Can clonidine be given to children with night terrors?

Clonidine for Children with Night Terrors

Clonidine can be used for children with night terrors, particularly when first-line non-pharmacological approaches have failed, though it is considered an off-label use with limited evidence compared to other treatment options. 1

Treatment Algorithm for Night Terrors in Children

First-Line Approach (Non-Pharmacological)

1. Implement good sleep hygiene practices:

   • Maintain regular sleep-wake schedule
   • Create a calm sleeping environment
   • Avoid heavy meals before bedtime
   • Limit screen time before sleep

2. Try anticipatory awakening:

   • Wake the child approximately 30 minutes before the typical night terror episode
   • This technique is often effective for frequently occurring sleep terrors 2

Second-Line Approach (Pharmacological)

If non-pharmacological approaches fail after 4-6 weeks:

1. Consider clonidine:

   • Initial dose: 0.1 mg at bedtime for children ≥12 years 3
   • Titrate slowly if needed
   • Maximum dose: Generally not exceeding 0.3 mg/day in children 3

2. Alternative medications (if clonidine is ineffective or contraindicated):

   • Benzodiazepines (short-term use only): Clonazepam may be considered for severe cases 2
   • Prazosin: Starting at 1 mg daily with careful blood pressure monitoring 1

Evidence for Clonidine in Night Terrors

Clonidine is a central α-agonist that has sedative effects and is commonly used off-label in children. The evidence supporting its use specifically for night terrors includes:

• It has been used for management of agitated patients including children, with somnolence being a significant effect 3
• Studies show it can be effective for PTSD-related nightmares in pediatric patients with a quick onset of action (average 1.59 ± 1.06 days) 4
• It has shown benefit for sleep onset difficulties in children with intellectual disability 5

Important Considerations and Monitoring

• Safety warning: The FDA label notes that safety and effectiveness in pediatric patients have not been established in adequate and well-controlled trials 6

• Blood pressure monitoring: Regular monitoring is essential as clonidine can cause hypotension

• Potential side effects:

  • Sedation/drowsiness (most common)
  • Dry mouth
  • Dizziness
  • Hypotension

• Important caution: Sudden discontinuation can lead to severe rebound hypertension 3

Dosing Considerations

• Start with the lowest effective dose (typically 0.1 mg at bedtime)
• Titrate slowly based on response and side effects
• For children <12 years, dosing should be even more conservative (though specific guidelines are limited)
• The medication is typically given at night due to its sedative effects 3

Clinical Pearls and Pitfalls

• Reassurance is key: Most children outgrow night terrors by late adolescence 2
• Avoid interrupting episodes: Attempts to wake or console during a night terror may prolong or worsen the episode 2
• Medication errors risk: Compounding and liquid dosing errors are common with clonidine in children and can result in overdose 7
• Overdose symptoms: Include poor responsiveness alternating with agitation, small pupils, dry mouth, and CNS depression 7
• Withdrawal risk: Never abruptly discontinue clonidine as this can cause rebound hypertension 3

Most children with night terrors will outgrow them without requiring pharmacological intervention. Medication should be reserved for cases where sleep disruption is severe, frequent, and causing significant distress or daytime impairment.