PSG Scoring for the Pediatric Patient

Jennifer Chen Hopkins, M.D.D. ABP, ABIM & Sleep Medicine

Texas Society of Sleep ProfessionalsOctober 28, 2011

ObjectivesIndications for pediatric sleep study

Normal sleep and EEG changes during childhood development

Differences between adult and pediatric PSG scoring and interpretation

Kids who may need a sleep study

Suspected OSA (snoring + “ADHD”/behavior problems, tonsillar hypertrophy, Down syndrome, craniofacial malformation, obesity, HTN)

Suspected Narcolepsy

Suspected PLMD

Suspected seizure disorder

Congenital neuromuscular disorder

Suspected central hypoventilation

Infants: apnea of prematurity, severe GER, ALTEs/SIDS

Normal sleep in kidsBirth to 1 year:

Sleep 50-75% of day, gradually decreasesCircadian rhythm begins by 6 mo., still 2-3 napsNREM-REM cycles shorter (50 min/50 wga), gradually

increasesMore REM: 40-50% of TST

Preschool kids:12-14 hours sleep/24hUsually phase advancedTake 1-2 napsBehavioral sleep problems start

Normal sleep in kidsSchool-age kids:

9-11 hours sleep/24hNo nap90 minute NREM-REM cycle Increase in slow wave sleepMore phase-delayed, towards puberty

Normal sleep

When to use Pedi Scoring Rules

2 months to 12 yrs – use pedi rules

13 yrs to 17 – can use either adult or pedi rules

Better to use 3% desat if use adult rules

(C. Marcus, SLEEP v33, n10, 2010)

Normal Pediatric Sleep EEG

Normal EEG in kids

ODR (“alpha”) present at birth

Spindles 2 to 3 mo

Delta waves 4 to 5 mo

K-complex 4 to 6 mo

Occipital Dominant Rhythm (ODR)

- AKA: Dominant Posterior Rhythm (DPR)

- Their “alpha” rhythm

- Occipital leads during eyes closed

Occipital Dominant Rhythm (ODR)

Development of EEG Characteristics

Spindles 2 to 3 mo

Delta waves 4 to 5 mo

K-complex 4 to 6 mo

Infants: -May have to stage sleep as Quiet (N) vs. Active (R) sleep.-Use other parameters to help stage: eye movements, chin tone, RR, HR, etc.

Things that look funny but really are quite normal…

Trace Alternans- NREM sleep- Seen in full term newborns (until 3 mo)

Hypnagogic hypersynchrony-Synchronous, high voltage theta waves associated with sleep onset-Seen in infants and children

Pediatric Scoring:Respiratory Events

Respiratory EventsOA

90% decreased flowAt least 2 missed breaths

OH50% decreased nasal pressure for at least 2

breathsAssociated with arousal or 3% desaturation

Respiratory eventsRERA

Discernable fall or flattening of nasal pressure, but <50%

Snoring or increase in pCO2Increased respiratory effortAt least 2 breaths

Central ApneaAbsence of respiratory effort for 2 breaths + arousal

or 3% desaturation20 sec or longer without arousal or desat

Pedi Diagnostic Criteria for OSA

Mild AHI 1 to 5

Moderate AHI 5 to 15

Severe AHI >15

Only need 7 events during a 7 hour PSG to earn a diagnosis of Sleep-disordered breathing!!!

Other respiratory considerations

Hypoventilation: >25% of TST with CO2 >50 mm Hg

Periodic breathing: >3 episodes of central apnea lasting >3 sec, separated by no more than 20 sec of normal breathing. (Physiologic in infants)

Non-invasive CO2End Tidal CO2 (more common)

Transcutaneous CO2

Periodic Limb MovementsPLMS in kids are scored the same way as in

adults.

Only need PLMAI ≥ 5 for diagnosis of PLMD.

Can support a diagnosis of RLS.

Take-Home PointsKids need sleep studies for some of the reasons that

adults do but also for some reasons specific to Pedatrics (hyperactivity/behavior problems, tonsillar hypertrophy, dysmorphic features).

EEG characteristics and sleep staging vary dramatically with age from birth to age 17. Pay attention to ODR and be able to recognize normal EEG patterns commonly seen in pedi patients.

Respiratory scoring in pediatrics: NOT the same as adults. Being meticulous is paramount because every event counts!

ReferencesThe AASM Manual for the Scoring of Sleep and

Associated Events, 2007.

Sheldon SH, Ferber R, Kryger MH. Principles and Practice of Pediatric Sleep Medicine, 2005.

C. Marcus, “Differences in Overnight PSG Scores using Adult and Pediatric Criteria for Respiratory Events in Adolescents”, SLEEP v33, n10, 2010.

http://naraamt.or.jp/Academic/kensyuukai/2005

Google images

Questions?