Pediatric Polysomnography

Julie Dewitte

Emmanuel (Joel) Porquez

LEARNING OBJECTIVES

On completion of this chapter, the reader should be able to:

1. Determine the special needs of the pediatric patient in performing sleep studies.
2. Identify the recommended hours of sleep in children and its importance for sleep stage development.
3. Implement age-appropriate techniques when applying electrodes to ensure a quality recording.
4. Understand the need for flexibility when performing pediatric sleep studies and the use of extra equipment, particularly CO₂ monitoring.

HISTORY OF PEDIATRIC MEDICINE AND SLEEP DISORDERS

Consider that at the beginning of the 20th century children’s health care was basically nonexistent. The physicians used the adult criteria for children, and at the turn of the 20th century, no more than 50 pediatric providers existed in the United States. Of these 50 providers, less than 12 limited their practice to be exclusive with children. The second half of the 20th century saw changes in priorities for pediatric disorders with the development of multi- and interdisciplinary approaches to diagnosing and treating children.

In 1953, eye movements in infant sleep were documented, and in 1958, rapid eye movement (REM) sleep and nonrapid eye movement sleep cycles were noted to occur throughout the sleep period. In 1972, Dr. Guilleminault managed uncontrolled hypertension in a 10-year-old boy by tracheostomy. This was the first identification of successful treatment of a comorbidity of obstructive sleep apnea in a human, and most remarkably, it occurred in a pediatric patient, not in an adult patient.

In 1971, A Manual for Standardized Techniques and Criteria for Scoring of States of Sleep and Wakefulness in Newborn Infants was published and it took another 42 years to develop criteria for all pediatric ages. Today there are criteria for infants older than 2 months till the attainment of puberty and updated criteria for infants younger than 2 months in the American Academy of Sleep Medicine’s (AASM) Manual for the Scoring of Sleep and Associated Events.

Since the 2002 inception of sleep medicine as an independent specialty, the growth and awareness of sleep disorders has evolved; however, pediatric sleep disorders have not been a primary focus. Pediatric sleep medicine is an evolving field that requires further development and awareness (1).

THE PEDIATRIC PATIENT AND POLYSOMNOGRAPHY

Although originally developed for adults, polysomnography (PSG) was later adapted for the pediatric age group. Until recently, pediatric PSG has not been well standardized in obtaining sleep data, scoring, or interpretation. This changed in 2007 with the publication of the AASM scoring manual describing pediatric scoring criteria and the physiologic parameters typically measured.

PSG is considered the gold standard for testing children with suspected sleep-disordered breathing, which includes central and obstructive sleep apnea or hypoxemia. There are many nonrespiratory indications for pediatric PSG, including nocturnal seizures versus parasomnia, narcolepsy, and periodic limb movement disorder (2).

The criteria for acquiring data and pediatric scoring are quite different for infants younger than 2 months as well as for children and adolescents younger than 18 years. The pediatric sleep specialist may opt to use
adult criteria for scoring respiratory events in children 13 years of age or older (3).

PSG is important in detecting and determining the severity of obstructive sleep apnea. Adenotonsillectomy may lead to significant improvement in sleep-disordered breathing in most pediatric patients; however, residual disease is present in a large proportion of children after surgery, particularly among older (>7 years) or obese children (4).

The acquisition process for pediatric PSG requires specially trained sleep technologists and extra equipment to obtain sleep data. Staffing ratios may be modified to meet the special needs of the pediatric population and may require one-to-one care, especially with infants, toddlers, and challenging patients.

Unlike adult studies, pediatric polysomnograms may require a lengthier setup time and a family-centered approach to meet the needs of the parent and child as well as modifications to standard sleep center policies and procedures. The goal is to obtain a quality study for physician interpretation with as little discomfort to the child as possible. Consideration must be given to the family bedtime routine, special needs, and possible stress levels of all involved. Simulating the child’s home sleep environment may be helpful in facilitating sleep in an unfamiliar place. For instance, if the child typically cosleeps with the parent, it may be beneficial to allow this for children who are 12 months and older. Cosleeping ordinarily should not be permitted in the sleep center for infants less than 12 months of age, unless allowed to facilitate sleep onset, because of increased risk of sudden unexpected infant death to which sudden infant death syndrome (SIDS) is a subcategory. When appropriate, health care providers should be encouraged to discuss unsafe sleeping practices with the parents (recommended and nonrecommended sleeping positions, loose or soft bedding around the infant, etc.). Thoroughly document any unsafe sleeping practices identified during the sleep study (5).

Car seats should not be allowed in the sleep center as a sleeping device for infants. There is a high risk of death associated with infants sleeping in car seats because of asphyxiation. Infants are at risk for sliding down in the car seat and becoming entangled in the safety straps. Another potential risk is positional asphyxia (6). Sleep center personnel should teach parents about unsafe sleep practices and modifiable risk factors for the prevention of SIDS as outlined in the sleep center policy manual.

Infants and children generally have earlier bedtimes than teenagers and should sleep longer than adults. In 2016, the AASM published a consensus paper in the Journal of Clinical Sleep Medicine with sleep recommendations on the basis of evaluation of scientific evidence (Table 60-1) (7).

During the sleep study, it is best to coordinate “lights off” as close to the child’s normal bedtime as possible to optimize data collection. Therefore, the setup process of placing electrodes should start earlier. Most sleep centers serving the pediatric age group schedule a technologist for a 12-hour shift, usually from 7 p.m. to 7 a.m. A technologist working earlier in the day can assist with setting up younger patients and infants who have an earlier bedtime or assist with those patients who might require extra assistance. Infants younger than 2 months typically have sleep-onset REM sleep, so it is important to get them to bed by their usual bedtime in order to capture all REM periods during the acquisition.

Technologists performing pediatric PSG should have experience in caring for pediatric patients of all ages. It is especially helpful for the technologist to have basic knowledge of common pediatric disorders such as Down syndrome, autism, and seizure disorders, as well as pulmonary diseases such as asthma and chronic lung disease. Sleep technologists who are experienced with pediatrics have learned various techniques that accommodate not only the age of the child but also their cognitive level. For instance, a child with Down syndrome may not tolerate anything placed on their face; however, if the child is given a small hand mirror so that they can see their reflection, applying electrodes becomes much easier because the child gets distracted. Another technique that may be useful is to allow the child to be involved with placing electrodes. Allowing the child to touch and feel the electrodes and even hand them to you may be beneficial because children like to help out with certain tasks. You can ask them which color of wire they want to put on first or if they want a sticker put on their stuffed animal or on the parent. It is generally a good idea to avoid asking “yes” or “no” questions because the child will probably say “no” to everything. Continued emphasis that they will not be hurt often puts the child at ease.

Table 60-1 Recommended Sleep Duration in the Pediatric Population

Age	Recommended Amount of Sleep in 24 Hours (Naps Included) (h)
0-3 mo	Not enough scientific evidence for consensus
4-12 mo	12-16
1-2 y	11-14
3-5 y	10-13
6-12 y	9-12
Teenagers, 13-18 y	8-10
From Paruthi, S., Brooks, L. J., D’Ambrosio, C., et al. (2016). Recommended amount of sleep for pediatric populations: A consensus statement of the American Academy of Sleep Medicine. Journal of Clinical Sleep Medicine, 12(6), 785-786.

There are various disorders seen only in pediatric sleep centers, which can add extra challenges to obtaining a high-quality acquisition. Technologists must have a great deal of patience and incorporate a family-centered approach to care in all situations. Age-specific care is highly important for the technologist to understand when caring for pediatric patients because there are different levels of age-specific care (e.g., neonate/infant, toddler/preschool, and adolescent). The sleep technologist must fully understand these different levels to appropriately interact with the patient (8). The family should also be involved in all aspects of the PSG process.

SLEEP CENTER ENVIRONMENT

There is no escaping the fact that a night in the sleep center will be different from a normal night’s sleep at home. It is important for the technologist to understand that the relationship with the child and the family begins when they enter the sleep center. A distraught, unhappy child may be a challenge to all involved. Favorite items brought from home, such as a blanket, bedtime book, or stuffed animal, may provide relief during the process. Toddlers, on the contrary, may fare better if their focus is directed to other activities during the setup: watching an appropriate video, coloring, or reading a book with the parent. Practice age-specific care at all times. Nighttime awakenings, diaper changes, or feeding require parental attention, and sleep center staff should assist with navigation of the sensor wires during these times (9).

Children of different ages have different fears and concerns. Normal childhood anxieties include fear of strangers, separation anxiety, and fears not based in reality, such as monsters and ghosts. Given the normal childhood anxieties of being separated from their caregiver and fear of strangers, a young child would be terrified of waking up in an unfamiliar environment without the immediate reassurance of a parent. Although a child may developmentally progress past these age-appropriate fears, there can be a regression in stressful situations. In patients with complex medical histories who have frequent hospital encounters, this effect can be compounding. Younger children should be reassured that they will not be separated from their caregiver and that nothing will hurt them. Children seek safety, comfort, and protection from their caregiver. Older children, particularly adolescents, need to be assured of privacy and may not want the parent sleeping in the same room. However, a caregiver is required to stay in the sleep center with the patient for the duration of the study if they are under the age of 18. The caregiver is typically provided a recliner or bed to sleep on and discouraged from cosleeping.

DESENSITIZATION

For children with particular disabilities or behavioral issues, a desensitization appointment before the PSG may be beneficial to the success of the study. Desensitization for these patients is especially important before a continuous positive airway pressure (CPAP) titration. The desensitization assessment process will assist the technologist performing the study to be prepared in advance with helpful techniques.

A simple prestudy tour of the sleep center is helpful for all pediatric patients. The family should be given information explaining the PSG procedure, preparation for the study, and follow-up information. The prestudy tour will help reduce anxiety (for both the child and the parent) and assist the parent in bringing the proper necessities on the night of the study (bedclothes, DVD of favorite movie, etc.).

The desensitization process provides a brief practice session with some sensations the child would be exposed to during the study. A more extensive desensitization session might be needed especially if the child is in the sleep center for a positive airway pressure (PAP) titration. The process might be performed at a date before the scheduled sleep study or on the day of the study. This hopefully will ensure that the child will tolerate the study and maximize outcomes. Conducting the desensitization session in one of the rooms used for sleep studies will also help the child become more comfortable with the surroundings and the procedure. During the setup, allowing the child to apply sensors to the parent or to the doll may diminish apprehension or fascination with the unusual objects being presented.

Begin desensitization starting with the child’s feet and working up to the head because most children seem to have the hardest time with head/face sensations. Let them feel the sensation of having an electrode site prepped and how it feels to have the electrode taped to their skin. Let the child feel and hold the nasal cannula before placing it by their nose. When fitting the CPAP mask, let the child hold and touch the mask so they know it will not harm them. Guide the patient’s hand, while holding the mask, up over their nose and involve the parent by having them assist with this process. Allow the child to become comfortable with the mask before turning on the air pressure. Try to apply the headstraps as the last step so the child has some sense of control
while adapting to the air pressure. The family can assist in the desensitization process by practicing at home, particularly with the nasal cannula and CPAP mask, which seem to be the most difficult items for children to tolerate. The desensitization process must remain flexible depending on the child’s progress.

A Child-Friendly Environment

A child-friendly sleep center is important to the success of your pediatric program. A comforting environment for both the parent and the child is essential. Colorful wallpaper borders with a pediatric theme, rocking chairs, and toys are helpful. The rooms should be private with enough space to allow one parent to stay in the room with the child. Ensuring that the room is soundproof will eliminate noise from outside of the room (e.g., other patients crying), which can affect the sleep environment and quality of the acquisition. The parent should have a separate bed within the room, which could be a recliner chair or foldaway bed. Having snacks, diapers, and pediatric gowns available is helpful to parents who may have forgotten to bring these items with them to the sleep center. The appropriate bed size or crib should be available, keeping in mind the necessity of side rails for toddlers and children with special needs. Patients with physical disabilities may need a lift to assist with transfers from the wheelchair to the bed and should have easy access to a wheelchair-accessible restroom. Some patients may require equipment for nocturnal gastrostomy feedings. Caregivers should be informed in advance to bring any formula or medications to the sleep center that the patient normally takes at home. Inform the caregiver that they will also need to administer any medications, because this is not within the scope of practice of sleep technologists. If the patient is asthmatic and requires a nebulizer treatment, the parent will need to bring the equipment.

Staff members working in a pediatric sleep center must always be aware of environmental safety hazards, which include sharp objects and hazardous chemicals. All electrical outlets should have safety cover plugs. Equipment used during the acquisition process such as pulse oximeters, capnographs, and noninvasive ventilation units should all be kept out of the patient’s reach and secured so that the child cannot pull it off of the shelf and injure themselves. Many items used during the sleep study can be a choking hazard, so a child should not be left unattended during the setup process. Toddlers could put items in their mouth because of their natural curiosity and desire to explore their new environment. Beds and cribs must have side rails to avoid falls. Remember to look at the environment from a child’s eyes and observe what could fall, be pulled down, or chewed. Even the fun stickers that are handed out as a reward to the child can be a choking hazard. A crash cart that is equipped for infants and pediatric patients should be available along with properly sized pediatric resuscitation equipment (10).

Nap Studies

Infants younger than 3 months have a cyclic sleeping pattern of 3 to 4 hours asleep with wakefulness for 1 to 2 hours. As the infant matures, the sleep cycles lengthen, with less sleep occurring during the daytime, usually around 6 months of age (11).

For evaluation of infants, a daytime nap study is appropriate to evaluate breathing and oxygen saturation as long as they sleep sufficiently. An adequate nap study will typically include about 4 hours of sleep with consolidated sleep and observation of REM sleep.

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