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SLEEP TERRORS AND NIGHTMARE DISORDER
Carla Moreno PGY-2
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INTRODUCTION
• Sleep plays a vital and often underestimated role in the growth
and development of children
• Sleep problems have a high prevalence
• 40% of teens have sleep related problems
• 25% to 50% of preschoolers
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INTRODUCTION
• They are often a clue to underlying emotional, interactional, or
family problems that deserve attention and may be the aspect of
the child’s functioning that the family is most open to address
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GENERAL CLINICAL GUIDELINES
• The clinician may want to ask some “trigger” questions to
determine related family/environmental factors:
• At what age did the problem begin
• What else was happening at that time
• How much of a problem is it
• What factors are associated with it worsening or getting better
• who are the family members most affected
• What have others told you about this sleep problem
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SLEEP IN INFANCY, CHILDHOOD, AND ADOLESCENCE
• The ability to sleep throughout the night usually does not develop
until 3 to 6 months of age
• Insufficient sleep and poor sleep quality may manifest as changes
in
• Mood
• Behavior
• Memory
• Attention
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COMMON PARASOMNIAS OF CHILDHOOD
• Night terrors
• Nightmares
• Parasomnias are undesirable
physical events that occur during
entry into sleep, within sleep, or
during arousal from sleep
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NIGHT TERRORS
• Arousals from deep (slow wave) sleep, usually in the first one third
of the night and come with intense fear
• Activates the autonomic system and causes
• Tachycardia
• Tachypnea
• Flushing of the skin
• Diaphoresis
• Increased muscle tone
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NIGHT TERRORS
• Episodes usually start 1 to 3 hours after falling asleep
• Each episode lasts 5 to 20 minutes and ends of its own accord
with the child falling asleep
• They tend to occur in bouts of up to 20 per night for several
weeks, then disappear, only to recur several weeks later
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NIGHT TERRORS
• The child is found sitting up in the bed unresponsive; if awakened,
the child is confused and disoriented
• Vocalizations occurs frequently
• Amnesia is usually present
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PREVALENCE
• 1% to 6.5% in early childhood
• 2.5% from the age of 15 years onward
• Seen within in 4 to 12 years of age
• Genetics may play a role: parents usually suffered from night
terrors
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DIAGNOSIS
• Night terrors are usually diagnosed based on history
• Differentials to exclude include obstructive sleep apnea, restless
legs syndrome/periodic limb movement syndrome, or seizures
• No need for a sleep study, although it could be helpful in
distinguishing night terrors from nocturnal complex partial seizures
• It could also rule out OSA in a snoring child
• OSA can lead to recurrent arousals and shifts in sleep stage and may
be associated with increased night terrors
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MANAGEMENT
• Management of night terrors is focused primarily on parental reassurance and education
• Parents should be informed of the essentially self limited natures of these episodes
• Most children stop having them after puberty
• Scheduled awakening may be considered for the children who is having nightly episodes and wake the child to the point of arousal 15 to 30 minutes before that time.
• This can be done for 2 to 4 weeks until the episodes stop occurring and can be repeated if the episodes start again.
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MANAGEMENT
• The bladder should be emptied routinely at bedtime and the
environment kept dark and quiet.
• A 30 to 60 minutes afternoon nap can also reduce stage IV sleep,
thereby decreasing episodes.
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MANAGEMENT
• Short acting benzodiazepines may be considered only if the
episodes are severe and excessively violent and place him or her
at high risk of injury
• Treatment for 3 to 6 months or until the episodes stop occurring
• Benzodiazepines should be slowly tapered because abrupt
discontinuation results in slow-wave sleep rebound and return of
nocturnal episodes
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NIGHTMARES
• Characterized by disturbing dreams that usually occur in rapid
eye movement (REM) sleep and result in awakening
• There is significant anxiety after awakening and difficulty returning
to sleep
• Common in younger children, who cannot distinguish between
dreams and reality
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PREVALENCE
• 10 to 50% of children between 3 to 5 years of age
• Peaks around age 6 to 10
• During this stage children have vivid imaginations
• Can be precipitated by stress or traumatic events
• Associated with
• Sleep deprivation
• Anxiety disorders
• Medications: antidepressants, antihypertensive agents, and dopamine
agonists
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MANAGEMENT
• They deserve brief comforting, preferably in the child’s bed
• Children who have chronic nightmares have been shown to
improve with targeted relaxation exercises and stories in which a
child masters a situation.
• Children can prepare to have good dreams through rehearsing
and imaging pleasant thoughts.
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MANAGEMENT
• Pediatricians should assess both the chronicity and severity of
nightmares because unusual severity has been related to
psychopathology
• Nightmares can be distinguished from night terrors by their
occurrence in the latter half of the night, when REM sleep
predominates.
• Unlike night terrors, return to sleep is significantly delayed
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MANAGEMENT
• Maintaining good sleep hygiene
• Limiting exposure to frightening or overstimulating television shows
and movies
• Children may respond well to parental reassurance or use of
security objects such as blankets
• Night light might be helpful
• Referral to a developmental-behavioral pediatrician should be
consider if the child is excessively disturbed by these events
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MEDICATIONS
• Severe nightmares may respond to bedtime diphenhydramine,
trazadone, or cyproheptadine, although counseling is mandatory
if the condition is of this severity.
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NIGHTMARES MAY SIGNAL A CHILD IS BEING BULLIED
• Stress/trauma from being bullied can lead to increased risk of
sleep arousal problems, such as nightmares or night terrors
• Pediatricians should consider peer bullying as a potential
precursor of nightmares or night terrors
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RESOURCES
• Diagnosis and Management of Common Sleep Problems in
Children. Sumit Bhargava. March 2011. Pediatrics in Review
• Nightmares may signal a child is being bullies. Aap news room
article
• Sleep Disorders. Barbara Howard and Joyce Wong. October 2001.
Pediatrics in Review