A 5-year-old girl is brought to the office for evaluation of night awakenings. The patient has awakened screaming 1 or 2 times a month over the past few months shortly after going to sleep. When her parents go to her room during these episodes, she is short of breath, crying, and sweating, and her face is flushed. The patient appears frightened, does not respond to her parents' attempts at comforting her, and continues to cry. She eventually goes back to sleep on her own and does not recall the incident the next morning. Until starting kindergarten 2 months ago, the patient stayed at home with her mother, and she no longer takes a nap during the day. Although the patient reports that she is happy and enjoys making friends, her mother wonders if she is having nightmares due to underlying anxiety about starting school. Developmental milestones are normal. Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 96/min, and respirations are 20/min. A complete physical examination is unremarkable. Which of the following is the best next step in management of this patient?

Question

A 5-year-old girl is brought to the office for evaluation of night awakenings.  The patient has awakened screaming 1 or 2 times a month over the past few months shortly after going to sleep.  When her parents go to her room during these episodes, she is short of breath, crying, and sweating, and her face is flushed.  The patient appears frightened, does not respond to her parents' attempts at comforting her, and continues to cry.  She eventually goes back to sleep on her own and does not recall the incident the next morning.  Until starting kindergarten 2 months ago, the patient stayed at home with her mother, and she no longer takes a nap during the day.  Although the patient reports that she is happy and enjoys making friends, her mother wonders if she is having nightmares due to underlying anxiety about starting school.  Developmental milestones are normal.  Temperature is 36.7 C (98 F), blood pressure is 100/60 mm Hg, pulse is 96/min, and respirations are 20/min.  A complete physical examination is unremarkable.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d7df_1179_bc81_7dd2fa1953a1_MD0003_00 This child's awakenings are suggestive of sleep terrors, a type of parasomnia that occurs during nonrapid eye movement (NREM) sleep, characterized by episodes of screaming and/or crying during which the child is inconsolable and cannot be fully awakened. A flushed face, sweating, and tachycardia are common. These episodes usually last a few minutes before the child settles back down to sleep. The child usually has no memory of the incident. Sleep terrors are most commonly seen in children age 2-12, with a peak incidence at age 5-7. In healthy children with a classic presentation, the diagnosis is clinical and no further workup is required. Parents should be reassured that sleep terrors are not dangerous and usually resolve spontaneously within 1- 2 years. (Choice A) Cognitive-behavioral therapy is not indicated for sleep terrors but can be helpful in the treatment of anxiety with related nightmares. In contrast to sleep terrors, nightmares usually occur in the latter half of sleep when REM occurs and are associated with complete awakening and dream recall. (Choice B) Although sleep deprivation can trigger sleep terrors, there is no evidence that this child is getting inadequate sleep (eg, moodiness, behavioral change, daytime sleepiness). As children grow, the necessity for daytime naps usually decreases. (Choices C and H) Desmopressin and imipramine are used in the treatment of nocturnal enuresis, not parasomnias. (Choice D) This patient's episodes are infrequent and do not result in functional impairment. If episodes are frequent or interfere with daytime functioning, a low-dose benzodiazepine can be considered. (Choice E) If another sleep disorder such as sleep apnea or restless leg syndrome is suspected, a polysomnogram (PSG) should be performed. Other indications for PSG include episodes with accompanying neurological symptoms (eg, stereotypies, staring spells), suggesting a seizure disorder. (Choice G) If restless leg syndrome is suspected, serum ferritin levels should be measured as iron deficiency can exacerbate symptoms. Educational objective: Sleep terrors are a common and usually benign parasomnia of childhood. They occur during non-REM sleep and are characterized by fear, crying and/or screaming, and amnesia of the event. The diagnosis is made clinically. Parents should be reassured that episodes are self-limited and typically resolve within 1-2 years. References: Just a scary dream? A brief review of sleep terrors, nightmares, and rapid eye movement sleep behavior disorder. (http://www.ncbi.nlm.nih.gov/pubmed/24126984) Sleep terrors and sleepwalking: common parasomnias of childhood. (http://www.ncbi.nlm.nih.gov/pubmed/26147057)

A 5-Year-Old Girl Is Brought to the Office for Evaluation