Sleep Disorder: Nightmares

Pediatrics: Developmental and Behavioral > Medical Topics

Author: Kevin P Connelly, DO, Clinical Assistant Professor, Department of Pediatrics, Division of General Pediatrics and Emergency Care, Virginia Commonwealth University; Medical Director, Paws for Health Pet Visitation Program
Updated: Feb 25, 2008

Introduction
Background
Sleep disorders occur in 35-45% of children aged 2-18 years. Nightmares are frightening events for a child and may cause the entire family distress; however, they are sporadic in most children. Nightmare disorder is characterized by repeated episodes of a frightening or unpleasant dream that disrupts the child's sleep. The child's reaction often interrupts the parents' sleep. Upon awakening from a nightmare, the child is alert and aware of the present surroundings, but the sleep disturbance causes distress and impairment in everyday functioning.

Nightmares are often confused with the parasomnia known as night terrors, which are episodes of extreme panic and confusion associated with vocalization, movement, and autonomic discharge. Children with night terrors are difficult to arouse and console and do not remember a dream or nightmare.

Pathophysiology
Sleep is divided into 2 distinct states: rapid eye movement (REM) and nonrapid eye movement (non-REM).
REM and non-REM sleep alternate in 90- to 100-minute cycles.
In older children and adults, 75% of sleep is non-REM sleep, which consists of 4 stages. Most dreaming occurs during REM sleep.
REM sleep is characterized by EEG activity similar to a wakeful pattern.

Frequency
United States
Prevalence varies because of different diagnostic criteria and different study populations. Some studies estimate as many as 50% of children aged 3-6 years have nightmares that disturb both their sleep and the parents' sleep.

Race
Nightmares occur in all races and cultures.

Sex
Both sexes are equally affected.

Age
Peak incidence occurs in children aged 3-6 years.1,2
Clinical
History
•Sporadic nightmares are common in children and usually occur in the middle of the night or early morning, when REM sleep is more common.
•The dream typically involves some danger or threat to the child.
◦The child may dream about physical danger (eg, being chased).
◦A nightmare may also involve psychological threat (eg, being teased).
◦Nightmares may involve a monster, ghost, fierce animal, or bad individual.
◦Loss of control and fear of injury are common themes.
•Vocalizations, movement, and autonomic symptoms are minimal.
•When awakened, the child becomes oriented, can be calmed, and usually recalls the details of the dream.
Physical
•Nightmares are not associated with specific physical findings.
•Heart rate and respiratory rate may increase or show increased variability before the child awakens from a nightmare. Mild autonomic arousal, including tachycardia, tachypnea, and sweating, may occur transiently upon awakening.
Causes
•Developmental, genetic, psychological, and organic factors can contribute to occurrence.
•Approximately 7% of individuals who have frequent nightmares have family history of nightmares.
•Nightmares are more common in children with mental retardation, depression, and CNS diseases; an association has also been reported with febrile illnesses.
•Medications may induce frightening dreams, either during treatment or following withdrawal. Withdrawal of medications that suppress REM sleep can lead to an REM rebound effect that is accompanied by nightmares.
•Daytime emotional conflicts and psychological stress often contaminate sleep and predispose the child to nightmares.
•Nightmares may result from a severe traumatic event and may indicate posttraumatic stress disorder

Treatment
Medical Care
•Reassurance
◦Reassurance is the only treatment required for sporadic nightmares. Although all stressors cannot be removed from a child's life, parents can attempt to make bedtime a safe and comfortable time.
◦Encourage parents to spend time reading, relaxing, and talking with the child.
◦If the child has a recurring nightmare, instructing parents to encourage the child to imagine a good ending may help.
Consultations
Psychological evaluation is indicated for patients whose nightmares occur more than twice a week over a period of several months.

Medication
Medications are neither helpful nor indicated.