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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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.[49]

If there is evidence of any coexisting sleep disorders such as obstructive sleep apnoea 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 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.

Consider – scheduled awakening

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confusional arousals
Consider – 

scheduled awakening

Additional treatment recommended for SOME patients in selected patient group

Anticipatory awakening may be helpful for some non-rapid eye movement sleep parasomnias, including confusional arousals, and probably works by preventing or interrupting the altered underlying neurophysiology of partial arousal, preventing the disturbing behavioural features of the parasomnia.[49]

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

Consider – biofeedback + relaxation

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confusional arousals
Consider – 

biofeedback + relaxation

Additional 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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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 apnoea and restless legs syndrome, education and counselling about good sleep hygiene, and the establishment of a safe home environment.[49]​ This last step consists of 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 (drugs, 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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sleepwalking
Consider – 

scheduled awakening

Additional treatment recommended for SOME patients in selected patient group

There is anecdotal evidence of the benefit of anticipatory scheduled awakening in treating sleepwalking in children.[49][65][66]​​​​

It is thought to work by preventing or interrupting the altered underlying neurophysiology of partial arousal, preventing the disturbing behavioural 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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sleepwalking
2nd line – 

pharmacotherapy

When episodes are severe and refractory, or dangerous to the patient and others, the use of drugs such as benzodiazepines (e.g., diazepam, clonazepam) may be tried.[64]​​​[67]​​​​ Care needs to be taken with use of clonazepam in children with obstructive sleep apnoea, in whom symptoms may be worsened.[68]​​

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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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 apnoea and restless legs syndrome, education and counselling about good sleep hygiene, and the establishment of a safe home environment.[49]​ 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 (drugs, 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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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 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.[49]​ 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 (drugs, car keys, knives, and guns). 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.

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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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, clonazepam) may be used.[33]​ 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.[69][70]

Other pharmacological treatment options include fluoxetine and tryptophan.[33]​​[71][72]​​[73]

Children should be monitored while on antidepressants, both for improvement of symptoms and for the development of adverse effects, including evidence of suicidal intent.[68]

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.[49]​ 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 (drugs, 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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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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nightmares
Consider – 

psychological therapy

Additional 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 behaviour therapy for adolescents.

2nd line – pharmacotherapy

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nightmares
2nd line – 

pharmacotherapy

For severe and refractory cases, the use of a rapid eye movement-suppressing agent, such as a low-dose tricyclic antidepressant or an selective serotonin-reuptake inhibitor (SSRI), for a short period of time may be helpful.[22][77][78]

However, the evidence for the use of these drugs 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 drug.

Tricyclic antidepressants may 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.[68] 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.[5]

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

Additional treatment recommended for SOME patients in selected patient group

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

recurrent isolated sleep paralysis

1st line – avoidance of precipitating factors

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recurrent isolated sleep paralysis
1st line – 

avoidance of precipitating factors

This is more common in teenagers. They should be counselled 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.

2nd line – pharmacotherapy

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recurrent isolated sleep paralysis
2nd line – 

pharmacotherapy

In cases when recurrent isolated sleep paralysis clinically results in significant distress or impairments in daily living, the use of a rapid eye movement-suppressing agent, such as a low-dose tricyclic antidepressant or a selective serotonin-reuptake inhibitor (SSRI) may be considered.[81]​ When episodes are severe and anxiety-provoking, the use of anxiolytics may be indicated provided there is no evidence of narcolepsy.

The evidence for the use of these drugs comes from studies in adults, and there is limited or no evidence for their use in children and adolescents for this indication. Therefore, a consultant needs to be consulted about the specific choice of drug.

Tricyclic antidepressants 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.

Plus – avoidance of precipitating factors

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ONGOING
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recurrent isolated sleep paralysis
Plus – 

avoidance of precipitating factors

Treatment recommended for ALL patients in selected patient group

Patients should be counselled 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).

Consider – narcolepsy treatment

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recurrent isolated sleep paralysis
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with narcolepsy
Consider – 

narcolepsy treatment

Additional 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).[79] Drug treatments for the management of recurrent isolated sleep paralysis, if used, must be taken into account when prescribing drugs for the treatment of narcolepsy. See Narcolepsy.

rapid eye movement sleep behaviour disorder

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

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rapid eye movement sleep behaviour disorder
1st line – 

avoidance of precipitating factors + environmental protective measures

Rapid eye movement sleep behaviour disorder (RBD) is extremely rare in childhood. When signs do present, it is important also to consider the possible diagnosis of narcolepsy.[12][13][14][15][16] 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 (drugs, 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).

In children, pharmacological treatment for RBD is not recommended, as RBD is always considered abnormal and management focuses on identifying and addressing the underlying cause. If drug treatment is required (e.g., the condition is associated with injuries that are proving difficult to prevent), it should be prescribed and supervised by a consultant who is experienced in managing this disorder in children.

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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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