sleep paralysis (ISP).

During a sleep paralysis episode, consciousness remains intact and the individual is perfectly aware of the surroundings. For a patient unfamiliar with the phenomenon, a terrifying feeling can arise from the sudden inability to move the body while being fully awake, albeit momentarily. The child may also experience hallucinations such as feeling the presence of others nearby, feeling pressure on the chest, or hearing footsteps [4]. Approximately 20 percent of young adults with anxiety disorder may manifest ISP [46]. Sleep deprivation in otherwise healthy teenagers is also a common trigger. The differential diagnosis includes partial seizures, periodic paralysis, and narcolepsy.

Occasional events are generally due to sleep deprivation and do not require treatment. Recurrent episodes may be very bothersome to the patient. Treatment approaches have not been evaluated. For patients with an underlying anxiety disorder, treatment for the anxiety is appropriate and may alleviate the ISP. In our practice, we have had some success treating ISP with REM-suppressing agents such as low doses of tricyclic agents, clonidine, or clonazepam.

OTHER PARASOMNIAS

Sleep enuresis — Sleep enuresis (also known as nocturnal enuresis) is defined as discrete episodes of urinary incontinence during sleep at least twice per week in children older than five years of age [3,47]. This age threshold is used because most children achieve control of the bladder by this age. Recurrent nocturnal enuresis affects approximately 15 percent of five-year-old children and gradually declines to approximately 5 percent by 10 years of age (figure 2). Enuretic episodes can occur in all sleep stages, including during the sleep-wake transition.

Primary enuresis refers to a child who has never achieved a period of dryness at night. This form is most common and has a strong familial pattern. Secondary enuresis describes a child who develops enuresis after a period of six or more months of nighttime dryness. Secondary enuresis is more likely to be associated with acquired factors such as urinary tract infection, obstructive sleep apnea (OSA), diabetes mellitus, diabetes insipidus, and psychological disturbances such as a stressful event.

OSA is increasingly recognized as a cause of some cases of nocturnal enuresis. Among 69 children with nocturnal enuresis, more than one-half had symptoms suggestive of OSA (using a standardized questionnaire) [48]. In a different study using polysomnography to diagnose OSA, there was an association between OSA severity and nocturnal enuresis in girls but not in boys [49]. Conversely, among children with established OSA, up to 40 percent have a history of nocturnal enuresis [50,51]. Among children with enuresis and OSA, the enuresis usually resolves if the OSA is treated [51,52].

The possibility of OSA should be considered in children presenting with nocturnal enuresis, particularly if they have one or more of the following characteristics:

Habitual snoring or observed apneas

Obesity

Adenotonsillar hypertrophy and/or mouth breathing

Secondary enuresis

Hypotonia

Craniofacial disproportion (ie, maxillary hypoplasia, micrognathia, high-arched palate)

Further evaluation of a child with suspected OSA, including the indications for and interpretation of a polysomnogram (PSG; sleep study), is discussed separately. (See "Evaluation of suspected obstructive sleep apnea in children".)

Other causes of nocturnal enuresis include nocturnal polyuria, maturational delay, and genetics. These causes, the clinical evaluation of a child presenting with this symptom, and treatment approaches (including medication) are discussed in separate topic reviews. (See "Nocturnal enuresis in children: Etiology and evaluation", section on 'Epidemiology and natural history' and "Nocturnal enuresis in children: Management".)

SLEEP-RELATED MOVEMENT DISORDERS — Sleep-related movement disorders are primarily characterized by relatively simple, usually stereotyped movements that disturb sleep or its onset, among which the following are important during childhood [3]:

Restless legs syndrome (RLS)

Periodic limb movement disorder

Sleep-related leg cramps

Sleep-related bruxism

Sleep-related rhythmic movement disorder

Benign sleep myoclonus of infancy

Isolated symptoms and normal variants

Sleep starts (hypnic jerks)

Hypnagogic foot tremor

These disorders are discussed in separate topic reviews. (See "Sleep-related movement disorders in childhood" and "Restless legs syndrome and periodic limb movement disorder in children".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Parasomnias, hypersomnias, and circadian rhythm disorders".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Night terrors, confusional arousals, and nightmares in children (The Basics)" and "Patient education: Sleepwalking in children (The Basics)")

SUMMARY AND RECOMMENDATIONS

Parasomnias occur frequently in preschool-aged children and generally decline in frequency during the preadolescent years (table 1). Most parasomnias occur at sleep onset or are associated with a specific type of sleep (rapid eye movement [REM] or non-rapid eye movement [NREM] sleep). (See 'Epidemiology' above and 'Classification of parasomnias by type of sleep' above.)

Confusional arousals, sleep terrors, and sleepwalking have distinct clinical manifestations, but the underlying pathophysiology and course is similar (table 2). Because they are associated with arousal from deep NREM sleep, they tend to occur during the first one-third of the night. There is a strong familial tendency. Triggers include any disorder that increases arousals from sleep, such as obstructive sleep apnea (OSA), restless legs syndrome (RLS), sleep deprivation, or fever. (See 'Pathophysiology' above and 'Clinical features' above.)

Otherwise healthy children who present with these parasomnias often require only a focused history and physical examination for diagnosis. Parasomnias that are infrequent (one to two times per month) or that have typical triggers such as sleep deprivation or fever generally do not require further investigation. The clinician can reassure the parent or caregiver about the benign nature of the disturbance and that it will probably resolve spontaneously over one to two years. The family should ensure that the child has adequate sleep. In the case of sleepwalking, environmental safety issues should also be discussed. (See 'General strategies' above.)

In children with frequent parasomnias (either NREM- or REM-associated), indications for nocturnal polysomnography (PSG) include (see 'Investigations' above):

Habitual snoring, observed apneas, nocturnal enuresis, or other symptoms suggesting OSA. Symptoms of OSA can be an indication for PSG even if the parasomnia does not occur frequently.

Significant safety concerns, excessive disruption of the family members' sleep, or contemplation of pharmacotherapy.

Atypical features that raise concern for nocturnal seizures, such as daytime neurologic symptoms, older age group, family history of seizures, and multiple occurrences on a single night (table 3). (See 'Differential diagnosis' above.)

Presence of excessive daytime sleepiness and/or features concerning for RBD. Children with these features should be evaluated with a PSG and next-day multiple sleep latency test to evaluate for narcolepsy. (See "Clinical features and diagnosis of narcolepsy in children".)

If the PSG or history suggests RLS, the serum ferritin level should be measured because RLS is associated with iron deficiency. If iron deficiency is present, iron supplementation may relieve the RLS and associated parasomnia. (See 'Investigations' above and "Restless legs syndrome and periodic limb movement disorder in children".)

If no specific underlying triggers are found and the parasomnia remains problematic, we suggest treatment with a low dose of a benzodiazepine (eg, clonazepam at a dose of 0.125 to 0.5 mg at bedtime) (Grade 2C). Anticipatory awakening is an alternative strategy but also can trigger the parasomnia. (See 'Medical/surgical strategies' above and 'Behavioral measures' above.)

Nightmares are disturbing dreams that awaken the dreamer, usually involving fear or anxiety. They are more common among children with anxiety or post-traumatic stress disorder and can be triggered by certain medications, including antihypertensives and antihistamines. When nightmares are recurrent and problematic, the child should be evaluated and treated for anxiety and psychological stressors. Several cognitive-behavioral techniques have been used to treat nightmares, supported by limited evidence. (See 'Nightmare disorders' above.)

Sleep enuresis (nocturnal enuresis) is defined as discrete episodes of incontinence during sleep at least twice per week in children older than five years of age. It affects approximately 15 percent of five-year-old children and gradually declines to approximately 5 percent by 10 years of age (figure 2). Causes include nocturnal polyuria, maturational delay, and genetic predisposition. OSA is increasingly recognized as a treatable cause of some cases of nocturnal enuresis. (See 'Sleep enuresis' above and "Nocturnal enuresis in children: Etiology and evaluation".)

Rhythmic movements in infants and toddlers at the time of sleep onset are physiologic and generally resolve spontaneously by three to four years of age. (See 'Sleep-related movement disorders' above and "Sleep-related movement disorders in childhood", section on 'Rhythmic movement disorder'.)

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References