Brief nocturnal arousals are normal in children. They occur typically in stage 4 non-REM sleep, 1 to 2 hours after sleep onset. They vary from normal events such as mumbling, chewing, sitting up, and staring to arousals that can be thought of as abnormal because of the disruption they cause the family. These include calm and agitated sleepwalking, and a spectrum from confusional arousals to night terrors or pavor nocturnus. The child may exhibit automatic behavior, but the events are not truly stereotyped. The affected children may be very agitated and look frightened, as if they do not recognize their parents. They are in an intermediate stage between waking and sleep, so they may respond, but not normally. They look awake and may be partially responsive but in fact are still in deep slow-wave sleep (stage 4). These events typically only occur once a night, especially 1 or 2 hours after falling asleep and nearly always in the first half of sleep. Children have no memory for them. Often they are very prolonged. Typically the events last 10 to 15 minutes before the child either wakes, or settles back to restful sleep.
By contrast, nocturnal frontal lobe epileptic seizures typically last less than 2 minutes and often occur in clusters. The distinction between NREM arousal disorders and benign partial epilepsy with affective symptoms (BPEAS), (91) and a variety of idiopathic focal epilepsies like benign Rolandic epilepsy, can be more difficult. Children arouse and look similarly wild and combative. However, the epileptic seizures are, brief, may occur while awake, in sleep do not arise particularly from stage 4 sleep, and are more likely to occur towards the end of sleep, in the early morning.
NREM arousal disorders likely represent a disordered balance between the drive to wake and the drive to sleep. They are more common in toddlers who sleep very deeply, in children who are overtired because of insufficient sleep, and in those who are unwell or on certain medications. An increased drive to wake occurs if the child has an irregular sleep schedule, is unwell, or needs environmental associations to fall asleep normally. These disorders are therefore primarily managed by reassurance, explanation, and behavioral means to establish stable sleep routines and ensure good sleep hygiene. Home videotape recording is invaluable, particularly if the camera can be left running to capture the onset of the event. It is generally true that home videotape of nocturnal events is more likely to be successful if they are nocturnal frontal lobe seizures rather than partial arousals due to the relative frequency and clustering of epileptic events.
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