Pediatr Clin N Am 51 (2004) 69 – 88

Parasomnias in childhood
Stephen H. Sheldon, DO, FAAPa,b,*
a b

Department of Pediatrics, Northwestern University, Feinberg School of Medicine, USA Sleep Medicine Center, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 43, Chicago, IL 60614, USA

Parasomnias are classified as dysfunctions associated with sleep, sleep stages, or partial arousals from sleep [1]. These disorders of sleep are strikingly dissimilar in presentation but share many clinical and biologic characteristics. Symptoms appear early in childhood. Steady, gradual transformation and resolution of symptoms suggest that the etiology of parasomnias may be maturational in nature. Few pathophysiologic abnormalities can be identified, despite the severe and often intense symptoms. Spontaneous remission as a child ages is common. Longitudinal observations have shown that many parasomnias may appear gradually or have a sudden onset. Frequency of parasomnic spells can vary and can range from single, rare episodes to nightly events that persist for a protracted period of time. During wakefulness, no obvious clinical abnormalities are present and patients appear medically and developmentally normal, only to express bizarre and sometimes violent behaviors during sleep.

Cause The cause of parasomnias is unknown. Because of the age at which they first manifest and their gradual resolution over time, a maturational origin has been hypothesized. Any theoretical basis of the genesis of parasomnias, however, must address their common features. The International Classification of Sleep Disorders [1] organizes the parasomnias into four major categories: arousal disorders, sleepwake transition disorders, parasomnias usually associated with rapid eye movement (REM) sleep, and other parasomnias. Additional characteristics that affect classification in pediatric patients include parasomnias typically associated with non-REM slow-wave sleep (SWS), parasomnias typically associated with REM sleep, parasomnias typically associated with wake-to-sleep transition, and other
* Sleep Medicine Center, Children’s Memorial Hospital, 2300 Children’s Plaza, Box 43, Chicago, IL 60614. E-mail address: ssheldon@northwestern.edu 0031-3955/04/$ – see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/S0031-3955(03)00177-9

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parasomnias. Classification is typically made with emphasis on observable behaviors [2].

Clinical and laboratory evaluation of a child with a parasomnia Evaluation begins with a comprehensive history and physical examination. Special attention must be placed on a detailed description of the nocturnal events, including—but not limited to—the following information: Usual time of occurrence of the spell Description of behaviors, movements, or symptoms manifested Whether intervention efforts by the caretaker improve or exacerbate symptoms Whether the child leaves the bed Recall of or amnesia for the event(s) Occurrence of symptoms during daytime naps Presence or absence of symptoms during wakefulness Presence of stereotypic movements or rhythmic behaviors during the spell Basic neurodevelopmental landmarks must be assessed carefully for the presence of daytime waking behavioral or developmental abnormalities. Typical sleep-wake schedules, habits, and patterns require delineation. Habitual morning wake time, evening bedtime, bedtime rituals, and naptime rituals should be described. The presence of excessive daytime sleepiness, snoring, or other respiratory symptoms [3] may assist in determining exacerbating factors. Presence of concurrent medical illnesses and medication history should be obtained in the clinical interview. A complete physical examination must be performed. Emphasis should be placed on a comprehensive neurologic and developmental evaluation. The existence of developmental delays or symptoms that suggest neurologic disorders might indicate an organic basis for the presenting symptoms. Other sleep disorders are common in children with parasomnias, and resolution of the primary underlying sleep disorder often results in resolution of the parasomnic spells [3]. A urine drug screen might be helpful if symptoms are considered to be side effects of medication. Video recording of the spell by the parents can provide significant information; video polysomnography is often indicated [4,5]. An expanded electroencephalogram (EEG) electrode array assists in differentiating a parasomnia from sleep-related seizures and might provide information localizing focal pathology. Concomitant video recording of the patient while sleeping may demonstrate clinical manifestations and chronicle movements [6]. The study should begin no later than 10:00 PM to avoid artificially short sleep onset latency and end no earlier than 6:00 AM to avoid missing the last REM episode. The patient should be allowed to wake spontaneously so a realistic natural recording may be obtained. It is often helpful to have the patient drink fluids and avoid urination before settling because

anxiety. Diagnosis of rhythmic movement disorder is based on the identification of characteristic symptoms in the absence of other medical or psychiatric disorders. embarrassment. If conducted. frequent arousal rhythms without state change. somniloquy and isolated sleep paralysis. arousal rhythms that occur during SWS. Sleep-wake transition disorders Sleep-wake transition disorders comprise a group of disorders that surround falling to sleep. routine sleep-deprived EEG. or other epileptiform activity associated with the stereotypic activity is absent. or the movement from sleep to wakefulness. and hypersynchronous theta intrusion into SWS (theta-delta pattern) have been associated with. At times they may be thought of as state dissociation or overlapping states. nighttime manifestations. Occasionally.S. special emphasis is placed on identification of other sleep-related pathology that might precipitate the parasomnia. Included in this classification of disorders are rhythmic movement disorders (head banging and body rocking). In analyzing the polysomnogram. Rhythmic movements that surround the sleep period are common and have been reported in approximately two thirds of normal children. They also may be seen during arousals from sleep or during sleep cycle transitions. and clinical symptomatology. sleep starts. Presentation varies considerably and can vary from rare. a sleepdeprived or prolonged EEG recording may be required to rule out seizure . transition between sleep states. Occasionally. paroxysmal. Movements vary in intensity and sometimes can be violent. Attention also should be paid to analyzing the amplitude of slow wave. but not diagnostic of. Video recordings can be helpful in characterizing these rhythmic movements. movements may be seen during SWS. They are typically self-limited and resolve spontaneously in most youngsters by age 4 [18]. home video recordings also can be helpful in classification. There seems to be a 4:1 male-to-female ratio. and disturbance of a youngster’s sleep and the sleep of the entire family. These movements also may occur during arousals from sleep and may persist into nonREM sleep. The need for all-night EEG recordings. Focal. and intrusion of 4 to 7 Hz EEG activity into SWS. arousal disorders [9]. and radiographic studies depends on the presenting situation. mild movements during state transitions to frequent and sometimes injurious movements that have the potential to result in discomfort. polysomnography demonstrates the typical rhythmic movements during the immediate presleep period that may extend into early stage 1 sleep. Rhythmic movement disorders Rhythmic movement disorders [10 –17] involve stereotypic body rocking or head banging that occurs during the transition from wakefulness to sleep. The cause is unknown. but rarely during REM sleep [19]. Polysomnography is rarely required for diagnosis.H. pain. Partial arousals. synchronization of slow-wave activity [8]. Sheldon / Pediatr Clin N Am 51 (2004) 69–88 71 bladder distension may precipitate some parasomnias [7].

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and use of antihistamines. it is typically of little concern to parents and caretakers. They also must be differentiated from seizure. Sleep starts: hypnic myoclonia Sleep starts (hypnic myoclonia) also have been termed ‘‘hypnogogic jerks’’ [1]. rhythmic sounds in the sleeping environment. Clinical course is usually self-limited. injury is rare. confusional arousals. and are not pathologic unless they are frequent and result in sleep-onset insomnia [21]. most reports are anecdotal and few treatment regimens have been replicable. Various treatments have been suggested. Riter S. 1999. 237. There is typically amnesia for the events. and carbamazepines. brief muscular contraction of the legs and occasionally the arms. such as autism.) . This 30-second polysomnographic epoch demonstrates rhythmic body rocking at a frequency of approximately 60 to 65 Hz. Fig. or utterances during the sleep period. Although vigorous head banging may seem aggressive. pervasive developmental disorder. however. (From Sheldon SH. This patient was transitioning from wake to sleep and was noted by the technician to rhythmically bang her head into the pillow. 1). Significant outbursts of loud talking or utterances are rare but occasionally may be significant enough to disturb the sleep of parents or other family members [23 – 25]. but foot injuries secondary to kicking a bedpost or crib rail may occur. and other disorders must be ruled out. especially if associated with a vocalization or cry. Somniloquy: sleeptalking Sleeptalking is common during childhood.H. This wake-to-sleep transition problem is characterized by a sudden. Somniloquy is not associated with pathologic states but may be associated with other parasomnias. and stage volumes are typically normal (Fig. especially if they occur in patients with known epilepsy [22]. Hypnic myoclonia may occur at any age and may be frightening when observed by a parent. head. occur in most individuals. Occasional bruising or abrasions might occur. and hypnogenic dystonia. Diagnosis of somniloquy is based on identification of typical manifestations of coherent speech. with permission. Sleep starts are common. single. 1. Although the exact incidence is unknown. ending with the myoclonic jerk. such as sleep terrors. Children should be protected from injury.S. Detrojan M. Spontaneous degradation of symptoms and spontaneous resolution occurs. and sleepwalking. Treatments vary and have included intentional rhythmic movements before bedtime. Once asleep. Armonk (NY): Futura Publishing Company. Sheldon / Pediatr Clin N Am 51 (2004) 69–88 73 disorders. sleep architecture. Success in all treatment regimens varies. Sensory hallucinations (hypnogogic hallucinations) often occur before the sleep start. state progression. benzodiazepines. Injury from the massive movement is rare. and the subjective perception of falling may occur. incoherent mumbling. Atlas of sleep medicine in infants and children. p. and postural muscles [20].

response to parental intervention is often inappropriate. there may be stage 1 sleep. Focal. Intensity of manifestations varies considerably. Symptoms begin in early childhood and resolve spontaneously. no!’’ [26]. Arousal disorders share several common features. and there is considerable disorientation. Arousal disorders may be exacerbated by factors that result in increased sleepiness. sleep terrors may occur at any time during the 24-hour continuum when sleep occurs [27]. The onset of a sleep terror is sudden and often . Sleep terrors Sleep terrors. They may be precipitated by stress. and it is difficult to wake the youngster from the spell. and a child might appear to be frightened after full awaking occurs. fever. might occur and is typically accidental. there is some degree of confusion or disorientation. with the child rapidly returning to sleep. however. anxiety. Although typically brief and lasting only a few minutes. noise). irregular sleep patterns. Medical or psychiatric disorders are notably absent.74 S. Confusional arousals Confusional arousal occurs upon arousal from SWS. Children must be protected from unintentional trauma during episodes. theta pattern. pain. agitation. youngsters may appear awake but might not recognize parents. They might yell anxiously during the spell. The clinical course is usually benign. Most common words spoken are ‘‘No. Children may cry. they may persist into adolescence and adulthood. Polysomnography reveals a sudden abrupt arousal from SWS. bladder distension. it can be frightening to the parent and child. Characteristics of arousal disorders stem from their occurrence during this deep sleep state. occasionally the arousal disorders may be prolonged or occur multiple times during the sleep period. and there is amnesia for the spell. The term ‘‘sleep terror’’ is preferred to ‘‘night terror’’ to clearly differentiate it from a nightmare. moan. although rare. Arousal disorders: non –rapid eye movement motor parasomnias Arousal disorders are believed to be caused by impaired or ‘‘partial’’ arousal from SWS. or speak in unintelligible sentences. Physical injury. Amnesia for the event varies. paroxysmal. are manifested by an abrupt sudden partial arousal from SWS during the first third to first half of the sleep period. Although muscle artifact often obscures the EEG pattern.H. These factors tend to increase brief arousal states in normal individuals. Diagnosis is based on identification of confusion or disorientation. or combativeness upon arousal. During a spell. they occur during the first half of the sleep period. Polysomnography reveals that somniloquy can occur in any stage of sleep. sleep deprivation. Sheldon / Pediatr Clin N Am 51 (2004) 69–88 but symptoms may persist. In general. similar to other arousal disorders. or poorly reactive alpha activity noted. or epileptiform activity is absent. environmental factors (eg. Rarely. and other sleep-related disorders.

S.H. diaphoresis. A sudden abrupt arousal from SWS during the first third to first half of the sleep period may occur (Fig. however. intense autonomic nervous system discharge results in intense pupillary dilation. the spells may be prolonged and there may be multiple episodes during a single sleep period. Onset of symptoms of sleep terrors is believed to be between 2 and 4 years of age. Psychopathology is rare in children with sleep terrors. Video recording reveals various behavioral manifestations during the spell. Sleep terrors. Boys seem to be more frequently affected than girls. time of spells. Partial arousals without motor manifestations may occur more frequently in children with sleep terrors when compared with children who do not experience these partial arousals (Fig. Sheldon / Pediatr Clin N Am 51 (2004) 69–88 75 begins with a ‘‘blood curdling’’ scream. 3). and tachypnea. Prolonged periods of inconsolable crying in younger children might be symptoms of partial arousal. can occur during SWS at any time of the night. the polysomnogram often reveals muscle artifact superimposed on a background EEG rhythm of 0. Intense behavioral manifestations of apparent fear are striking and frightening to the observer. last 3 to 5 minutes. Home video recording of a spell may be helpful in characterizing manifestations. and other sleep-related disorders that may be precipitating factors. the exact prevalence is unknown. Diagnostic considerations Diagnosis of arousal disorders typically is made by history and physical examination alone. Risk of injury and resistance to prior therapeutic interventions also should be considered. A decision to obtain a polysomnogram should be based on a patient’s clinical presentation. Similar to other partial arousal disorders. Polysomnography is rarely needed unless there is a suspected primary underlying sleep disorder. but few objective data are currently available. however. and end spontaneously. and there seems to be a familial pattern of occurrence [28]. In contrast to sleepwalking. During a partial arousal. Intensity also can vary from mild to severe. Partial arousals have been reported to occur in approximately 3% of prepubertal (Tanner 1) children and less than 1% of adults. tachycardia. Occasionally. and intensity of symptoms. Diagnosis is based on identification of characteristic symptoms. There is some anecdotal evidence that children who manifest intrusion of hypersynchronous theta activity into SWS (a theta-delta EEG pattern) (Fig.5 to 2 Hz. and the child rapidly returns to sleep [28]. There are no clearly defined polysomnographic characteristics of partial arousal disorders. frequent electrocortical arousal rhythms during SWS. Polysomnography typically reveals sudden arousal from SWS during the first third to first half of the sleep period. 2). or hypersynchronous delta band activity may be prone to partial arousal . As with other partial arousal disorders. The need for polysomnography is controversial. and spells are rare after 10 years of age. 4). the frequency decreases as youngsters age. exclusion of organic pathology. frequency of occurrence of episodes. Spells are typically brief. characteristics of motor activity.

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Fluids after the nighttime meal should be limited. In patients with epilepsy. Behavioral and sleep hygiene approaches are still included in the therapeutic regimen. Therapeutic considerations There is no clear consensus regarding when a partial arousal disorder requires treatment.29]. Severity of partial arousal disorders is considered moderate when symptoms occur less than once per week. medical causes. reassurance and a behavioral approach have been successful [26]. and a period of quiet activity or relaxation techniques should be instituted before bedtime. The technician noted the patient to be screaming during the sudden arousal. Sheldon / Pediatr Clin N Am 51 (2004) 69–88 77 (given the right set of circumstances). there are multiple nightly episodes. however. and their occurrence during any part of the sleep period or awake state. In these situations. because they may occur concomitantly in the same patient. periodic limb movement disorder) [3]. and daytime performance is normal. Symptoms are most often mild. the spells do not result in injury or harm to the children. Parents should be encouraged to let the event run its course and intervene minimally. . Interventions should be focused on preventing injury and guiding a child back to bed.S. primary sleep-related disorders should be addressed appropriately (eg. and children should be encouraged to empty their bladder before settling. occur infrequently. A comprehensive explanation of the nature of these parasomnias and reassurance that the children are normal mentally and developmentally should be provided. EEG may show abnormal discharges from the temporal or frontal lobes [6. Of particular importance. Identification of epileptiform activity. Fevers. A bell on the doorknob of a youngster’s room may alert parents to a child’s sleep-related walking. In these mild cases. Too vigorous intervention attempts may prolong the spell. and regular sleep-wake scheduling and sleep hygiene should be maintained consistently. Short daytime naps might be attempted. stereotypic behaviors. or injury has occurred (or there is significant risk of injury). 2. Epileptic events may be distinguished from disorders of partial arousal by the presence of a combination of clinical features. Warning of sleepwalking may be provided by an alarm system. Sleep deprivation should be avoided. Other environmental triggers. sleepdisordered breathing.H. does not completely rule out the presence of partial arousal. This 120-second polysomnographic epoch demonstrates a sudden arousal from slow-wave sleep precipitated by a periodic limb movement. and result in injury to neither children nor parents. and psychological precipitants must be addressed appropriately and reinforcing behaviors must be eliminated. if present. Sleep terrors require differentiation from sleep-related epilepsy with automatisms. When episodes occur almost nightly. These findings are normal variants and are clearly not diagnostic of partial arousal disorders. Note the left leg electromyogram reveals the movement followed by a sudden abrupt arousal from slow wave sleep. but Fig. reassurance may be all that is necessary. should be evaluated and appropriately treated. pharmacologic therapy may be indicated.

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Disorders rarely encountered during childhood are included because their importance to the practitioner might become clear when they are more completely understood and dysfunction associated with the sleeping state is further delineated in children. . and there is full orientation to the environment and clear sensorium. A sudden arousal from REM sleep occurs. or diazepam can be effective. and the reaction is emotional rather than associated with the intense autonomic nervous system discharges seen in association with sleep terrors. certain REM sleep parasomnias may share similar symptoms with partial arousal disorders. The age of onset seems to parallel development of dreams in childhood. there is arousal to full waking state. benzodiazepines are the most commonly prescribed medication [30]. Nearly all children experience nightmares. without state change. during the longest and most intense REM episode.H. manifestations of anxiety. Parasomnias usually associated with rapid eye movement sleep Parasomnias also occur during REM sleep. and some mild autonomic nervous system discharge. Children most often are fully awake and alert after the nightmare. Prevalence data are not clear. Young children generally respond well to behavioral and pharmacologic approaches. security. action-packed story line. When indicated. Dream recall is appropriate to the children’s developmental and maturational level. manifestations are markedly dissimilar to the non-REM sleep parasomnias and sleep-wake transition disorders. Treatment with medication should be conducted in conjunction with a behavioral approach. There seems to be equal sex distribution and no clear familial pattern. tachyphylaxis.S. and chronic disruption of sleep structure. Frequency varies considerably from commonly seen REM sleep parasomnias (nightmares) to others that are rarely described in childhood (REM sleep behavior disorder). complication.32]. The ‘‘dream story’’ is often complex and may involve credible threat to survival. Prolonged use of medication increases the potential for side effects. or self-esteem. 3. There is typically clear recall for the dream. This 30-second polysomnographic epoch demonstrates slow-wave sleep. Most parasomnias can be differentiated on clinical evaluation alone. Sheldon / Pediatr Clin N Am 51 (2004) 69–88 79 pharmacotherapy might be prescribed for a short period. Nightmares most commonly occur during the last half to one third of the sleep period. Movements are rare Fig. Children are often easily comforted after an arousal from a nightmare. On occasion. Nightmares: anxiety dreams A nightmare occurs during REM sleep and is characterized by a frightening dream that often results in a prolonged period of wake [31. The dreams are usually vivid and there is a clear. Note that during the last third of the epoch there is a burst of theta activity that represents an arousal rhythm. and return to sleep is delayed. Small nightly doses of clonazepam. In most cases. lorazepam.

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and nightmares are typically easily differentiated from sleep terrors on clinical grounds alone (Box 1). Atlas of sleep medicine in infants and children.H. paroxysmal. This 30-second polysomnographic epoch depicts theta intrusion into slow-wave sleep.S. a story-like quality to the dream report. Armonk (NY): Futura Publishing Company. Detrojan M. and epileptiform activity is absent. p. Manifestations are generally mild and vocalizations are rare. Rarely are other diagnostic techniques required. 4. an abrupt awakening from REM sleep is seen followed by a prolonged period of wake. absence of intense autonomic activation. 1999. Riter S. clear recall of the dream. and there may be increased frequency of phasic muscle twitches. 210. Diagnosis of anxiety dreams is based on the identification of the mild and characteristic manifestations of disturbing dreams that occur during the early morning hours. arousal from sleep with clear mentation is typical. however. If polysomnography is conducted. and a good response to parental interventions.) . Increased REM sleep eye movement density may be present during the nightmare. Fig. This occurrence is sometimes termed ‘‘theta-delta sleep’’ and can be seen as a normal variant in younger children. Focal. Sleep terrors versus nightmares Sleep terrors        Occur during first third to first half of the night Occur during non-REM (SWS) Child has brief and rapid return to sleep Child resists parental interventions Child has poor to absent recall for the event Child experiences intense autonomic nervous system discharges Child has confusion upon awakening Nightmares        Occur during second half to last third of the sleep period Occur during REM sleep (dream sleep) Child has prolonged return to sleep Child is easily comforted by parents Child has clear recall of dream/detailed story Child experiences mild autonomic nervous system activity Child is alert upon awakening during nightmares because of normal REM sleep hypotonia. with permission. Sheldon / Pediatr Clin N Am 51 (2004) 69–88 81 Box 1. Children may have mild tachycardia. appropriate functioning and alertness upon waking. (From Sheldon SH. Muscle tone is low.

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Sleep paralysis Isolated sleep paralysis [33. This 30-second polysomnographic epoch demonstrates rhythmic temporalis muscle artifact in the EEG leads. Hypnogogic or hypnopompic hallucinations are unusual during spells of sleep paralysis but can occur and increase anxiety related to the episode. Maintenance of appropriate sleep hygiene is essential. persist for prolonged periods of time. 228. Symptoms may be mistaken for resistance to waking. Clinical course varies significantly among individuals. (From Sheldon SH. stress. and this inhibition is similar (if not identical) to that which is associated with normal REM sleep. children who wake from an episode of sleep paralysis might be frightened and cry. and sleep paralysis) and in familial sleep paralysis. Armonk (NY): Futura Publishing Company. All muscle groups. hypnogogic hallucinations. The frequency of teeth grinding is approximately 1 Hz. irregular sleepwake schedules. last only a few minutes.) . with permission. except the diaphragm and the extraocular muscles. Patients often have a sensation of difficulty breathing because of inhibition of accessory muscles of respiration. are essential for appropriate management. conversely. cataplexy. Additional medical or psychological evaluation and management may be required. Isolated occurrences of sleep paralysis occur in normal individuals. Children are conscious and awake and vigilant to the environment. 5. Spells sometimes can be aborted by another person touching the patient or by volitional rapid movements of the eyes. Sheldon / Pediatr Clin N Am 51 (2004) 69–88 83 Occasional nightmares are common during childhood. and subside spontaneously. Sleep paralysis runs a more Fig. however. Sleep paralysis spells are most often brief. Atlas of sleep medicine in infants and children. Identifying and minimizing underlying causes. More frequent events are seen in patients with narcolepsy syndrome (as part of the tetrad of excessive daytime sleepiness/sleep attacks. Children who resist waking arouse cranky and obstinate.34] is characterized by a period of inability to move voluntarily that occurs at the beginning of the sleep period (hypnogogic) or immediately upon awakening from sleep (hypnopompic). Children have difficulty describing the events and may seem to be asleep throughout the duration of the event. and episodes are characteristically frightening. Treatment is based on reassurance and education. Active inhibition of alpha motor neurons is present. 1999. excessive sleepiness. Most cases are isolated and are provoked by sleep deprivation. but symptoms may begin during childhood. Riter S. and acute changes in sleep phase.H. Detrojan M. If they become frequent. or are associated with daytime behavioral or performance dysfunction. especially those that are anxiety or stress related. p.S. Onset of sleep paralysis usually occurs during adolescence. underlying medical or psychological causes should be considered. Parents may be unaware of the occurrence because touching or shaking might abort the hypotonia. are typically involved. There is equal sex distribution in the isolated form and a female preponderance in the familial form.

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patients may enter sleep during an episode of sleep paralysis and reveal an EEG pattern consistent with stage 1 sleep. especially clonazepam. There is increased phasic muscle activity.S. REM sleep motor disorder usually begins during late adulthood and progresses over a variable period of time. Atonic generalized seizures occur during wakefulness and may or may not be associated with changes in levels of consciousness. There is a paradoxic increase in muscle tone that might be considered the absence of REM sleep atonia. approximately 90 minutes after sleep onset.H. excessive limb movements and body jerking. Injuries to the patient or bed partner are common. REM sleep motor disorder is an unusual abnormality seen in REM sleep characterized by elaborate. Rapid eye movement sleep motor disorder REM sleep motor disorder. Most cases are idiopathic. Fig. Sleep paralysis associated with narcolepsy syndrome can be differentiated from the isolated form by the absence of other symptoms related to the clinical tetrad. 6.’’ Occasionally. Signs and symptoms also have been reported in posttraumatic stress disorder. which results in patients ‘‘acting out their dreams. especially REM sleep. This 60-second polysomnographic epoch demonstrates bruxism after an obstructive apnea during the first third of the epoch and bruxism after an obstructive hypopnea during the last third of the epoch. Polysomnography might reveal significant decrease in chin muscle tone in the presence of normal waking EEG rhythm. These behaviors are associated with vivid dream recall. which may not be obvious. neurologic disorders have been reported in approximately 40% of affected adults. originally described in adults as REM sleep behavior disorder. Conjugate eye movements also may be present. also has been described in childhood [35]. however. and periodic limb movements. Complex behaviors occur during REM sleep. violent behaviors occur. and a multiple sleep latency test may be required to differentiate these episodes from the narcolepsy syndrome. or leaping out of bed. Syncope also occurs during wakefulness and is commonly associated with altered levels of consciousness. and further understanding of this disorder may reveal the incidence and prevalence to be higher than current description suggests. Occasionally. REM sleep motor disorder in children and adults responds well to benzodiazepines. sometimes purposeful movements accompanied by vocalizations. Episodes usually occur during the first REM period of the night. kicking. Diagnosis is based on identification of presenting symptoms. Polysomnography reveals increased muscle tone that persists throughout sleep. True sleep-onset REM periods may occur at night. No epileptiform activity is noted on EEG. with patients punching. Children also may be affected. . Sheldon / Pediatr Clin N Am 51 (2004) 69–88 85 chronic course in patients with narcolepsy syndrome or the familial form of the disorder.

No longitudinal studies have demonstrated the natural course of bruxism. yet a most important factor is appropriate dental management. hyperactivity. A mouth guard may be worn to prevent damage to the teeth. Sheldon / Pediatr Clin N Am 51 (2004) 69–88 Sleep bruxism: teeth grinding Sleep bruxism [36] is forceful grinding or rhythmic clenching of the teeth or rhythmic movements of the mandible during sleep (Fig. Polysomnography reveals paroxysmal. Dental evidence of bruxism can be identified in 10% to 20% of the general population. Similar to many parasomnias. Diagnosis is made by identification of the loud. Predisposing factors for the development of bruxism have been reported to include minor abnormalities of the teeth. Several therapeutic approaches have been recommended. painful teeth. unmistakable sound of bruxism in the absence of other medical or psychiatric disorders that may produce abnormal movements during sleep. This rhythmic activity also may be seen in the chin muscle electromyogram or masseter muscle groups. with a mean age of onset of 10. or performance difficulties are present.86 S.H. hypertrophy of the masseter and temporalis muscles. and is used primarily as a preventive dental intervention. the muscle activity occurs during the arousal that immediately follows the obstructed respiratory event. Bruxism has been reported in more than 50% of children. craniofacial pain. Sleep bruxism also can be mistaken for atypical migraine cephalgia. Researchers have estimated that 5% to 20% of children have manifested symptoms of bruxism. and temporomandibular joint dysfunction can occur. 5). rhythmic muscle activity manifested by approximately 1 Hz muscle artifact over the temporalis muscle. and the condition is most commonly seen in children and young adults. and anxiety. 6). Resorption of alveolar bone. a familial pattern can be demonstrated. Daytime symptoms are common and include jaw pain. a loud. The mouth guard does not seem to prevent episodes of bruxism. chronic wear to the crowns of the teeth. stress. especially if morning headaches. attention span problems. If associated with obstructive sleep-disordered breathing. and bleeding from the gums. malocclusion. morning headaches. snoring. Presence of obstructive sleep-disordered breathing also should be assessed. Episodes of rhythmic jaw movements occur either periodically or paroxysmally in bursts of 5 to 15 seconds or longer and are often repeated many times during the sleep period. temporalis. restless sleep. unmistakable noise is produced. and pterygoid muscles. These rhythmic movements are a result of involuntary repetitive contractions of the masseter. Some anecdotal data have shown that rhythmic movement and protrusion of the mandible also occur during arousals associated with occlusive sleepdisordered breathing (Fig. however. especially when response to traditional treatment has been poor. without clear genetic transmission. When teeth grinding occurs.5 years. frequent nocturnal wakings (with or without headaches). periodontal tissue damage. There seems to be an equal sex distribution. daytime sleepiness. If .

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