Parasomnias in childhood

doi:10.1016/j.smrv.2008.09.005

Sleep Medicine Reviews

Volume 13, Issue 2, April 2009, Pages 157-168

https://doi.org/10.1016/j.smrv.2008.09.005 Get rights and content

Summary

Common childhood parasomnias, including those occurring at sleep onset and during rapid eye movement sleep or non-rapid eye movement sleep and their ontogeny are discussed. The events may be distressing to both the patient and family members. Stereotypic movements characteristic of some parasomnias most likely arise from disinhibition of subcortical central pattern generators. Genetic predisposition, an inherent instability of non-rapid eye movement sleep and underlying sleep disturbances such as obstructive sleep apnea may predispose to the activation of confusional arousals, sleep walking or sleep terrors. Many parasomnias can be recognized by history alone, but some require nocturnal polysomnography for appropriate diagnosis and management. A scheme to distinguish non-rapid eye movement sleep parasomnias from nocturnal seizures is provided. Behavioral therapy has a role in the management of many childhood parasomnias, but evidence based recommendations are as yet unavailable.

Introduction

This article provides an overview of common childhood parasomnias. An emphasis has been placed on formulating pathophysiological concepts. In the interests of brevity, some minor and inconsequential parasomnias have not been discussed.

Section snippets

Phylogeny, ontogeny, and pathophysiology

Parasomnias are the consequence of dissociation between wakefulness, NREM or REM sleep, with behaviors characteristic of one state becoming superimposed on another.¹ The dissociation between behaviors and motor patterns from their specific state occurs even amongst marine mammals, where it might help thermoregulation and in the maintenance of vigilance during continuous living in the aquatic environment. This is exemplified by the unihemispheric sleep of bottle nosed dolphins, seals, beluga

Epidemiology

In a longitudinal, population-based survey, Klackenberg found that up to 45% of children aged 4–16 years had experienced sleep walking; only 2–3% however reported a frequency of at least one episode per month.²⁶ Frightened awakenings from sleep were seen in about 40 of subjects, and 3.5% of this group met criteria for sleep terrors. Petit and Montplaisir have recently published their findings from the only known prospective study of childhood parasomnias.²⁷ The study was from the province of

Hypnic starts

Also termed sleep starts, these are isolated, quick jerks of the upper or lower extremities that occur at sleep onset. They may be accompanied by a sensation of falling, a dream-like feeling or a flashing sensation.²⁸ Hypnic starts do not portend a significant underlying neurological disorder. They are benign, occur in approximately 70% of people of all ages,²⁹ and most likely represent a release phenomenon that has been generated at the level of the brainstem or spinal cord due to transient

Arousal parasomnias

This group is composed of confusional arousals, sleep terrors, and sleep walking. More than one type may coexist within the same patient, and it is reasonable to discuss them here as a group. Typically, arousal parasomnias occur at the time of transition from slow wave sleep (N3) into lighter stages of sleep, and appear time-locked to appear during the first third of night sleep.34, 35Table 1 summarizes the characteristics of these three arousal parasomnias. Sleep deprivation and fever can

Nightmares

These events are bad dreams that awaken the dreamer. The International Classification of Sleep Disorders II defines nightmares as “recurrent episodes of awakening from sleep with recall of intensely disturbing dream mentation, usually involving fear or anxiety, but also anger, sadness, disgust, and other dysphoric emotions. There is generally full alertness upon awakening immediately after a nightmare, and intact recall of the dream experience. Additionally, there may be delayed return to sleep

Sleep related enuresis

Recurrent bedwetting affects approximately 4–15% of school children.*64, 65 In pre-pubertal subjects, boys are affected twice as often as girls, but after puberty, the incidence is similar in both sexes.

The majority of sleep enuresis occurs only at night, but about 15% of children have both daytime and night-time symptoms.⁶⁶ From the developmental standpoint, complete control of the bladder at night is usually achieved by the age of 5 years, thus bedwetting in toddlers is physiologic.⁶⁷ The

References* (78)

Y. Sekiguchi et al.
Resting behaviors of captive bottlenose dolphins (Tursiops truncatus)
Physiol Behav
(2003)
O. Lyamin et al.
Behavioral aspects of sleep in bottlenose dolphins mothers and their calves
Physiol Behav
(2007)
O.I. Lyamin et al.
Unihemispheric slow wave sleep and the state of the eyes in a white whale
Behav Brain Res
(2002)
I. Tobler
Is sleep fundamentally different between mammalian species?
Behav Brain Res
(1995)
V. Bertelle et al.
Sleep of preterm neonates under developmental care or regular environmental conditions
Early Hum Dev
(2005)
M. Saraga et al.
A stereotypic “elbowing” movement. A possible new primitive reflex in newborns
Pediatr Neurol
(2007)
M. Hafstrom et al.
Non-nutritive sucking in sick pre-term infants
Early Hum Dev
(2001)
S. Grillner et al.
Neural bases of goal-directed locomotion in vertebrates – an overview
Brain Res Rev
(2008)
Y. Nakamura et al.
Rhythm generation for food-ingestive movements
Prog Brain Res
(2004)
H. Gezelius et al.
Role of glutamate in locomotor rhythm generating neuronal circuitry
J Physiology – Paris
(2006)

B.J. Schmidt et al.

The role of serotonin in reflex modulation and locomotor rhythm production in mammalian spinal cord

Brain Res Bull

(2000)

L. Parrino et al.

CAP, epilepsy and motor events during sleep: the unifying role of arousal

Sleep Med Rev

(2006)

A.S. Walters

Clinical identification of simple sleep-related movement disorders

Chest

(2007)

M. Otto et al.

Rates of isolated sleep paralysis in outpatients with anxiety disorders

Anxiety Disord

(2006)

S.H. Sheldon