Practice Essentials
A common parasomnia, non−rapid eye movement (NREM) sleep arousal disorder, is described as being characterized by either somnambulism (ie, sleepwalking) or sleep terrors. The following describes NREM sleep arousal disorder, sleepwalking type.
Signs and symptoms
The history should address the following:
Detailed description of the event
level of consciousness before, during, and after the event
Time of night and sleep cycle when the events occur
Daytime sleepiness
Associated injury
Memory of the event
Family history
Any precipitating factors
Current Medications, if any
Reported symptoms may include the following:
Episodes ranging from quiet walking about the room to agitated running
Attempts to “escape” dangerous situations or terrifying threats
Eyes that are open and have a glassy, staring appearance
Slow or absent responses to questioning
In the absence of awakening, inability to remember the event; with awakening possible embarrassment (in older children)
Sleepwalking should be differentiated from the following conditions:
Confusional arousals
Sleep terrors
Physical and neurologic examinations are typically normal in sleepwalking children.
See Presentation for more detail.
Diagnosis
Diagnosis of sleepwalking should take into account miscellaneous sleep disorders, NREM parasomnias, and rapid eye movement (REM)–related parasomnias. Relevant miscellaneous sleep disorders include the following:
Benign neonatal sleep myoclonus
Bruxism
Congenital hypoventilation syndrome
Enuresis
Infant sleep apnea
Nocturnal paroxysmal dystonia
Periodic limb movements
Rhythmic movement
Somniloquy (sleep talking)
Normal NREM parasomnias are characterized by the following:
Hypnagogic or hypnopompic imagery
Sleep starts or hypnic jerks
REM-related parasomnias are much less common in children than in adults.
Other problems to be considered include the following:
Arrhythmias
Dissociative states
Dream anxiety attacks
Epilepsy in children
Gastroesophageal reflux
Nocturnal asthma
Tonic seizures
Principles of workup include the following:
No specific laboratory studies are indicated in the workup of routine parasomnias
No imaging studies are required
Polysomnography (PSG), with or without multiple sleep latency testing, is reserved for the few cases in which the diagnosis is still unclear after the history and physical examination
Electroencephalography (EEG) may be helpful; microarousals and sleep state disorganization are often noted on EEG done during nocturnal sleep
See DDx andWorkup for more detail.
Management
General management principles include the following:
Reassurance is the mainstay of treatment as sleepwalking is a benign condition
Any environmental or predisposing factors should be identified and eliminated
Auditory, tactile, and visual stimuli should be avoided early in the sleep cycle
Parents should be instructed to lock windows and doors, remove obstacles and sharp objects from the room, and add alarms (if necessary)
Comforting the child and gently redirecting him or her to bed may be appropriate; attempts to confront or awaken the patient during the events may be inadvisable
Pharmacologic therapy typically is not indicated
Sleepwalking associated with sleep-disordered breathing may improve or resolve with surgical treatment of the respiratory disorder
For long-term management, relaxation techniques, mental imagery, and anticipatory awakenings are preferred
See Treatment for more detail.