Update on Pediatric Parasomnias

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Update on Pediatric Parasomnias
Golda Milo-Manson, MD, FRCPC
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Objectives

• To outline the parasomnias and an approach to the
  clinical evaluation and management of these sleep
  disorders
• To highlight development in the evaluation and
  management of these disorders

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Parasomnia Topics

• Nightmares
• Night terrors
• Sleepwalking
• RMD - Rhythmic movement disorder

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Reminder of normal sleep physiology

• 2 types of sleep ( REM, NREM)
• NREM has 4 stages, stage III and IV called slow
  wave sleep
• Slow wave sleep predominates in first 1/3 of
  night
• REM sleep predominates in last ½ of the night

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NREM sleep

• 4 stages roughly parallel the depth of sleep
• Arousal threshold lowest in stage 1 and highest
  in stage IV
• Stage of relatively low brain activity which the
  regulatory capacity of brain is active and body
  movements are preserved
• Stage 1, may have brief involuntary muscle
  contractions ( hypnic jerks)

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REM sleep

• Paralysis or nearly absent muscle tone
• (except control of breathing and erectile tissue)
• High levels of cortical activity
• Dreaming
• Episodic bursts of phasic eye movements
• First REM- 70 to 100 minutes after sleep onset
  and lasts about 5 minutes

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Introduction What is a Parasomnia?

• Undesirable motor, autonomic or experiential
  phenomenon that occur exclusively or
  predominantly during the sleeping state
• Int. Class of Sleep Disorders, 1990

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Nightmares/REM Arousal

• Occur in last third of night during REM sleep
• Onset 3-6 years
• Prevalence 10-50
• Child often cries out, visibly upset
• Easily consoled by caregiver
• Child can recall episode with vivid detail

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Nightmare Treatment

• Caregiver comfort at time of episode
• Minimize night time discussion
• If stressor can be identified decrease exposure
• Rule out medication use

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Night Terror/Slow Wave Arousal

• Sudden onset, sudden resolution
• Generally occurs during the transition from
  non-rem to rem sleep
• Generally in 1st/third of sleep
• Considered a normal phenomenon
• Begins 18 mo
• Prevalence 6 healthy children
• Often occurs in clusters, disappears for several
  mo then recur

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Night Terror/Slow Wave Arousal

• Very frightening for caregivers
• Child inconsolable
• Often doesnt appear to recognize parents
• Duration seconds-10 min.
• No recall in a.m.
• Child may bolt upright, stare, diaphoretic,
  irregular breathing

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Evaluation of Night Terrors

• Diagnosis by history
• Consider pathology if starting in school age
  child
• Take careful sleep history to exclude other
  treatable causes of night terrors, e.g..
  disrupted sleep, sleep apnea
• Review sleep hygiene if history of insomnia, poor
  sleep continuity

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Review of sleep hygiene

• Environment
• Dark, quiet, comfortable
• Schedule
• Regular waking time, and bedtime
• Consistent nap time
• Activities
• No frightening T.V. or stories
• No vigorous physical activities before bedtime
• Consistent bedtime routine and soothing methods
• Child put into bed awake

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Good sleep hygiene- continued

• Avoid caffeine/nicotine/ethanol
• No nicotine/ethanol
• Avoid caffeinated foods/beverages in late
  afternoon, evening
• Exercise
• Regular exercise before evening promotes sleep
• Sunlight
• Exposure to sunlight or bright light in morning

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Night Terror Treatment

• Parent education and reassurance
• Outgrow by teen years
• Ensure safe environment
• Do not awaken the child
• Do not discuss in a.m.

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Guillement et al. Peds. 2003Sleep Walking and
Sleep Terrors What Triggers Them?

• n84
• 51/84 had additional sleep disorder (SDB, RLS)
• 45/51 had resolution of parasomnia with treatment
  of SDB, RLS

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For more resistant night terrors

• Scheduled awakenings, Lask 1997
• 5-6 nights recording of timing
• Wake the child 10-15 minutes before and maintain
  awake x 5 minutes
• Follow procedure 5-7 nights

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Medication

• not generally recommended however start
  benzodiazepine to ? arousals between sleep stages
  
• tolerance, rebound, hyperactivity may develop
• Evidence Level C

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Sleepwalking/Slow Wave Arousal

• Occurs during transition from non-rem to rem
  sleep
• 1st third of night
• No correlation to emotional disturbance
• Prevalence 15-30 of children have at least one
  episode
• Possible role for heredity

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Sleepwalking/Slow Wave Arousal

• Purposeless walking about the home, poor
  coordinated movement
• May appear calm or agitated
• Possible triggers sleep deprivation/extreme
  fatigue
• Generally no recall
• Duration seconds 30 minutes

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Sleepwalking Treatment

• Ensure safe environment
• Mechanism to alert parents
• Talk calmly and lead back to bed
• Do not discuss in a.m.
• Document frequency and timing ? scheduled
  awakenings (Level C evidence)
• Medication for intractable cases benzodiazepine
  however tolerance or rebound effects

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Frank et al. J Ped Psychology. 1997

• Case series of scheduled awakenings in
  sleepwalking
• 100 success, maintained at 6-month follow-up

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Definition Rhythmic Movement Disorder

• Sleep-related stereotypic, repetitive movements
  of the head, neck or large muscle groups,
  occurring with a frequency of 0.5-2 Hz., which
  can persist for a few minutes to many hours and
  may occur almost nightly

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When does RMD occur

• All sleep stages
• In waking state
• In 7 children studied with 37 episodes, usually
  stage 2 NREM sleep ( Dyken M, Ped. Neur, 1997)

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Sallustro, J of Peds, 1978 Head Banging in
normal children

• Incidence 3.3- 15.2
• Age- typically begins at 8.6 months and stops
  before age 4
• Malesfemales 31
• Prior to onset of head banging, most head bangers
  display other rhythmic habits, mostly body
  rocking
• Head banging usually takes place at bedtime

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Klackenberg G, Acta Ped Scand 1971 RMD
Incidence in normal children

• 66 of healthy children exhibited some form of
  rhythmic activity at 9 months of age
• Quality of their sleep as good as children
  without such activity

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Why children body rock?

• Rocking body movements provide sensations and
  pleasure to a child
• Movements are tension-releasing
• May help child to cope with frustration
• Highly repetitive rocking in autistic and
  severely MR children due to poor behavioural or
  emotional repertoire
• Vestibular stimulation
• Psychoanalytic interpretation' highly regressive
  and narcissistic behaviour with autoerotic
  function ( Kempenaers C, Sleep 1994)

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Can RMD be harmful?

• Reported to cause
• Soft tissue injury
• Eye injury
• Skull injury
• Internal carotid artery dissection( abstract
  only Jackson MA, Br. Med J, 1983)
• Subdural hemorrhage (Mackenzie JM, Lancet, 1991)

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Evaluation and Treatment

• Infants RMD generally benign and resolve with
  time
• Parental reassurance and protection of the
  environment
• After 3 years of age- may need neurologic and
  psychologic evaluation
• Consider evaluation if suggestion of seizure
• Patients with severe MR may need helmets, other
  sedating medication

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Take Home Message

• Good history and physical
• Stress good sleep hygiene
• Reassurance