Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

confusional arousals

1st line – avoidance of precipitating factors, observation, and reassurance

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ONGOING
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confusional arousals
1st line – 

avoidance of precipitating factors, observation, and reassurance

Initial measures include education and reinforcement of good sleep hygiene. In most children, reassurance can be given that it is likely that the episodes will remit as the child grows older.

If there is evidence for any coexisting sleep disorders such as obstructive sleep apnea or restless legs syndrome, 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.

Parents should be advised that efforts to curtail the behavior 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.

Consider – scheduled awakening

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ONGOING
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confusional arousals
Consider – 

scheduled awakening

Treatment recommended for SOME patients in selected patient group

Anticipatory awakening may be helpful for some non-rapid eye movement sleep (NREM) parasomnias, including confusional arousals, and probably works by preventing or interrupting the altered underlying neurophysiology of partial arousal, preventing the disturbing behavioral features of the parasomnia.

Anticipatory scheduled awakening involves gently waking the child at set times throughout the night.

Consider – biofeedback + relaxation

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ONGOING
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confusional arousals
Consider – 

biofeedback + relaxation

Treatment recommended for SOME patients in selected patient group

For children with very frequent episodes, biofeedback and relaxation techniques can be used, in addition to general sleep hygiene measures.

If possible, stress should be limited.

sleepwalking

1st line – avoidance of precipitating factors + environmental protective measures

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ONGOING
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sleepwalking
1st line – 

avoidance of precipitating factors + environmental protective measures

Sleepwalking is treated by avoidance of the precipitating factors such as sleep deprivation or sleep disorders such as obstructive sleep apnea and restless legs syndrome, education and counseling about good sleep hygiene, and the establishment of a safe living quadrant. This last step comprises environmental protective measures such as removing sharp objects from the bedroom, locking doors, placing door alarms on doors exiting the home, and arranging for a sleeping space on the ground floor. Parents should also consider removal of any potentially dangerous items and store them in locked boxes (medications, car keys, knives, and guns).

Good sleep hygiene includes the following measures: going to bed and getting up at the same time each day, avoiding excessive and late daytime naps, avoiding excessive light exposure before bedtime (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), and avoidance of dealing with school-related or work-related issues before bedtime (work issues may be relevant in older adolescents).

Consider – scheduled awakening

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ONGOING
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sleepwalking
Consider – 

scheduled awakening

Treatment recommended for SOME patients in selected patient group

There is anecdotal evidence for the benefit of anticipatory scheduled awakening in treating sleepwalking in children.[63][64]

It is thought to work by preventing or interrupting the altered underlying neurophysiology of partial arousal, preventing the disturbing behavioral features of the parasomnia.

This may be tried as an additional measure to avoidance of precipitating factors and environmental protection.

2nd line – pharmacotherapy

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ONGOING
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sleepwalking
2nd line – 

pharmacotherapy

When episodes are severe and refractory, or dangerous to the patient and others, the use of medications such as benzodiazepines (e.g., diazepam, clonazepam) may be tried.[2][65][66] Care needs to be taken with use of clonazepam in children with obstructive sleep apnea, in whom symptoms may be worsened.

Low-dose tricyclic antidepressants have been tried following benzodiazepine therapy, but there are limited data concerning specific choices, and caution is required because some tricyclic antidepressants may exacerbate sleepwalking. Tricyclic antidepressants (TCAs) may also cause cardiac arrhythmias. Children should be monitored while on antidepressants, both for improvement of symptoms and for the development of adverse effects, including evidence for suicidality. In 2004, the US Food and Drug Administration (FDA) issued a black box warning on suicidality associated with pediatric use of antidepressants.[67]

Primary options

diazepam: consult specialist for guidance on dose

OR

clonazepam: consult specialist for guidance on dose

Plus – avoidance of precipitating factors + environmental protective measures

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ONGOING
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sleepwalking
Plus – 

avoidance of precipitating factors + environmental protective measures

Treatment recommended for ALL patients in selected patient group

Sleepwalking is treated by avoidance of the precipitating factors such as sleep deprivation or sleep disorders such as obstructive sleep apnea and restless legs syndrome, education and counseling about good sleep hygiene, and the establishment of a safe living quadrant. This last step comprises environmental protective measures such as removing sharp objects from the bedroom, locking doors, placing door alarms on doors exiting the home, and arranging for a sleeping space on the ground floor. Parents should also consider removal of any potentially dangerous items and store them in locked boxes (medications, car keys, knives, and guns).

Good sleep hygiene includes the following measures: going to bed and getting up at the same time each day, avoiding excessive and late daytime naps, avoiding excessive light exposure before bedtime (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), and avoidance of dealing with school-related or work-related issues before bedtime (work issues may be relevant in older adolescents).

sleep terrors

1st line – avoidance of precipitating factors + environmental protective measures

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ONGOING
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sleep terrors
1st line – 

avoidance of precipitating factors + environmental protective measures

Treatment should first focus on eliminating the cortical arousals from sleep, such as from obstructive sleep apnea 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. These measures may involve such things as removing sharp objects from the bedroom, locking doors, and arranging for a sleeping space on the ground floor. Parents should also consider removal of any potentially dangerous items and store them in locked boxes (medications, car keys, knives, and guns). Occasionally, the episodes are frequent, intense, or disruptive to the patient's sleep. In these situations, after obstructive sleep apnea and restless legs syndrome have been evaluated for, a long-acting benzodiazepine (e.g., diazepam or clonazepam) may be used.

Good sleep hygiene includes the following measures: going to bed and getting up at the same time each day, avoiding excessive and late daytime naps, avoiding excessive light exposure before bedtime (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), and avoidance of dealing with school-related or work-related issues before bedtime (work issues may be relevant in older adolescents).

2nd line – pharmacotherapy

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ONGOING
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sleep terrors
2nd line – 

pharmacotherapy

Occasionally, the episodes are frequent, intense, or disruptive to the patient's sleep. In these situations, 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.[68][69]

Other pharmacologic treatment options that have been included in case reports include tricyclic antidepressants, fluoxetine, and tryptophan.[65][70][71]

Children should be monitored while on antidepressants, both for improvement of symptoms and for the development of adverse effects, including evidence for suicidality. In 2004, the US Food and Drug Administration (FDA) issued a black box warning on suicidality associated with pediatric use of antidepressants.[67]

Primary options

diazepam: consult specialist for guidance on dose

OR

clonazepam: consult specialist for guidance on dose

Secondary options

paroxetine: consult specialist for guidance on dose

OR

trazodone: consult specialist for guidance on dose

Tertiary options

fluoxetine: consult specialist for guidance on dose

OR

tryptophan: consult specialist for guidance on dose

Plus – avoidance of precipitating factors + environmental protective measures

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ONGOING
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sleep terrors
Plus – 

avoidance of precipitating factors + environmental protective measures

Treatment recommended for ALL patients in selected patient group

Education and advice on good sleep hygiene can be given. Environmental protective measures are recommended to prevent injury. These measures may involve such things as removing sharp objects from the bedroom, locking doors, placing door alarms on doors exiting the home, and arranging for a sleeping space on the ground floor. Parents should also consider removal of any potentially dangerous items and store them in locked boxes (medications, car keys, knives, and guns).

Good sleep hygiene includes the following measures: going to bed and getting up at the same time each day, avoiding excessive and late daytime naps, avoiding excessive light exposure before bedtime (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), and avoidance of dealing with school-related or work-related issues before bedtime (work issues may be relevant in older adolescents).

nightmares

1st line – avoidance of precipitating factors

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ONGOING
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nightmares
1st line – 

avoidance of precipitating factors

Treatment often involves simple reassurance, as the episodes seem to diminish in frequency and intensity over the course of the patient's lifespan. If recurrent nightmares are noted with recurring themes, imagery rehearsal should be tried. This 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.

Good sleep hygiene includes the following measures: going to bed and getting up at the same time each day, avoiding excessive and late daytime naps, avoiding excessive light exposure before bedtime (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), and avoidance of dealing with school-related or work-related issues before bedtime (work issues may be relevant in older adolescents).

Consider – psychological therapy

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ONGOING
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nightmares
Consider – 

psychological therapy

Treatment recommended for SOME patients in selected patient group

If stress is considered a factor, psychological therapy may be used. This may be provided in the form of cognitive behavior therapy for adolescents.

2nd line – pharmacotherapy

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ONGOING
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nightmares
2nd line – 

pharmacotherapy

For severe and refractory cases, the use of a rapid eye movement (REM)-suppressing agent, such as a tricyclic antidepressant or an SSRI, for a short period of time may be helpful.[30]​[45]​​[73]

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.

TCAs may cause arrhythmias. Children should be monitored while on antidepressants, both for improvement of symptoms and for the development of adverse effects, including evidence for suicidality. In 2004, the US Food and Drug Administration (FDA) issued a black box warning on suicidality associated with pediatric use of antidepressants.[67] In addition, individuals with frequent nightmares are at substantially greater risk for suicidal thoughts or behavior, even when sex and mental illness are taken into account.[12]

Plus – avoidance of precipitating factors

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ONGOING
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nightmares
Plus – 

avoidance of precipitating factors

Treatment recommended for ALL patients in selected patient group

Good sleep hygiene should be reinforced. In particular, the avoidance of sleep deprivation is important. Adolescents may be reminded to limit caffeine intake.

Good sleep hygiene includes the following measures: going to bed and getting up at the same time each day, avoiding excessive and late daytime naps, avoiding excessive light exposure before bedtime (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), and avoidance of dealing with school-related or work-related issues before bedtime (work issues may be relevant in older adolescents).

Consider – psychological therapy

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ONGOING
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nightmares
Consider – 

psychological therapy

Treatment recommended for SOME patients in selected patient group

If stress is considered a factor, psychological therapy may be used in addition to medication. This may be provided in the form of cognitive behavioral therapy for adolescents.

isolated recurrent sleep paralysis

1st line – avoidance of precipitating factors

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ONGOING
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isolated recurrent sleep paralysis
1st line – 

avoidance of precipitating factors

This is more common in teenagers. They should be counseled on good sleep hygiene and advised to avoid any precipitating factors.

Good sleep hygiene includes the following measures: going to bed and getting up at the same time each day, avoiding excessive and late daytime naps, avoiding excessive light exposure before bedtime (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), and avoidance of dealing with school-related or work-related issues before bedtime (work issues may be relevant in older adolescents).

When the episodes are infrequent, more active treatment is unnecessary; in most cases, reassurance is all that is needed.

Consider – anxiolytic drugs

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ONGOING
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isolated recurrent sleep paralysis
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without narcolepsy
Consider – 

anxiolytic drugs

Treatment recommended for SOME patients in selected patient group

When 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.

Primary options

diazepam: consult specialist for guidance on dose

Consider – narcolepsy treatment

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ONGOING
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isolated recurrent sleep paralysis
|
with narcolepsy
Consider – 

narcolepsy treatment

Treatment recommended for SOME patients in selected patient group

Frequent episodes in the context of narcolepsy require treatment of the narcolepsy (e.g., with central nervous system stimulants).[74]

rapid eye movement sleep behavior disorder

1st line – avoidance of precipitating factors + environmental protective measures

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ONGOING
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rapid eye movement sleep behavior disorder
1st line – 

avoidance of precipitating factors + environmental protective measures

Rapid eye movement sleep behavior disorder (RBD) is extremely rare in childhood. When signs do present, it is important also to consider the possible diagnosis of narcolepsy.[21][22][23][24][25] Conservative measures such as environmental protective measures, education, and implementation of good sleep hygiene are the first approach.

Environmental safety is prudent in every patient with likely RBD, to avoid injury. Measures may involve removing sharp objects from the bedroom, locking doors, placing door alarms on doors exiting the home, and arranging for a sleeping space on the ground floor. Parents should also consider removal of any potentially dangerous items and store them in locked boxes (medications, car keys, knives, and guns).

Good sleep hygiene includes the following: going to bed and getting up at the same time each day, avoiding excessive and late daytime naps, avoiding excessive light exposure before bedtime (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), and avoidance of dealing with school-related or work-related issues before bedtime (work issues may be relevant in older adolescents).

2nd line – pharmacotherapy

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ONGOING
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rapid eye movement sleep behavior disorder
2nd line – 

pharmacotherapy

If the condition is associated with injuries that are proving difficult to prevent, pharmacologic therapy may be considered. Medication should be prescribed and supervised by a specialist who is experienced in managing this disorder in children.

Pharmacotherapy 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][76][77] However, clonazepam may be contraindicated in some patients (e.g., those with liver disease), and abrupt discontinuation can precipitate withdrawal symptoms.[77] Melatonin has been shown to be effective in adults, and can also be considered a first-line alternative treatment option in children.[78][79][80]

Primary options

clonazepam: consult specialist for guidance on dose

OR

melatonin: consult specialist for guidance on dose

Plus – avoidance of precipitating factors + environmental protective measures

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ONGOING
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rapid eye movement sleep behavior disorder
Plus – 

avoidance of precipitating factors + environmental protective measures

Treatment recommended for ALL patients in selected patient group

Environmental protective measures, education, and implementation of good sleep hygiene are important for ongoing management. Environmental safety is prudent in every patient with likely rapid eye movement sleep behavior disorder (RBD), to avoid injury. Measures may involve such things as removing sharp objects from the bedroom, locking doors, and arranging for a sleeping space on the ground floor.

Good sleep hygiene includes the following measures: going to bed and getting up at the same time each day, avoiding excessive and late daytime naps, avoiding excessive light exposure before bedtime (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), and avoidance of dealing with school-related or work-related issues before bedtime (work issues may be relevant in older adolescents).

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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