Observations made by technicians throughout an overnight sleep study may offer more valuable information than actual scored data.

 Although there are established polysomnogram scoring criteria in the adult world of sleep, none exist in the pediatric world. Pediatric scoring may be more accurately described as “physician specific guidelines.” These guidelines, over time, became the “rules.” Typically, many different medical specialists refer to pediatric sleep laboratories (neonatology, pulmonology, gastroenterology, neurology, and sleep disorder pediatricians). The scoring criteria are often based on the child’s diagnosis as well as what specific information the ordering specialist may want to see. Often, a study may need to be rescored based on what the ordering specialist may determine during their review of the data, thus changing scoring criteria further.

Infant polysomnograms are done infrequently. The majority of the diagnostic studies done on infants are cardiorespiratory sleep studies. These studies do not include the EEG channels; however, if and when an infant polysomnogram is done, the Standardized Terminology, Techniques and Criteria for Scoring States of Sleep and Wakefulness in Newborn Infants1 rules are strictly applied to score sleep stages. If cardiorespiratory sleep studies are done, the scoring parameters vary from physician to physician as noted above, taking into account the diagnosis and age of the patient.

An important component of scoring the cardiorespiratory sleep study is the Significant Events Listing. This listing includes all occurrences of prolonged apnea, bradycardia, and desaturations of 10 seconds or more—time of event, duration of event, and lowest physiologic value during the event are logged. Each event is correlated with any activity such as feeding, awakening, or sleeping. Comments regarding the quality of tracing infant activity are made by the scoring technician.

Pediatric polysomnography followed by a multiple sleep latency test (MSLT) is the test of choice to diagnose narcolepsy in childhood or, more typically, in adolescence. Rechtschaffen and Kales (R & K) manuals2 are followed for sleep stage scoring along with the American Academy of Sleep Medicine Clinical Practice Parameters for MSLT for Accreditation3 rules that are applied to score the MSLT portion of the recording.

In the absence of rules, for both the cardiorespiratory sleep study and the polysomnogram, the technical observations made by the technicians throughout the recordings may offer more valuable information than actual scored data. This section of the report is called Technician Comments. The following observations may be included in this section: arousals, head of bed position, patient position, number of pillows, stertor (snoring), or stridor of other sounds heard both awake and asleep: occurrence of any cardiac arrhythmias, diaphoresis, or asynchronous and/or paradoxical chest/abdominal movement; any apnea, bradycardia, and/or desaturation events noted but not meeting scoring criteria; difficulty with bottling or feeding—observed suck/swallow dyscoordination; any unusual occurrences (particularly those that occur during hookup, feedings, or otherwise while awake); and overall impressions of the study.

It may be important to note the family’s interaction with the child or the child’s behavior. Technicians may note this from observations between parent and child or from conversation initiated by the parents or child themselves. All of this information combined may contribute to a more accurate diagnosis.

General Considerations
Each night, we work toward gaining a trusting relationship with our patients and their families. If we succeed, parents may entrust the technicians with the complete care of their child for the night. Gaining this confidence is important, as we strongly encourage parents to leave the child’s room, allowing us to get the best possible quality study without outside noise interference. Parents may often stay just until the child falls asleep and then feel comfortable to leave.

We make every attempt not to have parents sleep with their children during the study. In the majority of cases, this is not a problem. Even if parents insist that the child will not sleep unless they are allowed to sleep with them (we will negotiate that once the child falls asleep),¬∑they should try to leave the room to give the child the opportunity to sleep alone. We have a parent sleeping room that is close to their child’s room in the laboratory. Often these parents are shocked that their child was able to sleep alone through the night. We try to be sensitive to cultural differences and accommodate these differences without impacting the quality of the study. Most parents are reasonable if given sound rationales regarding the need to have the child sleep alone to reduce outside interference (parent snoring or parent arousals).

For the patient being recorded for a possible diagnosis of narcolepsy, the studies are scheduled at the beginning of the week. This allows the patients to sleep as much as they feel they need to during the weekend just prior to the study. This reduces their sleep debt, which, if not reduced, could impact the MSLT results of the study. On the morning following the night of their polysomnogram, they are allowed to sleep until they wake up spontaneously. This allows them to have their last REM during the polysomnography portion of the recording rather than experiencing early onset REM in their first nap; however, because we need to keep the sleep laboratory on schedule for the next night’s studies, we must wake the patients by 11:00 am to start their MSLT. Five naps will be offered at 1.5- to 2-hour increments—depending on their wake-up time in the morning.

In dealing with the pediatric teenage and adolescent population, there are those patients who will try to convince the staff that they will not be able to sleep with all the electrodes attached. Actually, those situations are very rare. Some teenagers waking in the night will request a movie or television to “help them get back to sleep.” We gently let them know they do not have to sleep, but we are not allowed to turn a movie or the television on during the night. Most often they fall back to sleep within minutes. This fact is often surprising to parents as well.

Conclusion
There are no established pediatric scoring rules that can be applied to all situations. It is further complicated by the fact that many teenagers are equivalent to adults in size and weight—but of course, not age. What rules should be applied in these cases?

For pediatrics, scoring rules are actually guidelines given by the ordering physicians and/or the professional sleep organization for consideration in the scoring of studies. In our small (pediatric) world, much work remains to be done in the area of standardization of scoring and standards of care.

Theresa R. Bauer, CRT/NPS, RPSGT, is clinical supervisor of the Sleep Disorders Center at Children’s Hospitals and Clinics, St Paul, Minn.

References
1. Anders T, Emde R, Parmelee A. A Manual of Standardized Terminology, Techniques and Criteria for Scoring States of Sleep and Wakefulness in Newborn Infants. Los Angeles: Brain Information Service; 1971.
2. Rechtschaffen A, Kales A. A Manual of Standardized Terminology, Techniques and Scoring System for Sleep States of Human Subjects. Los Angeles: Brain Information Service; 1968.
3. Standards of Practice Committee, American Academy of Sleep Medicine. Clinical Practice Parameters. Available at: http://www.aasmnet.org. Accessed April 7, 2005.