What is the best approach for managing night terrors in children?

Management of Night Terrors in Children

Educational and behavioral interventions should be the first-line approach for managing night terrors in children, with emphasis on establishing good sleep hygiene and implementing scheduled awakenings when appropriate. 1

Understanding Night Terrors

Night terrors are common parasomnia events that typically occur in children between 4-12 years of age (peak 5-7 years), affecting approximately 1-6.5% of children. They occur during the first third of the night during arousal from deep non-REM sleep and are characterized by:

• Sudden awakening with screaming or crying
• Intense fear and autonomic arousal (tachycardia, tachypnea, diaphoresis)
• Confusion and incoherence
• Difficulty consoling the child
• Amnesia for the event the next morning 2

Management Algorithm

1. Parent Education and Reassurance

• Explain the benign and self-limiting nature of night terrors
• Emphasize that most children outgrow night terrors by adolescence
• Advise against attempting to wake the child during an episode as this may increase confusion 2

2. Establish Good Sleep Hygiene

• Maintain consistent bedtime routines
• Ensure adequate sleep duration to prevent sleep deprivation
• Create a comfortable and safe sleeping environment
• Reduce stimulating activities before bedtime 1, 2

3. Scheduled Awakenings

• For frequent or severe night terrors, implement anticipatory awakening
• Wake the child approximately 15-30 minutes before the typical time of night terror occurrence
• Keep the child fully awake for 5 minutes before allowing them to return to sleep
• Continue for 1-4 weeks until episodes resolve 2

4. Environmental Modifications

• Consider co-sleeping for children over 1 year of age, as evolutionary perspectives suggest this may help prevent night terrors 3
• For younger children, room-sharing may be appropriate to allow quick response to episodes

5. Behavioral Interventions

• For children with associated nighttime fears:
  • The Huggy-Puppy intervention (providing a stuffed animal with instructions for the child to care for it) has shown effectiveness in reducing nighttime fears 4
  • Implement relaxation techniques before bedtime 1

6. Pharmacological Intervention

• Medication should be considered only when night terrors are:
  • Frequent and severe
  • Associated with significant functional impairment
  • Not responsive to behavioral interventions
• Clonazepam may be considered on a short-term basis in these cases 2

Special Considerations

• Rule out medical contributors: Sleep-disordered breathing, restless legs syndrome, and certain medications can trigger or worsen night terrors 1
• Address psychological factors: Anxiety, stress, or traumatic experiences may contribute to night terrors in some children 2
• Safety measures: For children who attempt to leave the bed during episodes, ensure the bedroom environment is safe and consider gates at doorways or stairs

Follow-up

• Reassess after 2-4 weeks of intervention
• If night terrors persist or worsen despite appropriate management, consider referral to a pediatric sleep specialist to rule out other sleep disorders

Pitfalls to Avoid

• Attempting to wake or restrain the child during an episode
• Using sedating medications as first-line treatment
• Dismissing parental concerns without providing education and support
• Failing to address sleep deprivation as a potential trigger
• Overlooking potential medical causes of sleep disruption

Night terrors, while frightening for parents, are generally benign and self-limiting. With proper education, sleep hygiene, and targeted interventions like scheduled awakenings, most cases can be effectively managed without medication.