Nightmares in Children

Standing outside a house that has seen too many years you wonder how you got here. Soil baked dry by a hundred summer suns tickles over your toes as you look down. No shoes! Why don’t you have any shoes on? The brown dirt crumbles between your toes as you take a single step forward, away from the decaying house.

A noise. The chitter-chatter of a feral Mogwai fed after midnight? It’s a sound you have heard before but cannot quite place. You turn and look behind you. There is nothing. The sound has stopped.

You take another step forward, earth becoming softer, wetter – feet sinking a little. That sound starts up again, except this time it doesn’t appear to be coming from behind you but from the field of never-mowed grass in front. As leaves bend and melt in the wind you can almost imagine them being moved by some small creature, darting away from you, making a path towards…

What the hell is that? The sky, once a dusty half-light is moving. Chunks of sod shifting, swirling, moving as if guided by some unseen agency, rising higher until…

The tentacles of some Elder God reach out towards you from the mess. They undulate unnaturally on a fast moving current of air. As they approach you feel the temperature drop. Hairs start to rise on the back of your neck. You exhale, a smokers exhale of white wisps.

They are getting closer just a few feet a way. If you reach out, you could almost touch them. Or they could touch you…

A fingers breadth now and you are rooted, stuck to the spot, paralysed, waiting for their not so gentle caress…

And – AWAKE.

Most of us have had a nightmare at some time in their lives whether it is about a clown in the drain or a Demogorgon chasing you down a school corridor. As an adult it is pretty easy to rationalise them away but it is not so easy for a child. Nightmares and the fear of nightmares (Kakoneirophobia) can have a real impact on quality of life. I’m going to unpack this in this year’s Halloween themed post.*

So we are all on the same page, a nightmare is dream associated with strong negative emotions that wakes one from sleep and is vividly recalled. It is one of a group of parasomnias, such as night terrors and sleepwalking. They usually occur in the REM stage of sleep and so, more often than not, occur between 4 and 6 am.

Where do nightmare come from?

The prevailing theory is that nightmares are a result of a mish-mash of factors – personality, coupled with anxiety traits and acute stressors.

Take the case of 13 year old Will. He has always had a nervous personality according to his mother Joyce, with his episodes of anxiety increasing in frequency around the time of her divorce from her husband, Lonnie. A recent mystery illness has led to an increase in  intensity of his nightmares.

Given that sleep disturbance of children leads to sleep disturbance of the parents, treating the child often improves the sleep of the parents and thus reduces their anxiety too. This co-dependent relationship also works in reverse. Treating the psychopathology of the parents can reduce nocturnal problems.

Whilst these cognitive-behavioural events are the most common cause of nightmares, potential medical problems such as allergies, reflux, or infantile movement disorders need to be at the back of one’s mind.

 

A variety of models have been used to describe the formation and function of nightmares.

The psychoanalytic model. Why do we dream? Freud didn’t say much about them in his seminal Interpretation of Dreams(1900). His concept that nightmares are the brain transforming these hidden urges of the libido into self-flagellation and anxiety doesn’t fit in with his general dream theory. In this case the dreams do not represent wish-fulfillment. That other great psychoanalyst from history, Jung, argued that nightmares are the leaking out of unresolved psychic stress/conflict.

The evolutionary model. Revonsuo proposed that nightmares are really just a form of virtual reality threat simulation. By actively rehearsing dangerous encounters whilst asleep the dreamer is better at threat-avoidance in the waking world. Children have more nightmares than adults as they are more vulnerable to threats.

Neurobiological models. If dreams are a form of stimulant – with emotional arousal as the end point – there comes a point when, perhaps, after a number of dysphoric dreams, the brain seeks to decouple arousal and response. One neurobiological theory would suggest that nightmares act as a form of decoupling, a circuit breaker if you will.

If you want to delve further into this complex and somewhat baffling topic then read

Nielsen T, Levin R. Nightmares: a new neurocognitive model. Sleep medicine reviews. 2007 Aug 31;11(4):295-310.

 

How common are they?

According to Coolidge et al. as many as 6.4% of children suffer from terrible nightmares at least once a week (7.7% in boys versus 5.1% in girls). This might be an underestimate as researchers often ask the parents (rather than the children themselves) about nightmare symptomatology. And whilst they may seem more common in younger children this may be because they are more likely to tell their parents. Older children are more likely to try and forget about their bad dreams.

 

Can we prevent them?

Whilst it is impossible to wrap children up in cotton wool there are some common sense approaches that may reduce the number of nightmares and their impact. In the main they revolve around good sleep hygiene – avoidance of stimulating games or programmes in the run up to bedtime and having a relaxing routine.

 

What if they happen every night?

The DSM-IV lists Nightmare Disorder as number 307.47 in a longlist of potential psychopathologies. Techniques such as desensitisation, imagery rehearsal, relaxation techniques and eye movement desensitisation.

Desensitisation. Just as the popular press feels we are becoming inured to the violence of everyday life because of the violence we see on screen, desensitisation therapy requires the dreamer to actively recall their bad dreams. The therapist then guides them on a journey of gradual exposure, first to the outer edges of the fear then deeper, to the very heart of it, pausing at each stage of the journey to allow frayed nerves and bounding hearts to settle.

 

Imagery Rehearsal/Rescripting. This psychotherapeutic approach involves a degree of supervised practice as the sufferer reviews a moderately scary nightmare and tries to change it into something more pleasant. This, coupled with daily practice over a 12 week period, has had positive outcomes in the adult population. Investigators have replaced verbal descriptors with drawings as an alternate form of imagery rehearsal therapy and found that though it might decrease frequency it did not decrease the intensity of feeling.

 

 

Eye movement desensitisation. This form of therapy, coined by Shapiro in the late 80’s is based on a curious premise. Shapiro noticed that if she became stressed or anxious her eyes would move more rapidly. She found that by deliberately slowing her eye movements down her stress lessened. Whilst far-fetched there have been a number of case reports of its successful use in sufferers of PTSD as well as victims of recurrent nightmares.

 

*Some people like April Fools themed posts (Damian Roland and Radiopaedia, I’m looking at you). I prefer Halloween.

References

Handler L. The amelioration of nightmares in children. Psychotherapy: Theory, Research & Practice. 1972;9(1):54.

Mindell JA, Barrett KM. Nightmares and anxiety in elementary‐aged children: is there a relationship?. Child: care, health and development. 2002 Jul 1;28(4):317-22.

Pellicer X. Eye movement desensitivation treatment of a child’s nightmares: A case report. Journal of Behavior Therapy and Experimental Psychiatry. 1993 Mar 1;24(1):73-5.

Acierno R, Hersen M, Van Hasselt VB, Tremont G, Meuser KT. Review of the validation and dissemination of eye-movement desensitization and reprocessing: A scientific and ethical dilemma. Clinical Psychology Review. 1994 Jan 1;14(4):287-99.

Schredl M, Fricke-Oerkermann L, Mitschke A, Wiater A, Lehmkuhl G. Longitudinal study of nightmares in children: stability and effect of emotional symptoms. Child psychiatry and human development. 2009 Sep 1;40(3):439-49.

Schredl M, Fricke-Oerkermann L, Mitschke A, Wiater A, Lehmkuhl G. Factors affecting nightmares in children: parents’ vs. children’s ratings. European child & adolescent psychiatry. 2009 Jan 1;18(1):20-5.

Sadeh A. Cognitive–behavioral treatment for childhood sleep disorders. Clinical psychology review. 2005 Jul 31;25(5):612-28.

Coolidge FL, Segal DL, Coolidge CM, Spinath FM, Gottschling J. Do nightmares and generalized anxiety disorder in childhood and adolescence have a common genetic origin?. Behavior genetics. 2010 May 1;40(3):349-56.

Simard V, Nielsen T. Adaptation of imagery rehearsal therapy for nightmares in children: A brief report. Psychotherapy: Theory, Research, Practice, Training. 2009 Dec;46(4):492.

Morgan III CA, Johnson DR. Use of a drawing task in the treatment of nightmares in combat-related post-traumatic stress disorder. Art Therapy. 1995 Oct 1;12(4):244-7.

Nielsen T, Levin R. Nightmares: a new neurocognitive model. Sleep medicine reviews. 2007 Aug 31;11(4):295-310.

Kales A, Soldatos CR, Kales JD. Sleep disorders: insomnia, sleepwalking, night terrors, nightmares, and enuresis. Annals of Internal Medicine. 1987 Apr 1;106(4):582-92.

The Mornington Meet-Up

This year I was asked to give not one, but two talks at the Victorian branch of the Australasian College of Emergency Medicine Annual Scientific Meeting. It takes place on the picturesque Mornington peninsula. With specific streams for doctors in training as well as fully fledged FACEMs I have tasked with providing a little bit of a paediatric update. This post will focus on the talk I am giving to the consultant stream.

When you are given the title “Sentinel Papers in Paediatric Emergency Medicine 2017” it’s easy to roll your eyes and think “What a dull topic.” Then I realised that most people probably don’t read or scan through 40+ paediatric journals a month and might not know what has been going on in the world of PEM. Of course the readers of DFTB are a discerning bunch and so have been enjoying our monthly Bubble Wrap updates for almost a year now, so I have had plenty of material to choose from.

With 30 minutes and a personal mission statement to ‘not be boring’ I chose the following 5 papers.

Babl FE, Borland ML, Phillips N, Kochar A, Dalton S, McCaskill M, Cheek JA, Gilhotra Y, Furyk J, Neutze J, Lyttle MD. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. The Lancet. 2017 Apr 11.

Children with seemingly minor head injuries present to the emergency department every day. Whilst it might appear to some of my juniors that I rely on my gut feeling I usually lean heavily on the PECARN head injury guidelines to identify children at very low risk of clinically significant injury. There are two other decision rules out there, though, that are in widespread use – the CATCH tool and the CHALICE tool. Whilst some countries recommend using a specific guideline Australian colleges have not taken this step.

It is important to understand that they are not equivalent. They apply to children of different age ranges, different injury severities and have different outcome measures. Table 1 of the article lists all the points of difference.

So what did PREDICT do?

This was a prospective, multi-centre observational study involving 10 paediatric emergency departments in Australia and New Zealand. All children that presented with a head injury of any severity and who were under the age of 18 years of age were enrolled. Data was then collected on the potential inclusion or exclusion criteria of the three rules, as well as the usual demographic data. Emergency department and hospital management data was recorded  and all those patients that did not get neuro-imaging were followed up over 90 days .

How many were enrolled?

In all, 29433 children presented to one of the 10 sites over the study period. 22 524 were eligible for inclusion. 2106 children (10%) underwent a head CT, 4544 (23%) were admitted for observation and 83 (<1%) required neurosurgery.

What were the results?

Each of the three decision rules = PECARN, CATCH and CHALICE – performed well in their own ways. The PECARN rules (plural because there are really two rules – one for under twos and one for over twos) had a high sensitivity (90.7-100%) and missed one clinically significant traumatic brain injury that did not require neurosurgery. CATCH had a much greater sensitivity range (76.2-99.9%) and could only be applied to a relatively small proportion of the population due to the exclusion criteria. CHALICE was really sensitive (96-100%) but missed 31 patients of which 2 required neurosurgical intervention.

So what does this mean to me?

CHALICE is sensitive but I’m going to have to at least double my rate of CT scans if I’m going to use it for very little return.  I’m going to continue to use PECARN as my go-to decision instrument. I find that showing worried parents the flow chart really helps them understand the low risk of anything serious. (If anyone wants to develop an even more visually appearing data visualization tool we can use then let us know).

Further reading

Who to scan by Anna Ings on DFTB

Duel of the Rules by Gareth Hardy over at St Emlyn’s

And if you can’t remember PECARN then take a look at this great ALIEM infographic

Look out for Franz Babl’s talk on the APHIRST trial from DFTB17 – coming soon

Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a randomized controlled trial. BJA: British Journal of Anaesthesia. 2017 Jan 18;118(2):232-8.

Just the thought of intubating a child can make some of us come out in a cold sweat. We don’t do it that often and when we do, it is not without risks. With around 14% of ED intubations complicated by desaturation anything that prolongs the safe apnoea time is a good thing. Whilst there is a great deal of debate on the effectiveness of Ap-Ox in adults the data in children is even more scarce. This was a proof of concept study looking at time to desaturation (SpO2 < 92%) in 48 children undergoing elective procedures in the operating room environment. 24 children underwent standard care (jaw support with no O2) whilst the other 24 had THRIVE applied. Those in the standard treatment group took 109.2 seconds to drop their sats. Those in the THRIVE group took 192 seconds.

This has led the way to the Kids THRIVE trial which is currently actively recruiting across Australia. The researchers aim to take the technology out of the operating room and down to the emergency environment (and PICU) and assess its effectiveness in a real world setting.

Further Reading

We covered this paper in the 3rd Bubble Wrap.

Cronin JJ, McCoy S, Kennedy U, an Fhailí SN, Wakai A, Hayden J, Crispino G, Barrett MJ, Walsh S, O’Sullivan R. A randomized trial of single-dose oral dexamethasone versus multidose prednisolone for acute exacerbations of asthma in children who attend the emergency department. Annals of emergency medicine. 2016 May 31;67(5):593-601.

I hate taking medications. I’m rubbish at it and gag on a single paracetamol. If there is ever anything I can do to reduce the number of tablets that I have to take then I will do it. Cronin et al. randomised 245 children (between the ages of 2 and 16) to take either a single dose of 0.3mg/kg dexamethasone or 1mg/kg of prednisolone for 3 days. They then looked at the Paedatric Respiratory Assessment Measure (PRAM) at 4 days.

What is the PRAM score?

The PRAM score is a 12 point scoring system that combines a number of clinical examination findings to determine the severity of an asthma attack.

What was the outcome?

There was no discernible difference in PRAM scores 4 days after the index visit leading the authors to conclude that a single dose of dexamethasone was not inferior to three days of prednisolone. This has certainly been looked at before. A 2014 paper in Paediatrics by Keeney et al. performed a meta-analysis of the available data  and found 2 doses of dexamethasone were not inferior to 5 days of prednisolone.

So this trial, coupled with previous data means I am going to start prescribing a single dose of dex for my mild asthma exacerbations that come into the ED.

Further reading

We covered this paper in the 9th Bubble Wrap.

Why don’t we use dexamethasone for children’s asthma? by Niall Morris at St Emlyns

Dexamethasone for asthma by Sean Fox at Pediatric EM Morsels

Single dose dexamethasone by Alli Boyd at RebelEM.

Kaufman J, Fitzpatrick P, Tosif S, Hopper SM, Donath SM, Bryant PA, Babl FE. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ. 2017 Apr 7;357:j1341.

Over my lifetime I must have spent hours just waiting for children to provide urine samples. And just when you think it is going to happen the dad (and it is always the dad) blinks or turns away and misses the opportunity whilst the child misses the pot. Non-invasive methods of bladder stimulation have been suggested before but Kaufman et al. have taken a real world problem and turned it to their advantage.

What is the technique?

Jono explains the Quick-Wee method.

If you have ever changed a nappy you may have noticed that the mere act of getting a wet wipe out and cleaning the perineum seems to be enough to the flow of urine. They randomised 353 children to the standard watch and wait versus gentle suprapubic stimulation with gauze soaked in saline.

Does it work?

When children (less than a year of age) were left to their own devices only about 12% ‘performed’ within 5 minutes. When the Quick-Wee technique was used 31% of infants did the deed. This gives an NNT of just 4.7. Compare this with the NNT for antibiotics for pain reduction in otitis media of 16. Next time I’m after a urine sample I’m going to give it a go.

Further reading

We covered this method in the 6th Bubble Wrap

Urine collection by Andy Tagg on DFTB

The Quick-Wee method journal club by Natalie May over on St Emlyns

Wee are the Champions of Paediatric Urine Samples by Ken Milne and Nat May over at the SGEM

Trick of the Trade: Urine Collection in Neonates by Salim Rezaie over at ALIEM

Urine Trouble by Tim Horeczko of the PEM Playbook

Kildare CA, Middlemiss W. Impact of Parents Mobile Device Use on Parent-Child Interaction: A Literature Review. Computers in Human Behavior. 2017 Jun 5.

It is hard to keep up with the paediatric literature. In order to scan through the literature I use a variety of electronic devices – my phone, an iPad and my laptop – at various times of day. I try and only pick them up when the girls are in bed as I’m sure having my face glued to a screen cannot be good for them. This narrative review from the appropriately titled Computers in Human Behaviour asks the question for me. By using the search terms parent, child, mobile device and interaction the authors found 27 articles dealing with the topic.

What were the main themes?

Most parents reported using their phone whilst supervising their children and levels of engagement and interaction dropped off during these periods. Whilst correlation does not indicate causation there has been an increase in injures in young children after the introduction of the 3G phone network. Perhaps the parents that are absorbed in mobile use are less responsive to their kids, fail to respond to negative behaviours and thus children take more risks.

My favourite paper by Harmon and Mazmanian broke parents into four distinct types – the multitask master, distracted addict, authentic human and technological Luddite. If you are not the multitask master then perhaps you might need some help (take a look in the Further Reading section below).

Further reading

Ring-Xiety and how to unplug by Henry Goldstein on DFTB

Save the Date – DFTB18

We couldn’t just stop after one conference, could we? Next year we will be swapping the glamour of Brisvegas for the coffee capital of Australia, Melbourne. With a day dedicated to some fantastic pre-conference workshops, it’s going to be an event not to be missed so save the date.

 

 

Bookmark www.dftb18.com and keep on checking back for more details.

Tickets will go on sale on the 1st of November at 0900 AEST.

 

If you want to speak at DFTB18 then you have a couple of weeks to get your pitch into us – don’t miss out!