Pediatric and Sleep for Technologists

Jennifer Despain, RPSGT Pediatric Specialist, Central Utah Clinic Sleep Disorders Center;

Salt Lake City, Utah

Objectives: • Recognize sleep disorders in children • Discuss how to perform a successful hook up and study for a

polysomnogram on a child • Discuss the differences in scoring a child versus an adult • Describe how to successfully desensitize and titrate a child

on CPAP

Pediatrics and SleepFor Technologists

Presenter: Jennifer Despain, RPSGT, RST

Why Pediatrics? 10-33% of children and 40% of adolescents

experience sleep problems◦ Trouble sleeping/insomnia◦ Snoring◦ Sleep apnea 1-4% have sleep apnea around 27% snore◦ Snoring◦ Narcolepsy◦ Movement Disorders◦ Sleepwalking◦ Bedwetting◦ Circadian rhythm disorders

Sleep Problems in Kids Linked to…

Obesity Asthma Greater risk-taking in teens Perturbations in development of sleep

mechanisms in early childhood pose higher risk for problems with attention, alertness, and emotional well being in life

Motivational problems

Meeting with a Doctor Specializing in Sleep Helps to keep kids with poor sleep

hygiene (with no other disorders out of the lab)

Allows tech to have a better idea of what will benefit the child when they arrive in the lab

Allows the doctor to give the parent information so they can help prepare their child for their visit to the sleep center

Possible causes for some sleep disorders in children:

Possible genetic/inherited causes:

-large adenoids and tonsils

-abnormal dentition

-upper airway allergies

-craniofacial abnormalities

-obesity

-iron deficiency

External factors:

-home and bedroom environment

-TV, cell phones, electronic gaming

-Social stress

-Medications including drugs of abuse

-Substances like Caffeine/nicotine

Indications for PSG in Children

Diagnose sleep related breathing disorders (central and obstructive)

Titration of positive airway pressure Evaluate SRBD treatment effectiveness Diagnose PLMD Diagnose narcolepsy/CNS Hypersomnia Evaluate unresponsive insomnia Evaluate parasomnias and seizures

Before You even see them at the lab Have the secretary let them know they can bring

their favorite: blanket, pillow, stuffed animal, movie, books, etc.

Have the parent refer to the study as a sleepover especially in children under the age of 9.

Have the parent’s child let them know that they will have stickers/wires stuck on them that will make the look like a ‘robot’ and won’t hurt (if the child is over 9 you can use the word electrodes, but describe them as stickers with wires attached)

There are some books that you can read about having a sleep study as well

Have the parent call the study a sleepover and try to make sure it sounds like fun

THINGS TO BRING THAT CAN MAKE A VISIT MORE COMFORTABLEHome away from Home

Pillow/blanket Pajamas Stuffed animal/toy

Book/movie

Useful Items:

Hook up chair Room Kid friendly items

3 Times is the Charm

First, show them to room and tell them to make themselves at home

Second, take in paperwork and ask the child to change into their bedroom attire

Third, hook up or with a nervous child see if they want something to drink and let them know we will be hooking them up soon

Two Tech Hookups

Faster Hook Ups One tech can distract the child with

helping put the wires in the front on while the other tech measures the head and puts wires on

Other tricks for making hook ups easier Allow the child to watch a movie/tv show Talking to them about things they like Letting the help put the electrodes/stickers on Hoodie/Jacket to wear over scrubs in medical

attire makes child nervous Make hook ups fun by blowing up a balloon or

drawing a smiley face on mom and dad if they are nervous about having their head measured

STOP if they get upset◦ Very young children tend to grab

the wires and pull them off when becoming upset

The child starts crying and becomes extremely emotional and upset what can I do?

Make sure to get belts on and heads measured if a child is nervous. This cute

three year old was fine with being drawn on, but the thought of stickers on her

caused her to cry, hit, and scream. Once they are asleep it is easy to add the

wires on.

Useful Equipment

Dual cannulas with a flow holder help keep the flow and cannula in place Cloth cover around wires keeps limbs

from getting tangled

Educating the Parent/Guardian

Proper bedtime routine What is normal in sleep CPAP importance and what it does How much sleep should a child be getting What they can do if their child wakes up

during the night etc.

Electrode Placement Differences“Adult electrode derivations for EEG, EOG and chin EMG are acceptable for recording sleep except that the distance between the chin EMG electrodes often needs to be reduced from 2 cm to 1 cm and the distance from the eyes in EOG electrodes often need to be reduced from 1 cm to .5 cm in children and infants with small head size. These changes can make scoring much easier and accurate especially identifying things like REM.”

In these photos the EOG electrode is about 1 cm away to the top of the electrode which means it should be even closer if possible.

Calibrations

May need to do in the room rather than over a speaker

Help from other tech/parent

Staging in Children

Age-related changes in EEG and sleep architecture cause “normal” findings to change with age

Knowing what’s normal for age is a necessary precursor to knowing what’s abnormal

Normal or benign EEG variants in children sometimes seem abnormal compared to adults

POSTERIOR DOMINANT RHYTHMWaking posterior dominant rhythm exceeds 9 Hz in 65% of children by age 9

Hypnagogic hypersynchrony during drowsiness subsides, becomes uncommon after age 12 years

Arousals/Limb CardiacMovements Same in children as

adults Make sure to

document what type of movements you see in your notes

Slightly different than adults due to children having a higher heart rate. Most of the cardiac rules listed in the scoring manual can be used for ages 6 and up

Adult vs Child scoring Rules in TeensTo use adult vs child scoring rules in teens is something that should be left up to the medical director for your lab. It is important to remember however that scoring is different than interpreting. Some things to consider when determining which way to score is from several studies suggesting that the apnea hypopnea index (AHI) will be higher in adolescent patients when using pediatric compared to the adult rules presented in the 2007 version of the AASM scoring manual. As adult and pediatric hypopnea rules are similar in the current rules except for the duration of the event, there may now be less difference in the AHI when using adult versus pediatric rules.

Apnea Scoring in children

Obstructive Apnea

Central Apnea

Not a Central Apnea

Mixed Apnea (order of central and obstructive component doesn’t matter in children)

Hypopnea

Snoring

Monitoring snoring is optional Options for monitoring snoring: acoustic

sensor (microphone), piezoelectric sensor or the nasal pressure sensor

Hypoventilation

Good Waveform etCO2

Arterial vs end-tidal and transcutaneous PCO2 Clinical judgment is essential when assessing the

accuracy of end-tidal PCO2 and transcutaneous PCO2 readings. The values should not be assumed to be accurate surrogates of the arterial PCO2when the values do not fit the clinical picture.

The end-tidal PCO2 often malfunctions or provides falsely low values in patients who have marked nasal obstruction, profuse nasal secretions, are obligate mouth breathers, or who are receiving supplemental oxygen It is crucial to obtain a plateau in the end-tidal waveform for the signal to be considered valid.

etCO2-Need squared off wave form

Transcutaneous PCO2

CPAP desensitization is KEY!

CPAP FITTING

Parent education Wear mask in a safe environment for

short periods of time Work up to wearing mask at night with

pressure before coming into the lab

CPAP challenges Claustrophobia Cranial facial abnormalities Limited pediatric masks/machines Adult equipment improper sizes and difficult

for children to use General anxiety Social concerns Machines not approved for children younger

than 7 though machines are approved for those as young as 2

Solutions

Humidification Validating concerns Start with more comfortable equipment Recruiting family and friends Education Expiratory pressure relief

Titration guidelies Raise CPAP 1 cm for 1 obstructive events

apnea/hypopneas or >1 min of loud snoring heard. It is also important to note that when paradoxical breathing and or RERA’s are seen higher pressure is likely needed. If severe apneas are noted you can go up 2 cm on the pressure. The maximum CPAP should be 15 cm H2O for children <12 years old. If a patient needs to be on higher pressures bilevel can be used up to 20 cm.

Follow up

Important to follow up on CPAP frequently. Children grow quickly. Their weight and body structure can change, so it is important to have follow up appointments scheduled at least once or twice a year to make sure they do not need the pressure adjusted or possibly no longer need CPAP

Saying Goodbye

Use adhesive remover for less pain on electrodes

Leave the child with a small toy/treat Make sure that their experience at the lab

was a positive one

Remember Be Patience (Kids don’t always do what you

want them to do) Be Observant (you need to pay attention to

kids or you might miss them talking, walking, moving, pulling wires off, etc.)

Be a great note taker (It is very important to document what you see going on with a child so the day scorers can know if what they are looking at is accurate such as low Co2 levels or what wires are missing

Be Happy

Conclusion

Children are not being screened as well as they should for sleep disorders. More awareness needs to be made so that children can grow up healthy and happy. We as sleep professionals have the responsibility to spread the word and help children have an enjoyable time when they visit the sleep center.