About 69% of children under the age of 10 experience some type of sleep problem, according to the National Sleep Foundation.1 Perhaps due to a boost in awareness about sleep disorders in children, sleep studies on pediatric patients have increased over the last several years. With this increase has come a keen interest in opening sleep laboratories that perform pediatric polysomnography (PSG), or augmenting existing facilities by adding pediatric sleep programs. The decision to start a pediatric sleep program prompts special considerations and techniques for the sleep facility studying these young patients.

Honor a Child’s Natural Sleep Window

It is generally advised to perform sleep studies on children according to the child’s sleep schedule. To determine a child’s typical sleep schedule, some sleep laboratories obtain a 2- to 3-week log of sleeping and waking function. “Most children between ages 2 and 9 years old need an average of 10 to 11 hours of sleep, which means their bedtimes should be between 7:30 pm and 8:30 pm,” says Kim West, LCSW-C, author of Good Night, Sleep Tight: The Sleep Lady’s Gentle Guide to Helping Your Child Go to Sleep, Stay Asleep and Wake Up Happy. “By honoring a child’s natural sleep window in the sleep laboratory, the child can go to sleep more easily and quickly.”

Overall Acclimation for PSG procedures

Acclimation of a child can be accomplished by visiting the sleep facility in the weeks prior to the study. During the acclimation, the child can view where they will be sleeping and where they will be hooked up. When dealing with pediatric patients, clinicians should consider that a child may have a difficult time falling asleep in unfamiliar surroundings. “I would encourage sleep labs to ask parents if their child knows how to put themselves to sleep independently (without bottle feeding, nursing, rocking, lying down with the child, etc). If the child does not know how to put themselves to sleep, the night of the sleep study is not the night to start sleep training! Allow the parent to work their magic to get their child to sleep,” West says. She adds that labs should encourage parents to allow children to bring their special security objects such as blankets or teddy bears with them. It is also helpful to have calm music and picture books available.

“Just try to make the study a fun ‘sleep over’ for the patient. Get them as involved as possible so they know that it’s not a painful procedure,” says Forrest Broderick, RPSGT, lab coordinator at Massachusetts Eye & Ear Infirmary (MEEi) for Sleep HealthCenters, LLC, in Boston.

CPAP Desensitization

In the United States, CPAP is prescribed off-label for some pediatric patients since it is not cleared by the US Food and Drug Administration (FDA) for children under the age of 7 or who weigh under 40 pounds. If the child is suspected to have OSA, and if CPAP is expected to be titrated during the pediatric study, desensitization becomes even more critical. “The overall consensus in the CPAP in Children Workshop at this year’s Pediatric Sleep Medicine meeting at Amelia Island, Fla, was that an acclimation program was critical for the best chance of success for long-term CPAP compliance in children,” says Patrick Sorenson, RPSGT, a longtime sleep technologist from the Boston area whose career has been concentrated in pediatric PSG.

Broderick says her facility tries to encourage parents to start their child with the mask for about an hour at a time, working up to a full night of wearing the mask before their study. “We also recommend that parents make sure that the siblings are aware of the importance of CPAP, and that no one makes fun of the patient, as this will greatly decrease use [of the equipment],” she says.

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Sorenson suggests that an open nasal mask be used when the patient is testing the treatment without the CPAP unit. The open-mask desensitization could include wearing the mask during nonbedtime hours when watching TV or playing in the home. “Wearing the open mask around the house may also help the parent to address any social issues or concerns if there are siblings or other children in the house,” Sorenson says. But the patient should be instructed to get used to wearing the mask, and the caregivers should be informed that simply wearing the mask will not prevent apneic events, Sorenson says.

The successful completion of titrating CPAP for pediatric patients depends on both the technologist’s knowledge of the nature and consequences of OSAS in children, and a formal desensitization or acclimation program. “The acclimation program should be designed to maximize the outcome of a CPAP titration and improve overall compliance to CPAP in the patient’s home. The pediatric population can be better served—and the lives of these children and their families improved—through appropriate CPAP education, an appropriate acclimation program, an optimal titration, and intense follow-up to ensure compliance,” Sorenson says.

Pediatric Patient Setup

PSG setup on pediatric patients is especially challenging, and ideally requires technologists to have a lot of patience. “I think kids are definitely harder in some respects than adults, such as setups or keeping equipment on,” says Broderick.

In order to decrease difficulties, sleep clinicians should be imaginative when setting children up for studies. “I have heard of some pediatric sleep labs putting fun stickers on the child’s body to show them where the electrodes will go and that it will feel the same way,” West says. “This reassures children that nothing comes out of the electrodes and that they do not hurt. Practice on the parent’s hand and then the child’s before putting them on their chest. You may be able to use TV characters to make it fun and ‘cool,’ ” West says.

Monitoring system capabilities and varied equipment sizes

Data acquisition systems for sleep studies should not be “one size fits all” when considering pediatric PSG. “It’s not appropriate to study children the way we study adults. The system needs to have the capability of adding extra channels for placing extra EEG leads,” Sorenson says. He further explains that it is desirable to have access to routine monitoring of possible epileptiform discharges in pediatric populations.

Equipment such as thoracic and abdominal respiratory effort belts, end-tidal CO2 cannulas, and CPAP masks should be available in various pediatric sizes in the sleep center. Oximeter plethysmograph waveform output data is also desirable when doing pediatric studies, Sorenson says.

There is increasing evidence that disturbed sleep may be associated with more intrinsic deficits in daytime alertness. Behavioral problems, including ADHD2 and related cognitive executive dysfunction3 and, perhaps more extrinsically, poor school performance,4 have now been documented in children with suspected poor sleep. There will likely be more sleep centers across the country in the near future looking to study pediatric patients.


Theresa Shumard is a longtime sleep technician and medical columnist, and the founder of REMgazer Sleep Communications. She is also host of the “Let’s Talk Sleep with Theresa Shumard” radio program and can be reached at sleepreviewmag@allied360.com.

References

  1. National Sleep Foundation: Sleep For Kids. Children’s sleep problems: what they are and how to deal with them. www.sleepforkids.org/html/problems.html. Accessed August 20, 2007.
  2. Archbold KH, Giordani B, Ruzicka DL, Chervin RD. Cognitive executive dysfunction in children with mild sleep-disordered breathing. Biol Res Nurs. 2004;5(3):168-176
  3. Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998;102:616-620
  4. Rains JC. Treatment of obstructive sleep apnea in pediatric patients. Behavioral intervention for compliance with nasal continuous positive airway pressure. Clin Pediatr (Phila). 1995;34:535-41.