A 5 year old boy presents to the ED with his parents at 1:15AM. The parents report that they went to their son’s room when they heard him screaming. It started all of a sudden, and aside form his attending his cousin’s birthday party the day before there was nothing remarkable about his recent history (except for the party – because it truly was remarkable). His parents stated that they arrived in his room to find him sitting up screaming. The parents turned on the lights and saw that he was staring off into the distance, his face was red, and his heart “was beating out of his chest.” When they attempted to calm him he began thrashing about. He eventually calmed down in 7-10 minutes, and seemed to want to fall back asleep. In the ED he is tired appearing, but easily answers your questions about his Spider Man PJs. He does not remember what happened. His vitals are normal, as is his physical examination. You learn that he has no prior history of seizures, trauma, or ingestions He has been well with no recent illnesses. He is on no medicines. The parents deny a family history of epilepsy – but they are very worried that their son had a seizure because of the way he was moving his limbs and not responding. You take a deep breath, and discuss the diagnosis…
Discussion
Sleep Terrors (pavor nocturnus – not a Harry Potter spell) are a common parasomnia seen between age 4 and 12 years. Children awaken from sleep with screaming and agitation. They can have facial flushing, tachycardia and sweating. Children may climb or jump out of bed and thrash their limbs, or even try to escape from a frightening stimulus. They can last 5-30 minutes. Particularly frightening to parents is that their calming efforts do not initially work. In most instances the child does not remember what happened in contrast to nightmares which result in immediate awakening and remembrance of the dream. Though most children have no associated issues they can be seen with psychiatric or neurologic problems.
Petit et al in 2007 noted that sleep talking (84%) was the most common parasomina, followed by bruxism (45%) and then sleep terrors (40%). Others include sleepwalking, confusional arousals (no flushing, sweating, or stereotypical limb movements like in sleep terrors), and sleep enuresis. It is important to discuss what differentiates sleep terrors from seizures (especially since this is what brought this family in). Nocturnal seizures are more likely to be associated with a positive family history, daytime seizures and occur randomly and multiple times throughout the night. Children with nighttime seizures may also be sleepy during the day. GERD, OSA and panic attacks may also result in nighttime awakening with frightened behaviors.
It is important to tell parents that these may reoccur, and that they usually resolve over 1-2 years. Many children have 1-2 per month. The focus of ED disposition should be on safety issues done in order to assure that the child doesn’t get hurt – especially if they sleepwalk. Restraining the child during events is not necessary, and may lead to injury to the parent. Making sure that children that still nap take their nap can reduce the chance that a parasomnia will occur. Recurrent parasomnias can be evaluated via a polysomnogram (sleep study) and rarely children benefit from nighttime doses of benzodiazepines.
I’ll leave you with this video…
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