Brief Answer:
I believe your pediatrician is on the right track

Detailed Answer:
Good afternoon XXXX My name is Dr. Saghafi and I would like to try and help you with your son's situation.

I've read through your son's presentation and thank you for the detailed explanation of his pediatrician's thoughts and feelings as well as the results of their neurological assessment. Allow me to summarize just a bit to make sure I've got everything. Your son began having night terrors from the age of 5 on and off to the present. He is now 7. Since putting him on melatonin and over the last few months his episodes seemed to have been spacing out and he has seemed to respond better than in the past. However, as of the last week they've gotten worse and you question whether the medication may be working as well anymore.

You didn't say anything about what he might've been on prior to melatonin or how much worse things were when they first started compared to now. At any rate, these episodes don't seem to be as scary anymore as they used to be and it seems that now he has developed some type of phenomenon where he can "see far." You've interpreted this to be similar to what might be seen in someone suffering from XXXXXXX In Wonderland Syndrome. Your pediatrician has reassured you though after a thorough examination on her part that he may benefit from a good ophthalmological exam but not necessarily a neurological examination due to a concern that unnecessary testing may be suggested. She also didn't believe an EEG would be warranted since the parasomnia (night terror) was pretty straight forward. Your son also has a DX of ADHD. You believe that your son is either not as bothered by these episodes anymore or he may just becoming "used" to them.

Your question is: "Do you think seeing a neurological Dr. is warranted."

I hope I've interpreted your case correctly above. If so, then, my thoughts are the following. I think that essentially your pediatrician is on the correct path of being more conservative with these entities rather than aggressive for a couple of reasons. One they seem to be OVERALL better than in the beginning though this past week wasn't necessarily an example of that.

You also mention that he has a very normal neurological examination according to the pediatrician. Furthermore, in fact, is not suffering from signs or symptoms of an intracranial mass of any sort which is likely one of your biggest fears when you started researching all of this.

However, I would bring up this point that from a neurological perspective those children who tend to have something organically wrong such as seizures causing these are in an older age group. This seems to describe your child. The vast majority of night terrors end in children by age 5-6. Your child in now 7 and there are still episodes. Therefore, the chance of there being a neurological issue is slightly higher than if we were to be speaking of a 4 or 5 year old.

Having said that I think that pediatric epilepsy manifesting in the form of night terrors would also tend to show itself as a progressively worsening picture and the duration of these episodes would begin to look like 30 second to 3 minute episodes of complex partial seizures or even tonic/clonic in some cases and less and less as time went on as night terrors. You did not comment on the duration of these episodes so I don't know where your son fits into this picture.

Also, one question I would ask is how the distinction was made to begin with between night terrors and nightmares in your son because I think this is potentially important. In night terrors children are much more difficult to wake up and if you are successful in waking them up they are typically inconsolable. In contradistinction nightmares are more easily awoken from and children are able to be calmed down without much difficulty.

To directly answer your question about your son seeing a neurologist or not I can't disagree with your pediatrician that there is the possibility that additional testing may be recommended but in my opinion because your child is slightly on the older side of when these should've ended perhaps a workup (even if it were to turn up negative, proving your pediatrician correct) would not hurt. And now it's summertime which would be better for him being out of school.

On the other hand, since it's only been this past week that has not been as good as before I think it's also possible that a wait and see at least for a couple more weeks could run before making the call to see a neurologist. If I were treating the child I might consider having you document things over the next couple of weeks and really looking at this distinction between nightmares vs. night terrors.....vs. NEITHER? Recall that you said he seems to be getting USED TO THEM now more so than in the past and they're not as scary. One might think that they are either downgrading themselves to just "vivid dreams" or milder nightmares in which case the whole idea of an EEG, MRI, and neurological workup becomes moot.

So, I hope that discussion lends a bit more clarity.

In summary, I believe I would proceed with a bit more watchful waiting before calling in the "big guns" but I would also ask my patient's mom to begin at least a 2 week run of strict documentation of these episodes keeping track of things such as time of the night they occur, behaviors noted, duration of event, ease of awakening the child or not. Are there any other things going on as well such as bed-wetting or fecal incontinence, is there anything going on strange in terms of eye movements, speech garbled/slurred, and what is his breathing pattern after it's over. These are all things we look for when assessing for seizures or epileptic episodes.

I would speak with the pediatrician about the possibility of slightly raising the melatonin if that seems appropriate....OR...did he just have a less than better week and should we just hold everything at status quo until we get with the documentation.

Please keep in mind that night terrors, believe or not, are more distressing and harmful to the state of mind of parents than they are of children. Children's remembrances and cognitive affectation by night terrors is little to none according to the research so your worry and fear is more out of your own feelings of desperately wanting your child to wake up and feel better while in point of fact, your child is not necessarily feeling badly in any physical way and will likely have absolutely no recollection after the episode stops on its own.

In fact, as difficult as this may sound a parent's best way to help take care of a child having a night terror attack is to simply remain close and keep them safe from hurting themselves. Do nothing to try and stop the process because it will go away on its own more efficiently than by trying to stop it which usually just results in more frustration and agitation on both the parent's as well as the child.

If this plan fails to result in a satisfactory improvement in things then, I believe having him seen by a neurologist for another opinion (which could include neurological testing) would be your next step.

I hope this answer has helped you understand a bit more of your son's situation. Please feel free to return any question you may have over what I've written. At the same time, if you feel that I've satisfactorily supplied you with useful information I would very much appreciate your feedback on our interaction in the form of a activity rating as well as your CLOSING OUT THE QUERY at your earliest convenience. Hope all goes well for your son.

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Brief Answer:
I believe watchful waiting is warranted

Detailed Answer:
Dear XXXX

Thanks for those clarifications. I now believe that your son probably is not suffering from seizures or epileptic fits from your description.

In addition, I think it would be extremely difficult for your son to have pure micropsia caused by a tumor in the brain with no progression to things such as headaches, other visual disturbances, or weakness in an arm or leg that doesn't resolve, etc. Nevertheless, a good fundus examination by a pediatric ophthalmologist would also be worthwhile to know that there is no sign of increased intracranial pressure which reduces even more the chance that he could have an occult tumor growing.

Everything you mentioned about bed-wetting and other issues seen in epilepsy is what I had also written in my other note that we typically look for in seizure disorder. Without those bits of data seizure disorder is much more unlikely.

I am only aware of micropsia as it relates to infectious causes (Epstein Barr virus especially or meningitis), epilepsy, intracranial tumors, strokes, aneurysmal bleeds, illicit drugs, certain ophthalmic pathologies such as irregular swelling either in the cornea, the retina, or the lens, and there is the catch all category of psychogenic.

Again, an ophthalmologist can rule out some of those causes, a neurologist can rule out others, and a child psychologist can rule out the remaining ones. Bingo....figured out.

But I really still believe that a course of watchful waiting to see if the melatonin increase helps is worth trying. I wouldn't get too far off into medication unless absolutely necessary. Have you ever tried trying figuring out if your son gets up at a specific time each night and then, trying to wake him up about 15-30 min. before the expected onset of his event?

I've had several patients try that tactic with some success.

Make sure your son has a good bedtime routine and that he is not overly tired or fatigued throughout the day since this is considered a risk factor for night terrors. Now, that he's on vacation from school the danger is he may be staying up later and especially with the sun being up longer not want to go to bed when he should. Try and keep him on a good routine to reduce fatigue during the day.

Once again, I thank you for the additional information and look forward to more questions if you should have any. Otherwise, your evaluation of these discussions and CLOSING OF THE QUERY would be greatly appreciated.

All the best!

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Brief Answer:
Treatment of micropsia based upon cause

Detailed Answer:
I agree that the major purpose behind visiting with the ophthalmologist is to rule out the possibility of increased intracranial pressure as well as to survey the architecture of the eye to be sure everything is in order.

I would add to my last answer on causes of micropsia that there are many specific ones which could be considered "subheadings" to the general categories that I mentioned. Therefore, recommendations on how to deal with micropsia is highly dependent upon its cause.

If your son's condition occurs in situations of low light or while playing video games then, it makes sense to my way of thinking that the best intervention is full circumvention of those environments. In other words, be sure he stays in rooms and situations where plentiful light sources are present and to limit time doing repetitive activities on screens of computers, smart phones, and video games which actually have rapid flicker rates that can fatigue eyes and lead to eyestrain.

The ophthalmologist would be best able to expand on this end of things than I so make it point to ask him next week.

Keep in mind that most cases of micropsia will disappear over time (and we don't know exactly why...but who's complaining, right?). It doesn't sound as if your son suffers from migraine headaches but if that were the case then, know that medications for the headaches tend to shorten the duration of micropsia events. Finally, there are several nutritional supplements which have been found to significantly improve the course of micropsia in patients. I have seen particular improvement in patients taking zinc supplements (independent of serum levels).
I hope these answers to this set of questions has helped you understand more of your son's situation.

I do look forward to your feedback on our interactions today and thank you in advance for CLOSING OUT THIS QUERY at your earliest convenience. Best of luck to you and your son.

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