As pediatricians become more aware of the importance of sleep for good health and parents become educated about the quality of their child’s sleep behavior, traditional sleep laboratories will be challenged to do more. Although the quality of a child’s sleep is evaluated in a manner similar to that for adults, there are differences the pediatric sleep technologist must consider. Age of the patient and medical condition of the child may challenge the sleep technologist’s skills in obtaining a quality study. As a sleep technologist, how prepared are you to implement sleep studies in the pediatric age group?
Unless sleep technologists work in a medical facility specifically dedicated to children, they may have limited work experience with pediatric patients. Polysomnograms are frequently ordered in the pediatric patient population, ranging from birth to 18 years of age. Obstructive sleep apnea and various other medical conditions pertaining to respiratory pathology, including genetic and craniofacial anomalies, can affect the quality of the child’s sleep. Fragmented and otherwise poor sleep can influence growth and development, including academic performance in the older child and behavior at any age. The polysomnographic technologist, with the proper knowledge and understanding, can derive valuable information for later analysis.
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There are three broad age groups that display a variety of behavior patterns in sleep; birth to 2 years old (infants), 2-5 years old (toddler/preschool), and 5-18 years of age (school age/adolescents). While performing pediatric polysomnograms, sleep professionals need to be especially cognizant of age-specific communication methods, electrode application techniques, and often-encountered medical conditions in the pediatric population.
BIRTH TO 2 YEARS OF AGE
Communication within this age group is mainly between the parent(s) and sleep technologist. The infant usually sleeps the majority of the night, with brief interruptions for feedings and diaper changes. Infants and toddlers are too young to understand and express their needs. They are totally dependent on the parent/caregiver for assistance. Explaining the testing procedures will calm an anxious parent and allow a better understanding of the sleep study process.
Electrode application takes careful planning, and diligence and care should be emphasized. With this in mind, the sleep technologist must consider the child’s fragility and small size. An asset to the sleep technologist is having the cooperation of the parent(s). A parent can be an indispensable assistant, aiding by holding the infant, keeping little hands away from secured electrodes, as well as distracting the baby. Electrode placement is usually performed in a crib, where the child should be held in a sitting position or lying down. Note that cribs must be readily available in the sleep laboratory where infant/toddler studies are performed. Not only can parents assist the sleep technologist during the placing of electrodes, they can provide additional information describing their child’s sleep pattern and behavior at home. Accommodations must be available in the bedroom for the parent. A spare bed is provided for the caregiver since “co-sleeping” should be avoided. Circumstances where “co-sleep” might be allowed would be to achieve sleep onset, when co-sleeping is the routine at home, or to prevent inadvertent electrode removal by the child until they fall asleep.
Medical conditions seen within this age group may consist of upper airway, craniofacial, and chest wall anomalies, as well as neurodevelopmental abnormalities. Disorders such as Down’s syndrome, Treacher Collins syndrome, Pierre Robin syndrome, cerebral palsy, and spina bifida/Arnold Chiari malformation may compromise normal sleep. An infant born premature (< 37 weeks gestation) may also have apnea of prematurity or upper airway obstruction that affect breathing and disrupt sleep. Infants presenting with noisy breathing, snoring, abnormal movements in sleep, and possible seizure activity may be referred to your sleep laboratory. Recording respiratory and EEG parameters in a continuous fashion can provide valuable information to the physician for diagnosis and management.
AGES 2-5 YEARS OLD
Introduction and communication for this age group should be initiated by the sleep lab prior to the scheduled appointment. It is appropriate for the sleep facility day staff to assist in properly preparing the child, by giving tours of the sleep lab or supplying a video of what to expect. Encourage parents to use age-appropriate words while explaining the sleep study process to their child to relieve their anxiety.
A child is more likely to fall asleep naturally if they feel comfortable in their environment. Allowing adequate time for the child and parent to acclimate to their new surroundings is essential. The technologist’s frequent visits in and out of the room help to increase familiarity, earning parent’s and child’s trust while placing electrodes. The parent is encouraged to initiate the child’s nightly routine by bringing books, snacks, pajamas, a favorite blanket, teddy bear, etc to help further simulate a homelike atmosphere. It is advisable for the patient to sleep in a bed with bedrails for safety. The sleep technologist should document “lights out” as close to the child’s typical bedtime as possible.
How sleep technicians present themselves to patients can influence the behavior of the children in regard to the study. Scrubs or white coats may further frighten a child. More comforting wear such as casual street clothes or colorful scrubs should be considered. Mentioning “no shots” several times will relieve anxiety and apprehension. Having the setup cart containing supplies and electrodes already in the room, or allowing the child to feel some of the items, are more helpful techniques. These actions reaffirm to the child that there will be no surprises. If the child comes in holding a doll or stuffed animal, demonstration of one or two electrodes placed on the doll impresses upon the child that pain is not involved. If a doll is not available, placing an electrode on mom or dad can be entertaining and encourage family rapport.
In difficult situations where the child is crying or restless and comfort measures are not successful, a fast yet effective hookup is suggested. One must be mindful to allow appropriate breaks for the crying child to catch their breath. Methods that expedite the hookup process include using disposable electrodes, utilizing a dim-lit room, and applying arm immobilizers. Sometimes it’s necessary to have a second sleep technologist available to assist with a difficult patient. In rare situations, the placement of the thermistor or end-tidal CO2 cannula may need to be delayed until sleep onset has been achieved. Once the electrodes are properly placed and the hookup is completed, allow the parent to embrace and console the upset child.
The sleep technologist may encounter medical cases as a follow-up to previous sleep studies or have to evaluate existing medical conditions. A history of seizures, enlarged tonsils/adenoids, and sleep disorders associated with behavioral problems are commonly seen within this age group.
5 TO 18 YEARS OF AGE
While adolescents may appear to be similar to adults, there are subtle but important differences. Certain techniques can be helpful in achieving a successful sleep study. Identifying the patient’s presenting behavior can give insight to the sleep technician and help gain rapport. For example, by observing a teenager wearing headphones, looking down, or avoiding eye contact, you can assume they are either a little anxious about the study, just bored, or even angry with their parent for making them go through this embarrassing study. The technologist who recognizes this might say, “I know this might be difficult for you,” or “I know you would rather be someplace else, but let me help you.” By being observant, perceptive, and empathetic, the sleep technologist should be able to coax a cooperative spirit and obtain a good quality recording. Respect for the adolescent’s privacy by knocking before entering the room and using the appropriate age-related terminology will also increase compliance.
Since this age group is more mature and cooperative, electrode placement is performed with relative ease. Sleep technologists must be willing to answer questions and treat adolescents with respect as they attempt to understand the sleep study process. Another helpful tip is to allow the adolescents to participate in the hookup process. Participation provides a sense of control in an attempt to lessen anxiety about the testing procedure.
Disorders the technologist may encounter in this age group are sleep terrors, sleepwalking, narcolepsy, sleep-related breathing disorders, delayed sleep phase syndrome, and sleep deprivation. Adolescents may also develop poor sleep hygiene habits that disrupt sleep at home. Poor sleep hygiene may be observed in the sleep lab as the adolescent may request to play video games, have the television turned on, or require music playing while trying to fall asleep.
Understanding normal development and behavior is helpful in providing individualized attention in an age-appropriate manner. In the pediatric sleep lab, flexibility is critical in obtaining a good quality study. In addition, using the appropriate size and type of equipment, along with a secure hookup, will help assure a quality study is collected.
Monitoring the pediatric age group also requires special considerations. The implementation of established pediatric protocols developed with the program’s medical director is crucial in order to standardize procedures and ensure optimal data collection. For example, accidental electrode removal and re-referencing of electrodes may be tolerated more in a child than in an adult, in order to avoid disrupting sleep or further prolonging a difficult sleep onset. Vigilant and constant documentation of the child’s (and parent’s) behavior adds to the information obtained during the sleep study. Behavioral observations can help with the scoring and interpretation of the pediatric polysomnogram.
Despite the child’s age, medical condition, or obstacles that may have occurred, the pediatric sleep technologist has the ability to provide reliable medical data for physician review and management of pediatric sleep disorders. The sleep technologist plays an integral role in the care of pediatric sleep patients. This can be a rewarding experience, as the sleep technologist has a significant impact on the well-being of the child and the entire family.
Emmanuel J. Porquez, RPSGT, has been affiliated with the Atlanta School of Sleep Medicine and Technology since 2004, where he has taught and participated in physician’s board reviews, technician’s board reviews, and technician’s A-STEP program, including lecturing in pediatric courses. He currently works for Children’s Healthcare of Atlanta. The author wishes to thank Gary Montgomery, MD, sleep center director, Children’s Healthcare of Atlanta; Scott Leibowitz, MD, medical director, The Sleep Disorders Center of the Piedmont Heart Institute; and Susan Keller Yenney, RPSGT, SKY Sleep Consulting, LLC.