Sleepwalking in Children

Sleepwalking is a non-rapid eye movement parasomnia in which the child rises from deep sleep and performs complex motor behaviours without full awareness.

• It affects up to 15 to 17 percent of children, peaking at age 8 to 12 years, with onset after 3 years.
• Episodes arise from slow-wave sleep, typically in the first third of the night, lasting 1 to 30 minutes.
• Family history is common (a child has a 45 percent chance if one parent sleepwalked, more if both).
• Triggers include sleep deprivation, fever, irregular sleep schedules, stress, full bladder, sleep-disordered breathing, restless legs, noise and some medications.
• Most children outgrow it by adolescence.

Episodes are stereotyped and amnesic.

• Child sits up or gets out of bed and walks about, with eyes open and a blank, glassy look.
• Poor response to speech, confusion if woken, and no memory of the event the next day.
• May perform simple tasks (dressing, opening doors, going to the toilet or kitchen).
• Possible injury from falls, collisions, or leaving the house.
• Often co-occurs with night terrors or confusional arousals.
• Differential diagnosis: nocturnal seizures (frontal lobe epilepsy), REM sleep behaviour disorder, night terrors, confusional arousals, nightmares, obstructive sleep apnoea, psychiatric dissociation and drug effects.
• Complications: injury, sleep disruption for the family, daytime sleepiness, embarrassment and anxiety.

Diagnosis is clinical, from the history.

• Detailed sleep history with an eyewitness account: timing, duration, behaviour, recall, triggers.
• Examination, including growth, tonsil size, neurological exam.
• Overnight polysomnography with video-electroencephalography when episodes are frequent, violent, occur later in the night, are stereotyped and repetitive (suggesting seizure), or associated with suspected sleep apnoea.
• Investigate sleep-disordered breathing (snoring, apnoeas) and iron deficiency if restless legs are suspected.

Safety and sleep hygiene are first-line.

• Supportive: keep a regular sleep schedule with enough sleep (children aged 6 to 12 years need 9 to 12 hours), avoid sleep deprivation, caffeine, and stimulating activity at night, and empty the bladder before bed.
• Make the bedroom safe: lock doors and windows, put alarms or bells on bedroom doors, remove sharp objects, keep the child on the ground floor if possible, and use gates on stairs.
• Do not wake the child; gently guide them back to bed.
• Scheduled awakening: if episodes occur at about the same time each night, wake the child 15 to 30 minutes before that time for 1 month.
• Treat precipitants: obstructive sleep apnoea (adenotonsillectomy), restless legs (iron if ferritin low), reflux and pain.
• Pharmacological: rarely needed. For dangerous or frequent episodes, clonazepam 0.25 mg at bedtime (children over 6 years) for a short course under specialist care, or melatonin 3 to 5 mg at bedtime.
• Special groups: children with injuries or leaving the house need prompt safety measures and specialist assessment.
• Red flags: injury, violent behaviour, episodes in the second half of the night, daytime events, stereotyped repeated movements (possible seizures), and onset after puberty.
• Follow-up: review in 4 to 8 weeks. Refer to a sleep or neurology specialist if atypical or persisting beyond adolescence.