Thursday, February 22, 2024


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 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


Congenital hypoventilation syndrome


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:


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.


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.

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