Approach
The emphasis of treatment for most of the paediatric parasomnias is identification and elimination of the underlying trigger for the arousal (such as obstructive sleep apnoea, restless legs syndrome), behavioural or lifestyle changes (e.g., education concerning adequate sleep amount, good sleep hygiene, environmental changes to room, timed scheduled wakings), and reassurance. Medications are rarely prescribed in paediatric clinics for parasomnias. At present, the evidence concerning all types of therapy for parasomnias in children is limited. Parents and children can be reassured that most of these conditions are common, and that children will usually grow out of them. Safety measures should be addressed to prevent child injuries.
Sleep hygiene
Although some parasomnias are considered normal in children, it is good practice to ensure adequate sleep time and avoid sleep deprivation. Parents and children should be counselled on measures to ensure good sleep hygiene in all types of parasomnia. These measures include: American Academy of Sleep Medicine: healthy sleep habits Opens in new window
Going to bed and getting up at the same time each day
Avoiding excessive and late daytime naps
Avoiding excessive light exposure before bedtime (any device with a screen, including TV, video games, cell phones, and computer use)
Avoiding spending a lot of time awake in bed
Getting regular exercise every day in the mid to late afternoon
Limiting caffeine-containing drinks
Avoidance of nicotine (relevant in adolescents)
Avoidance of alcohol (relevant in adolescents)
Avoidance of dealing with school-related or work-related issues before bedtime (work may be relevant in older adolescents)
If sleep onset does not take place within 20 minutes of going to bed, it is suggested that the patient gets out of bed and engages in a relaxing activity, such as reading, for a while and then returns to bed when feeling sleepy.
Adequate sleep time for children is considered to be approximately:
Infants: up to 16 hours daily
Toddlers and preschool children: 11-14 hours (includes overnight and nap sleep times)
Primary school children (1st-8th): 10 hours
High school children (9th-12th): 9 hours.
Confusional arousals
Initial measures include education and reinforcement of good sleep hygiene, and particularly avoidance of irregular sleep-wake patterns.[48] With adolescents the use of alcohol or other substances may be discussed, and they should be advised to avoid these substances. The child is observed by the parents and followed up in the clinic. If there is evidence of any coexisting sleep disorders, these need to be investigated and treated appropriately. Occasionally, features of other parasomnias may develop (e.g., sleepwalking, sleep terrors), and these need to be managed as well. In most children, reassurance can be given that it is likely that the episodes will remit as the child grows older.
Anticipatory awakening, also called scheduled awakenings (gently waking the child at set times throughout the night), may be helpful for some NREM parasomnias, including confusional arousals.[48] It is thought to work by preventing or interrupting the altered underlying neurophysiology of partial arousal, preventing the disturbing behavioural features of the parasomnia. For children with very frequent episodes, biofeedback and relaxation techniques can be used.
Parents should be advised that efforts to curtail the behaviour during confusional episodes should be avoided, as these may lead to aggression and prolongation of the episode. The confusional arousal should simply be allowed to run its course, unless there is a potential for injury, such as an attempt to walk or exit the home.
Sleepwalking
This condition is managed by avoidance of the precipitating factors, education and counselling about good sleep hygiene, and the establishment of a safe living quadrant. This last measure may involve removing sharp objects from the bedroom, locking doors, and arranging for a sleeping space on the ground floor.[48] Furthermore, door alarms should be purchased and placed on all doors exiting the home, such as front doors, back doors, garage doors, and basement doors. Door alarms are inexpensive and can be purchased from home-improvement stores. Parents should also consider removal of any potentially dangerous items and store them in locked boxes (medications, car keys, knives, and guns).[48]
There is anecdotal evidence for the benefit of anticipatory scheduled awakening (involving waking the child at set times throughout the night) in treating this disorder in children.[60][61] It is thought to work by preventing or interrupting the altered underlying neurophysiology of partial arousal, preventing the disturbing behavioural features of the parasomnia.
When episodes are severe and refractory, or dangerous to the patients and others, the use of medications such as benzodiazepines (e.g., diazepam, lorazepam, clonazepam) may be tried.[2][62][63] Care needs to be taken with the use of clonazepam in children with obstructive sleep apnoea, in whom symptoms may be worsened. Low-dose tricyclic antidepressants (TCAs) have been tried following benzodiazepine therapy, but there are limited data concerning specific choices, and caution is required because some TCAs may exacerbate sleepwalking. TCAs may also cause arrhythmias. Children should be monitored while on antidepressants, both for improvement of symptoms and for the development of adverse effects, including evidence of suicidal intent. In 2004, the US Food and Drug Administration (FDA) issued a black box warning on suicidal risk associated with paediatric use of antidepressants.[64]
Sleep terrors
Treatment should first focus on eliminating the cortical arousals from sleep, such as from obstructive sleep apnoea or restless legs syndrome. Treatment may be unnecessary when episodes are rare. Education and advice on good sleep hygiene can be given. Environmental protective measures are recommended to prevent injury (as for sleepwalking). Occasionally, the episodes are frequent, intense, or disruptive to the patient's sleep. In these situations, after obstructive sleep apnoea and restless legs syndrome have been evaluated for, a long-acting benzodiazepine (e.g., diazepam or clonazepam) may be used. These may act by suppressing the autonomic excitability that accompanies sleep terrors during slow-wave sleep and by reducing the time spent in slow-wave sleep. Paroxetine and trazodone have been reported to be effective in isolated cases.[65][66] Other pharmacological treatment options that have been included in case reports include tricyclic antidepressants, fluoxetine, and tryptophan.[62][67][68] Children should be monitored while on antidepressants, both for improvement of symptoms and for the development of adverse effects, including evidence of suicidal intent. In 2004, the US Food and Drug Administration (FDA) issued a black box warning on suicidal risk associated with paediatric use of antidepressants.[64]
Nightmares
Treatment often involves simple reassurance, as the episodes seem to diminish in frequency and intensity over the course of the individual's lifespan. For recurrent nightmares in which a theme can be identified, imagery rehearsal is effective for reducing distress in adults.[69] This technique may also be applied in an age-appropriate fashion to children. Imagery rehearsal involves the child and parent discussing alternative endings to the recurrent nightmare, for the last 10-15 minutes before the lights are put out, nightly for approximately 4 weeks. Alternatively, if the child cannot adequately describe the nightmares, the parent and child can focus on 'good things' to dream about, such as playing in the park or petting the family pet. Good sleep hygiene should be reinforced. In particular, the avoidance of sleep deprivation is important. Adolescents may be reminded to limit caffeine intake. If stress is considered a factor, psychological therapy may be used. This could be given in the form of cognitive behaviour therapy for adolescents.
For severe and refractory cases, the use of a rapid eye movement (REM)-suppressing agent, such as a tricyclic antidepressant or a serotonin selective reuptake inhibitor (SSRI), for a short period of time may be helpful.[28][30][70] However, the evidence for the use of these medications comes from studies in adults, and there is limited or no evidence for their use in children for this indication. Therefore, a specialist needs to be consulted about the specific choice of medication. Children should be monitored while on antidepressants, both for improvement of symptoms and for the development of adverse effects, including evidence of suicidal intent. In 2004, the US Food and Drug Administration (FDA) issued a black box warning on suicidal risk associated with paediatric use of antidepressants.[64] In addition, individuals with frequent nightmares are at substantially greater risk for suicidal thoughts or behaviour, even when sex and mental illness are taken into account.[12]
Isolated recurrent sleep paralysis
This is more common in teenagers. They should be counselled on good sleep hygiene and should be advised to avoid any precipitating factors, such as caffeine use, irregular sleep habits, disturbances of the sleep-wake cycle, and sleep deprivation.[48]
When the episodes are infrequent, more active treatment is unnecessary; in most cases, reassurance is all that is needed. If episodes are severe and anxiety-provoking, and when there is no evidence of narcolepsy, the use of anxiolytic medications (e.g., diazepam) may be indicated. Frequent episodes in the context of narcolepsy require treatment of the narcolepsy (e.g., with central nervous system stimulants).[71][72]
Rapid eye movement sleep behaviour disorder (RBD)
RBD is extremely rare in childhood. However, when signs present, it is important to consider the possible diagnosis of narcolepsy.[21][22][23][24][25] Conservative measures such as environmental protective safety, education, and implementation of good sleep hygiene are the first approach. Environmental safety is prudent for every patient with likely RBD in order to avoid injury. It is suggested to remove/pad all sharp corners (furniture/tables) in the child’s room. The child may even choose to sleep on a mattress on the floor until the RBD is brought under good control.
If the condition is associated with injuries that are proving difficult to prevent, pharmacological therapy may be considered. Medication should be prescribed and supervised by a specialist who is experienced in managing this disorder in children. Pharmacotherapy for RBD may be in the form of clonazepam, which has been found to be effective in 90% of adult cases, with little evidence of tolerance or abuse.[1][73][74] It may be contraindicated in some patients (e.g., those with liver disease), and abrupt discontinuation can precipitate withdrawal symptoms.[74] Melatonin has been shown to be effective in adults, and can also be considered a first-line alternative treatment option in children.[75][76][77]
Use of this content is subject to our disclaimer