1. Parasomnias in children M Maldonado MD

2. Classification During REM sleep During REM sleep During Non-REM sleep During Non-REM sleep Mixed. Not to a particular state Mixed. Not to a particular state Secondary Secondary

3. Parasomnias. Clinical Tend to occur in the transitions between the three states of the brain: Tend to occur in the transitions between the three states of the brain: Wakefulness- non-REM sleep-REM sleep Wakefulness- non-REM sleep-REM sleep Surprising no more parasomnias, given so many transitions Surprising no more parasomnias, given so many transitions

4. Parasomnias/transitions Transition between REM Sleep and wakefulness : Transition between REM Sleep and wakefulness : -Sleep paralysis -Lucid Dreams -Hypnagogic hallucinations

5. Parasomnias, transitions Between NON-REM-Sleep and wakefulness: Between NON-REM-Sleep and wakefulness: Confusional awakening Confusional awakening Somnambulism Somnambulism Sleep terrors (Pavor nocturnus) Sleep terrors (Pavor nocturnus)

6. Other parasomnias Within sleep itself ( Non REM to REM) Within sleep itself ( Non REM to REM) Nightmares or Anxiety dreams Nightmares or Anxiety dreams -Behavioral disturbance during REM sleep -Hypnotic fright OTHERS. Bruxism, somniloquism, enuresis, restless leg

7. Other disturbances during sleep CNS problems. Cephalgia (Headache), Seizures CNS problems. Cephalgia (Headache), Seizures Cardiopulmonary problems: Cardiopulmonary problems: Arrhythmia during sleep. Hiccups during sleep. Angor pectoris. Respiratory dyskinesis Arrhythmia during sleep. Hiccups during sleep. Angor pectoris. Respiratory dyskinesis Gastrointestinal Problems. Gastrointestinal Problems. Gastroesophageal reflux. Spasm of esophagus Gastroesophageal reflux. Spasm of esophagus

8. Mixed disturbances/parasomnias Panic attacks during sleep Panic attacks during sleep Dissociative states that occur during sleep Dissociative states that occur during sleep Nocturnal leg cramps Nocturnal leg cramps Malingering during sleep (eg. pretend one is sleep waking) Malingering during sleep (eg. pretend one is sleep waking) Night eating syndrome Night eating syndrome

9. Nightmares Anxiety dream, vivid recollection, perception as if reality Anxiety dream, vivid recollection, perception as if reality Association with autonomous nervous changes Association with autonomous nervous changes Child regains consciousness fully after the nightmare Child regains consciousness fully after the nightmare Recollection the next day Recollection the next day Fear of another nightmare Fear of another nightmare May occur during later part of the night May occur during later part of the night

10. Awaking disorders Lack of response to environmental cues during the episode Lack of response to environmental cues during the episode Automatisms, automatic behaviors during the episode Automatisms, automatic behaviors during the episode Some degree of amnesia about the episode Some degree of amnesia about the episode

11. Confusional awakening Tends to occur during the first part of the night (first 1-3 hs) Tends to occur during the first part of the night (first 1-3 hs) At the end of the first cycle of sleep At the end of the first cycle of sleep When sleep goes from deeper to more superficial sleep When sleep goes from deeper to more superficial sleep Child may cry, gibber, attempt to move in uncoordinated way, not really awake Child may cry, gibber, attempt to move in uncoordinated way, not really awake

12. Sleep terrors Initiated with a scream Initiated with a scream Child appears frightened Child appears frightened May move as if to get away, get something off, or say things May move as if to get away, get something off, or say things Not awake Not awake Not remember next day Not remember next day May last several minutes, up to 5-10 May last several minutes, up to 5-10 During the first part of the night During the first part of the night

13. Pavor nocturnus (sleep terror) Frequent cause of consultation and concern for parents Frequent cause of consultation and concern for parents Some children have more than one episode per night and they can be quite frequent Some children have more than one episode per night and they can be quite frequent Cause major disturbance to the possibility of rest and of the child waking up “refreshed” Cause major disturbance to the possibility of rest and of the child waking up “refreshed”

14. Sleep terror. Causes Genetic vulnerability and transmission Genetic vulnerability and transmission Association with anxiety symptoms and preoccupations (Laberge et al, 2005) Association with anxiety symptoms and preoccupations (Laberge et al, 2005) Possible association with traumatic experiences in some children? Possible association with traumatic experiences in some children?

15. Awakening disorders, intervention Diminish sleep deprivation, deprivation predisposes to episodes Diminish sleep deprivation, deprivation predisposes to episodes Diminish the amount of stress Diminish the amount of stress Pre-emptive awakening during the first sleep cycle Pre-emptive awakening during the first sleep cycle Medications? For severe cases Medications? For severe cases

16. Medications. Sleep terror Melatonin described as possibly useful Melatonin described as possibly useful L Trytophane L Trytophane Tricyclic antidepressants (e.g. amitriptyline or imipramine) Tricyclic antidepressants (e.g. amitriptyline or imipramine)