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Sleepwalking and Sleep Terrors in Prepubertal Children: What Triggers Them?

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Sleepwalking and Sleep Terrors in Prepubertal Children: What Triggers Them? Sleepwalking and Sleep Terrors in Prepubertal Children: What Triggers Them? Christian Guilleminault, MD, Biol D; Luciana Palombini, MD; Rafael Pelayo, MD; and Ronald D. Chervin, MD, MS ABSTRACT. Objectives. To evaluate the clinical pre- the control children had any parasomnias. Fifty-one sentation and polysomnography of prepubertal children (61%) of 84 children with parasomnia had a diagnosis of with repetitive sleep terrors and sleepwalking, to com- an additional sleep disorder: 49 with sleep-disordered pare them with a control group, and to evaluate the breathing (SDB) and 2 with restless leg syndrome (RLS). treatment of associated sleep disorders. Twenty-nine of the children with both parasomnia and Methods. Patients with complaint of sleep terrors SDB had a positive family history of parasomnias, and 24 with or without sleepwalking were studied retrospec- of the 29 also had a positive family history of SDB. Of the tively. A control group was also recruited. Each subject 51 children with associated sleep disorders, 45 were received a standardized evaluation, which included the treated. Forty-three of 49 children with SDB were treated following: 1) Pediatric Sleep Questionnaire; 2) interview with tonsillectomy, adenoidectomy, and/or turbinate re- regarding child’s medical and sociofamilial history, orth- vision, and 2 of 2 children with RLS were treated with odontic history, schooling, psychological difficulties, Pramipexole, a dopamine agonist, at bedtime. Treatment medication intake, and family history of medical and of the precipitating sleep disorder eliminated parasom- sleep disorders; 3) general pediatric physical examination nias in all 45 children. In all 43 children who received and neurologic, otolaryngological, and craniofacial exam- surgery, polysomnography performed 3 to 4 months later ination by a specialist; 4) obtaining medical history on indicated the disappearance of SDB. The recordings also variables relevant to early life sleep disorders; 5) poly- showed an absence of confusional arousals. The number somnography, which included electroencephalogram of EEG arousals significantly decreased from a mean of EEG; C3/A2, Fp1/T1, T1/O1, O1/C3, C4/A1, Fp2/T2, T2/ 9 ؎ 2.6 EEG arousals >3 seconds/hour during total sleep) O2, O2/C4), chin and leg electromyelogram, right and left time to 3 ؎ 1.5. The number of EEG arousals >3 seconds electro-oculogram, and electrocardiogram (modified V2 during the first sleep cycle of slow wave sleep (stage 3–4 lead); respiration was monitored with a nasal cannula/ non–rapid eye movement sleep) decreased from 4 ؎ 1.4 to -pressure transducer system, mouth thermistor, chest and 1 ؎ 0.2. In all surgically treated cases, parents also re abdominal bands, pulse oximeter, and neck microphone; ported subsequent absence of the parasomnia. The 2 respiratory effort was monitored with calibrated esoph- symptomatic children who were treated with ageal manometry; variables were collected on a comput- Pramipexole had a complete absence of confusional erized sleep system; and 6) available family members arousals on the follow-up recording and reported no with a positive history of sleep terrors and sleepwalking parasomnia since treatment. The periodic limb move- received clinical evaluations similar to those used for ment syndrome arousal index (number of EEG arousals index cases; they also underwent ambulatory monitoring associated with periodic limb movement/hour) decreased with an Edentrace system, which monitors heart rate, from 11 and 16 to 0 and 0.2, respectively. Parasomnia body position, oro-nasal flow, chest impedance, breath- persisted in the 6 children who were untreated for SDB. ing noises (neck microphone), and pulse oximetry. Move- Surgeons had refused to perform surgery on these chil- ments are deduced from artifact, and leg movements may dren because of lack of data on the relationship between be recorded on one channel if the equipment is preset for parasomnia and SDB-related tonsil and adenoid enlarge- such recording. Subjects used logs to record “lights out” ment. time, “lights on” time, nocturnal awakenings, and other Conclusion. Children with chronic parasomnias may events that occurred during the night. All original and often also present SDB or, to a lesser extent, RLS. Fur- follow-up recordings were rescored by 2 of 4 randomly selected specialists who were blind to subject identity. thermore, the disappearance of the parasomnias after the Mann-Whitney U test was used for group comparison. treatment of the SDB or RLS periodic limb movement Nonparametric ␹2 test was used to compare percentages syndrome suggests that the latter may trigger the former. of symptoms in symptomatic children versus control The high frequency of SDB in family members of chil- children. dren with parasomnia provided additional evidence that Results. Eighty-four children (5 with sleep terrors SDB may manifest as parasomnias in children. Children and 79 with both sleep terrors and sleepwalking) and 36 with parasomnias are not systematically monitored dur- normal control children formed the studied population. ing sleep, although past studies have suggested that pa- All subjects were Tanner stage 1 (prepubertal). None of tients with sleep terrors or sleepwalking have an ele- vated level of brief EEG arousals. When children receive polysomnographies, discrete patterns (eg, nasal flow lim- itation, abnormal respiratory effort, bursts of high ␪ or From the Stanford University Sleep Disorders Clinic, Stanford, California. slow ␣ EEG frequencies) should be sought; apneas are Received for publication Jun 17, 2002; accepted Sep 11, 2002. Reprint requests to (C.G.) Stanford University Sleep Disorders Clinic, 401 rarely found in children. Children’s respiration during Quarry Rd, Ste 3301, Stanford, CA 94305. E-mail: [email protected] sleep should be monitored with nasal cannula/pressure PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- transducer system and/or esophageal manometry, which emy of Pediatrics. are more sensitive than the thermistors or thermocouples http://www.pediatrics.org/cgi/content/full/111/1/Downloaded from www.aappublications.org/newse17 by guestPEDIATRICS on September Vol. 25, 2021 111 No. 1 January 2003 e17 currently used in many laboratories. The clear, prompt identified a cause for frequent arousals or decreased improvement of severe parasomnia in children who are ⌬ EEG power in the first sleep cycle. treated for SDB, as defined here, provides important To explore what might precipitate sleep terrors evidence that subtle SDB can have substantial health- and sleepwalking in children, we performed a retro- related significance. Also noteworthy is the report of spective analysis of clinical and polysomnographic familial presence of parasomnia. Studies of twin cohorts data from 84 prepubertal children, aged 2 and 11 and families with sleep terror and sleepwalking suggest genetic involvement of parasomnias. RLS and SDB have years, who were referred for these behavioral prob- been shown to have familial recurrence. RLS has been lems during sleep. We compared their findings with shown to have genetic involvement. It remains to be those of 36 normal children who were recruited from investigated whether a genetic factor directly influences the community. sleep terror and sleepwalking or instead influences other disorders that fragment sleep and lead to confusional METHODS arousals. Additional studies are needed to investigate the Subject Recruitment association between SDB and non–rapid eye movement All parents of the children who were seen and monitored in the parasomnias in the general population. Pediatrics sleep clinic were asked to sign a consent form approved by the 2003;111:e17–e25. URL: http://www.pediatrics.org/cgi/ institution for use of clinical data and polysomnographic record- content/full/111/1/e17; sleepwalking, sleep terrors, sleep ings for research purposes. Parents of community children also disordered breathing, restless leg syndrome, periodic limb signed an informed consent to participate in this research. movement syndrome, familial aggregation, prepubertal. Inclusion Criteria Eighty-four children (39 girls) met the following inclusion cri- ABBREVIATIONS. NREM, non–rapid eye movement; SWS, slow teria: 1) diagnosis of sleep terrors or sleepwalking; 2) availability wave sleep; EEG, electroencephalogram; SDB, sleep-disordered of complete chart and nocturnal polysomnographic data from a breathing; RLS, restless leg syndrome; AHI, apnea-hypopnea in- minimum of 8.5 hours of recording; 3) sleep study performed dex; RDI, respiratory disturbance index; PLMS, periodic limb within the past 4 years; 4) clinical follow-up obtained for at least movement syndrome. 12 months, and 5) if treated, follow-up nocturnal polysomnogra- phy had been obtained, at a mean of 3 months after treatment. All children who were seen consecutively and met the above criteria leep terrors and sleepwalking, 2 common child- were included. hood parasomnias, are arousal disorders that Thirty-six prepubertal children (19 girls) with parental report of arise from deep non–rapid eye movement at least 8.5 hours of nightly sleep, absence of known daytime S 1,2 consequences of sleep disorders (eg, daytime sleepiness, cata- (NREM) sleep. In a landmark study, Klackenberg Ͼ plexy, hyperactivity, morning headache, mouth breathing), and followed for 20 years 200 children who were born normal health as reported by physicians over systematic visits in Stockholm and documented these parasomnias were
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