Parasomnias are unusual things that happen at night
like screaming, peeing, talking, and walking.
Alex is an 8 yo boy presenting with recurrent severe “night terrors” for the last 2 years. He is still bedwetting at night and was diagnosed with ADHD last year but is not responding to medications. Parents report that his night terrors happen at “any time of the night” and often occur multiple times during the night. The first night terror can occur as soon as 30 minutes after going to sleep. They often hear him “kicking the wall” even in the early morning around 3-4 am. Patient does not recall any of the events in the morning. The parents usually don’t observe the events at night because he just calls out or screams.
They are not sure if he is tired during the day but he is very difficult to wake up during the morning. He does not snore. Some mornings they actually find him sleeping on the floor of his bedroom so they wonder if he has fallen out of bed. He does not sleepwalk.
Because the events have been persistent in combination with the ongoing bedwetting, they sought evaluation.
What are the concerning components of Alex’s sleep history that are unusual for “night terrors”?
Check all that apply:
The concerning components that are unusual for Alex's case are:
When evaluating possible NREM parasomnias like night terrors or sleepwalking, it is important to distinguish these from seizures. Red flags of possible nocturnal seizures include:
| Characteristics | Sleepwalking/night terrors/confusional arousals | Nightmares | Nocturnal Seizures |
|---|---|---|---|
|
Timing During Night |
First Thrid |
Last thrid |
Variable - often at sleep wake transitions - i.e., soon after falling asleep or waking up in the AM |
|
Sleep Stage |
Slow wave sleep |
REM |
NREM>Wake>REM |
|
Daytime Sleepiness |
None |
+/– |
Often |
|
Increased by Insufficient Sleep |
Yes |
Sometimes |
+/– often |
|
Incontinence, tongue-biting, drooling, stereotypic, repetitive behavior |
No |
No |
Yes |
|
Recall of event |
None or fragmentary |
Vivid |
Not usual |
|
Multiple Episodes per Night |
Rare |
Occasional |
More common |
|
Family History |
Common |
Rare |
Variable |
|
Polysomnography |
Indicated if atypical features |
Not indicated |
Indicated if atypical features; requires extended EEG montage; consider overnight EEG |
Adapted from Mindell and Owens, Clinical guide to pediatric sleep, p. 108
What evaluation & diagnostic protocol should the medical provider use to diagnose Chris’s nighttime behaviors?
Check all that apply:
The evaluation protocol strategies we recommend for Alex's case are:
From this patient’s brief sleep history, the overall impression is that there is more going on than typical night terrors. Concern should be raised when patients or caregivers are noticing multiple night terrors at night that are occurring in the context of frequent bedwetting, falling out of bed, daytime symptoms of sleepiness and ADHD, and events that happen right after falling asleep as well as in the early morning (3-4am). The pattern of screaming or thrashing right after falling asleep or in the early morning is concerning of nocturnal seizures and is in need of further evaluation.
For physical exam: Because this patient’s sleep history is concerning for possible seizures, a thorough physical exam is needed in particular concentrating on a neurologic exam. Additionally, bedwetting that is not improving with medication also requires a more thorough physical exam.
Other tests that should be considered is a sleep deprived or overnight EEG for evaluation of nocturnal seizures. In this case, either a sleep study or an overnight EEG may be sufficient for evaluation. If there is greater concern of nocturnal seizures, a sleep deprived EEG is a more specific test to order. However, if the clinician has difficulty determining if this is night terrors or seizures, then a sleep study is recommended. However, a sleep study done with an expanded EEG would be preferred.
Referral to a specialist is indicated in this case. Ideally, a pediatric neurologist would be consulted related to the irregular nighttime episodes that are not typical for night terrors. Although bedwetting is occurring, Pediatric Urology is not primarily indicated in this case until seizures are ruled out. It is likely that the bedwetting or enuretic events are occurring due to seizures.
Good news!
This case was an example of a primary diagnosis that was NOT a parasomnia although night terrors and bedwetting were components of the history.
Nocturnal frontal lobe epilepsy occurs primarily at night. The seizures are often short and can last only seconds to minutes occurring out of NREM sleep. The seizures can be loud vocalizations, dystonic movements, sudden thrashing, pedaling or kicking of the lower extremities. Typically the movements are stereotyped in nature. There may be no post-ictal phase accompanying the seizures. Age of onset can be between 5 to 7 years of age and there often is a family history of epilepsy. The EEG may appear normal and thus careful review of the video is important to determine stereotyped appearance of the events. In addition, children with nocturnal frontal lobe epilepsy have a higher proportion of NREM parasomnias such as night terrors or sleepwalking which can further complicate the diagnosis. Thus, it is important to investigate for other primary sleep disorders such as night terrors or obstructive sleep apnea when evaluating and managing these patients.
Triggers: