Parasomnias in children
- Overview
- Theory
- Diagnosis
- Management
- Follow up
- Resources
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
confusional arousals
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]Mainieri G, Loddo G, Provini F, et al. Diagnosis and management of NREM sleep parasomnias in children and adults. Diagnostics (Basel). 2023 Mar 27;13(7):1261. https://www.mdpi.com/2075-4418/13/7/1261 http://www.ncbi.nlm.nih.gov/pubmed/37046480?tool=bestpractice.com
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.
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]Mainieri G, Loddo G, Provini F, et al. Diagnosis and management of NREM sleep parasomnias in children and adults. Diagnostics (Basel). 2023 Mar 27;13(7):1261. https://www.mdpi.com/2075-4418/13/7/1261 http://www.ncbi.nlm.nih.gov/pubmed/37046480?tool=bestpractice.com
Anticipatory scheduled awakening involves gently waking the child at set times throughout the night.
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
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]Mainieri G, Loddo G, Provini F, et al. Diagnosis and management of NREM sleep parasomnias in children and adults. Diagnostics (Basel). 2023 Mar 27;13(7):1261. https://www.mdpi.com/2075-4418/13/7/1261 http://www.ncbi.nlm.nih.gov/pubmed/37046480?tool=bestpractice.com 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).
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]Mainieri G, Loddo G, Provini F, et al. Diagnosis and management of NREM sleep parasomnias in children and adults. Diagnostics (Basel). 2023 Mar 27;13(7):1261. https://www.mdpi.com/2075-4418/13/7/1261 http://www.ncbi.nlm.nih.gov/pubmed/37046480?tool=bestpractice.com [65]Tobin JD Jr. Treatment of somnambulism with anticipatory awakening. J Pediatr. 1993;122:426-427. http://www.ncbi.nlm.nih.gov/pubmed/8441100?tool=bestpractice.com [66]Frank NC, Spirito A, Stark L, et al. The use of scheduled awakenings to eliminate childhood sleepwalking. J Pediatr Psychol. 1997;22:345-353. http://jpepsy.oxfordjournals.org/cgi/reprint/22/3/345.pdf http://www.ncbi.nlm.nih.gov/pubmed/9212552?tool=bestpractice.com
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.
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]Proserpio P, Terzaghi M, Manni R, et al. Drugs used in parasomnia. Sleep Med Clin. 2022 Sep;17(3):367-78. http://www.ncbi.nlm.nih.gov/pubmed/36150800?tool=bestpractice.com [67]Reid WH, Ahmed I, Levie CA. Treatment of sleepwalking: a controlled study. Am J Psychother. 1981;35:27-37. http://www.ncbi.nlm.nih.gov/pubmed/7020438?tool=bestpractice.com Care needs to be taken with use of clonazepam in children with obstructive sleep apnoea, in whom symptoms may be worsened.[68]Nemeroff CB, Kalali A, Keller MB, et al. Impact of publicity concerning pediatric suicidality data on physician practice patterns in the United States. Arch Gen Psychiatry. 2007 Apr;64(4):466-72. http://archpsyc.ama-assn.org/cgi/content/full/64/4/466 http://www.ncbi.nlm.nih.gov/pubmed/17404123?tool=bestpractice.com
Primary options
diazepam: consult specialist for guidance on dose
OR
clonazepam: consult specialist for guidance on dose
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]Mainieri G, Loddo G, Provini F, et al. Diagnosis and management of NREM sleep parasomnias in children and adults. Diagnostics (Basel). 2023 Mar 27;13(7):1261. https://www.mdpi.com/2075-4418/13/7/1261 http://www.ncbi.nlm.nih.gov/pubmed/37046480?tool=bestpractice.com 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
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]Mainieri G, Loddo G, Provini F, et al. Diagnosis and management of NREM sleep parasomnias in children and adults. Diagnostics (Basel). 2023 Mar 27;13(7):1261. https://www.mdpi.com/2075-4418/13/7/1261 http://www.ncbi.nlm.nih.gov/pubmed/37046480?tool=bestpractice.com 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).
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]Irfan M. Sleep terrors. Sleep Med Clin. 2024 Mar;19(1):63-70. http://www.ncbi.nlm.nih.gov/pubmed/38368070?tool=bestpractice.com 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]Lillywhite AR, Wilson SJ, Nutt DJ. Successful treatment of night terrors and somnambulism with paroxetine. Br J Psychiatry. 1994;164:551-554. http://www.ncbi.nlm.nih.gov/pubmed/8038949?tool=bestpractice.com [70]Balon R. Sleep terror disorder and insomnia treated with trazodone: a case report. Ann Clin Psychiatry. 1994;6:161-163. http://www.ncbi.nlm.nih.gov/pubmed/7881496?tool=bestpractice.com
Other pharmacological treatment options include fluoxetine and tryptophan.[33]Irfan M. Sleep terrors. Sleep Med Clin. 2024 Mar;19(1):63-70. http://www.ncbi.nlm.nih.gov/pubmed/38368070?tool=bestpractice.com [71]Guzman CS, Wang YP. Sleep terror disorder: a case report. Rev Bras Psiquiatr. 2008;30:169. http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1516-44462008000200016&lng=en&nrm=iso&tlng=en http://www.ncbi.nlm.nih.gov/pubmed/18592111?tool=bestpractice.com [72]Bruni O, Ferri R, Miano S, et al. L-5-Hydroxytryptophan treatment of sleep terrors in children. Eur J Pediatr. 2004;163:402-407. http://www.ncbi.nlm.nih.gov/pubmed/15146330?tool=bestpractice.com [73]van Zyl LT, Chung SA, Shahid A, et al. L-Tryptophan as treatment for pediatric non-rapid eye movement parasomnia. J Child Adolesc Psychopharmacol. 2018 Jul/Aug;28(6):395-401. http://www.ncbi.nlm.nih.gov/pubmed/29741922?tool=bestpractice.com
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]Nemeroff CB, Kalali A, Keller MB, et al. Impact of publicity concerning pediatric suicidality data on physician practice patterns in the United States. Arch Gen Psychiatry. 2007 Apr;64(4):466-72. http://archpsyc.ama-assn.org/cgi/content/full/64/4/466 http://www.ncbi.nlm.nih.gov/pubmed/17404123?tool=bestpractice.com
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
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]Mainieri G, Loddo G, Provini F, et al. Diagnosis and management of NREM sleep parasomnias in children and adults. Diagnostics (Basel). 2023 Mar 27;13(7):1261. https://www.mdpi.com/2075-4418/13/7/1261 http://www.ncbi.nlm.nih.gov/pubmed/37046480?tool=bestpractice.com 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
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).
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.
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]Mahowald MW, Schenck CH. NREM sleep parasomnias. Neurol Clin. 1996;14:675-96. http://www.ncbi.nlm.nih.gov/pubmed/8923490?tool=bestpractice.com [77]Wise MS. Parasomnias in children. Pediatr Ann. 1997;26:427-33. http://www.ncbi.nlm.nih.gov/pubmed/9225359?tool=bestpractice.com [78]Aldrich MS. Sleep medicine. Oxford, UK: Oxford University Press; 1999.
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]Nemeroff CB, Kalali A, Keller MB, et al. Impact of publicity concerning pediatric suicidality data on physician practice patterns in the United States. Arch Gen Psychiatry. 2007 Apr;64(4):466-72. http://archpsyc.ama-assn.org/cgi/content/full/64/4/466 http://www.ncbi.nlm.nih.gov/pubmed/17404123?tool=bestpractice.com 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]American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 5th ed. text revision, (DSM-5-TR). Washington, DC: American Psychiatric Publishing; 2022
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).
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
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.
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]Sharpless BA. A clinician's guide to recurrent isolated sleep paralysis. Neuropsychiatr Dis Treat. 2016;12:1761-7. https://www.dovepress.com/a-clinicianrsquos-guide-to-recurrent-isolated-sleep-paralysis-peer-reviewed-fulltext-article-NDT http://www.ncbi.nlm.nih.gov/pubmed/27486325?tool=bestpractice.com 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.
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).
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]Mitler MM, Hajdukovic R, Erman M, et al. Narcolepsy. J Clin Neurophysiol. 1990;7:93-118. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=1968069 http://www.ncbi.nlm.nih.gov/pubmed/1968069?tool=bestpractice.com 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
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]Nevsimalova S, Prihodova I, Kemlink D, et al. REM behavior disorder (RBD) can be one of the first symptoms of childhood narcolepsy. Sleep Med. 2007;8:784-786. http://www.ncbi.nlm.nih.gov/pubmed/17569582?tool=bestpractice.com [13]Stores G. Rapid eye movement sleep behaviour disorder in children and adolescents. Dev Med Child Neurol. 2008;50:728-732. http://onlinelibrary.wiley.com/doi/10.1111/j.1469-8749.2008.03071.x/full http://www.ncbi.nlm.nih.gov/pubmed/18834385?tool=bestpractice.com [14]Bonakis A, Howard RS, Ebrahim IO, et al. REM sleep behaviour disorder (RBD) and its associations in young patients. Sleep Med. 2009;10:641-645. http://www.ncbi.nlm.nih.gov/pubmed/19109063?tool=bestpractice.com [15]Bonakis A, Howard RS, Williams A. Narcolepsy presenting as REM sleep behaviour disorder. Clin Neurol Neurosurg. 2008;110:518-520. http://www.ncbi.nlm.nih.gov/pubmed/18343568?tool=bestpractice.com [16]Dauvilliers Y, Rompre S, Gagnon JF, et al. REM sleep characteristics in narcolepsy and REM sleep behavior disorder. Sleep. 2007;30:844-849. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978363/?tool=pubmed http://www.ncbi.nlm.nih.gov/pubmed/17682654?tool=bestpractice.com 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.
Choose a patient group to see our recommendations
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
Use of this content is subject to our disclaimer