eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics
Sleep Disorder: Night Terrors
Updated: Feb 25, 2008
Introduction
Background
Sleep disruption is a frequent concern among parents of children aged 2 years or younger. Half of all infants develop a disrupted sleep pattern serious enough to seek physician evaluation.
Night terror disorder is characterized by recurrent episodes of intense crying and fear and by difficulty in waking the child. Children with night terrors often experience signs of autonomic arousal (eg, tachycardia, tachypnea, sweating) during episodes. Children do not recall a dream after a night terror and typically do not remember the episode the next morning. Night terrors are frightening episodes for parents to watch and may cause the child significant distress, fatigue, and impaired daily function. Onset is usually in children aged 4-12 years; the disorder generally spontaneously resolves by adolescence.
Pathophysiology
Sleep is divided into 2 categories: rapid eye movement (REM) and nonrapid eye movement (non-REM). Non-REM sleep is further divided into 4 stages, progressing from stages 1-4. Night terrors occur during the transition from stage 3 non-REM sleep to stage 4 non-REM sleep. Approximately 30-90 minutes after falling asleep, the child enters this light sleep stage and suddenly arises with symptoms of autonomic discharge.
Frequency
United States
An estimated 1-6% of children experience night terror episodes. Recurrent night terror episodes accompanied by significant distress and impairment are less frequent.
Mortality/Morbidity
Most children outgrow night terrors as they mature neurophysiologically.
Race
Children of all races and cultures are affected.
Sex
Males and females are equally affected.
Age
Night terrors are most common among children aged 3-12 years. The median age of onset is 3.5 years. Peak frequency in children younger than 3.5 years is at least one episode per week; among older children, peak frequency is 1-2 episodes per month.1
Clinical
History
The most important step toward diagnosing this disorder is to obtain a detailed history.
- Approximately 90 minutes after falling asleep, the child sits up in bed and screams. Prominent autonomic activity (eg, tachycardia, tachypnea, diaphoresis, flushing) occurs. The child appears awake but confused, disoriented, and unresponsive to stimuli.
- Most episodes last 1-2 minutes, but the child may remain inconsolable for 5-30 minutes before relaxing and returning to quiet sleep.
- If the child awakens during the night terror, only fragmented pieces of the episode may be recalled.
- In the morning, the child typically has no memory of the experience.
Physical
A complete physical examination is important to exclude other disorders. In general, however, physical examination adds little to information obtained from a complete history.
Causes
- Episodes of night terrors may be preceded by the following:
- Stressful life events
- Fever
- Sleep deprivation
- Medications that affect the CNS
Differential Diagnoses
Sleep Disorder: Nightmares
Other Problems to Be Considered
Temporal lobe seizures
Other sleep disorders
Workup
Laboratory Studies
- A complete history and physical examination is normally sufficient to diagnose night terrors.
Imaging Studies
- When nocturnal seizures are a possibility, a routine EEG or sleep-deprived EEG may be helpful.
- Polysomnography is useful if a respiratory disturbance is suspected.
- Neuroimaging is typically unnecessary.
Treatment
Medical Care
- Management consists of educating the family about the disorder and reassuring them that episodes are not harmful. See Patient Education for more information on this subject.
Medication
Medications rarely are indicated and usually provide no long-term help to patients. Prescribe medications only for severe symptoms that affect waking behavior such as school performance and peer or family relations. Administer medications only as a temporary treatment.
Tricyclic antidepressants
These agents decrease deep delta sleep and arousal between sleep stages.
Imipramine (Janimine, Tofranil, Tofranil-PM)
Stopped disorder in limited studies when administered at bedtime for 8 wk.
Dosing
Adult
Pediatric
<6 years: Not established
>6 years: 25-50 mg PO qhs; not to exceed 8 wk
Interactions
Possible added effects when coadministered with other CNS depressants; not for concomitant use with MAOIs; increases toxicity of sympathomimetic agents such as isoproterenol and epinephrine by potentiating effects and inhibiting antihypertensive effects of clonidine
Contraindications
Documented hypersensitivity; ECG changes reported in children receiving twice recommended maximum daily dose; hypersensitivity to sulfites, in formulations containing sulfites; do not use in patients taking MAOIs or fluoxetine or in patients who used these drugs in the previous 2 wk
Precautions
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
May mask symptoms rather than treat disease; tolerance occurs frequently; possible rebound effect upon discontinuation, with worsening of episodes; reports of sudden death in small number of children; possible stomach upset; administer with food
Caution with urinary retention, angle-closure glaucoma, hyperthyroidism, or other conditions in which anticholinergic activity aggravates condition; caution with seizure disorders; eliminate possibility of underlying cardiac disease based on ECG and physician's judgment
Follow-up
Further Outpatient Care
- Frequent contact with the family to provide support and reassurance helps alleviate their anxieties.
Prognosis
- Episodes usually are short-lived but occur over several weeks.
- Nearly all children outgrow night terrors by adolescence.
Patient Education
- Instruct parents to make the child's room a safe environment and to provide barriers that prevent the child from impulsively leaving the room in environments that could lead to injury.
- Examine the adequacy of the child's sleep, and educate parents about consistent bedtime routines.
- Eliminating all potential sources of sleep disturbance and maintaining a consistent wake-up time are also important.
- For excellent patient education resources, visit eMedicine's Sleep Disorders Center. Also, see eMedicine's patient education articles Night Terrors, Disorders That Disrupt Sleep (Parasomnias), and REM Sleep Behavior Disorder.
Miscellaneous
Medicolegal Pitfalls
- Failure to obtain an adequate history may lead to an incorrect diagnosis and unnecessary testing.
- Failure to educate the parents adequately about the benign nature of the problem and its final outcome may cause excessive parental anxiety that could prompt parents to search for an alternative cure.
References
DiMario FJ Jr, Emery ES 3d. The natural history of night terrors. Clin Pediatr (Phila). Oct 1987;26(10):505-11. [Medline].
Dahl RE. The pharmacologic treatment of sleep disorders. Psychiatr Clin North Am. Mar 1992;15(1):161-78. [Medline].
Guilleminault C, Palombini L, Pelayo R, Chervin RD. Sleepwalking and sleep terrors in prepubertal children: what triggers them?. Pediatrics. Jan 2003;111(1):e17-25. [Medline].
Pesikoff RB, Davis PC. Treatment of pavor nocturnus and somnambulism in children. Am J Psychiatry. Dec 1971;128(6):778-81. [Medline].
Siegel JM. Why we sleep. Sci Am. Nov 2003;289(5):92-7. [Medline].
Wise MS. Parasomnias in children. Pediatr Ann. Jul 1997;26(7):427-33. [Medline].
Keywords
night terrors, night-terrors, sleep terrors, night frights, parasomnia, pavor nocturnus, autonomic arousal, sleep disruption, rapid eye movement, REM, nonrapid eye movement, non-REM, tachycardia, diaphoresis, disrupted sleep pattern, night terror disorder, sleep deprivation
Contributor Information and Disclosures
Author
Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program
Kevin P Connelly, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.
Medical Editor
Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.
Pharmacy Editor
Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation
CME Editor
Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School
Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Academy of Pediatrics, American Medical Women's Association, American Psychiatric Association, and American Society for Adolescent Psychiatry
Disclosure: Nothing to disclose.
Chief Editor
Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.
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