Transcript The-Pediatric-Sleep

Cynthia D. Nichols, PhD, FAASM, CBSM
Munson Sleep Disorders Center
Traverse City, MI
Describe the unique challenges and rewards of
working with children and their families in the
sleep center
Discuss methods to protect the safety of
children in the sleep center
Understand basic differences in recording and
scoring sleep in children vs. adults
Explain effective methods of communication
with children of different ages
Discuss legal issues specific to evaluating
children in the sleep center
Children are never boring, always changing.
Observing the development of sleep in children
of different age levels is very interesting.
It is a rapidly growing area of sleep medicine,
with opportunities for creative, innovative
people.
When you help a child, you help the whole
family.
When you improve a child’s sleep, you have the
potential to change their entire future.
Children are fragile and it is easy to hurt them.
Children can become very sick, very quickly, and
with little warning.
Working with children is more time-consuming
than working with adults.
Children have parents.
Children are less cooperative and less
predictable than adults during PSG.
Many children are on state-funded programs
and reimbursement is poor.
Young or very challenging children often require
1:1 which is cost-ineffective for many centers.
Job security or the desire to increase the
number of PSGs in your sleep center is not a
good reason to specialize in pediatric sleep.
When parents are divorced, it is important to
determine who has the right to seek nonemergent medical treatment for the child
The custodial parent is not always the one who
pays the bill.
The specific laws regarding consent vary from
state to state.
Best to obtain both parental informed consent
and child assent for the test in children age 8
and older.
Abduction
Potential for child to walk out if unsupervised
Chemicals
Electrical outlets
Things that a toddler can put in the mouth
Keep bed at setting closest to the floor
Abusive parents
Inattentive parents
Medications must be listed and specifically
ordered by the attending physician, including
inhalers, Tylenol, and breathing treatments.
Medications must be brought to the sleep
center in the original package/bottle; each
medication must inspected and verified by a
pharmacist or a technologist with specific
training in comparing the medication to the
picture in your medication database.
Each medication that was administered to the
child in the sleep lab must be witnessed and
documented by the sleep technologist.
“Screens” including television, video games, etc.
Phones and texting (parents also)
Co-sleeping
Parent in room
Parent in bed
The sleep environment is VERY different in the
lab as compared to the home.
Be prepared for anxiety in the child and the
parent; some private time may help.
Syndromes of many types
Muscular dystrophy
Seizure disorder
Cerebral palsy
Spina bifida
Arnold Chiari malformation
Apnea of prematurity
Apnea associated with gastroesophageal reflux
Children and their parents do not always have
the same goals.
A phone call by the attending technologist to
the parents prior to the study is helpful.
Children (and even adolescents) are often very
concrete in their understanding.
A child may not tell you the really important
things unless you ask directly.
It is important to adapt your communication to
the child’s level of comprehension.
Genuinely like children
Empathy
Patience
Adaptation
Curiosity
Creativity
Ability to demonstrate respect for the child as a
unique individual
It is difficult or impossible for them to express
their needs with words.
They are dependent on the caregiver for
assistance.
They are more often (but not always) calmed
when being held by a parent or familiar
caregiver.
Explain the test procedures to the parent; the
parent will be able to communicate their
calmness to the infant.
Babies are not just small but are also fragile.
Keep little hands away from electrodes by
wrapping the head or using splints or mittens.
Distance between EMG chin electrodes or
distance from eye for EOG often needs to be
reduced by 50%.
Do a “tape test” and “goo test” with all
materials for at least 10 minutes, then check
skin for irritation.
A crib should be available even when the
child is sleeping in a toddler bed at home.
Use both end-tidal and transcutaneous
CO2 if possible.
OK to put pulse oximeter on foot in infants
and small children, but use hand when
possible in children age 1 or older.
Children in this age group should almost always
have an orientation to the sleep lab.
Allow extra time for the child and parent to
acclimate to the room before initiating the
hook up.
Start by gaining trust. Avoid scrubs and white
coats.
You may need to say “no shots” for some
children.
Young children respond very well to distraction
with a special movie or a new toy.
This is usually the most challenging age to obtain a
PSG.
In difficult hookups, use anything that expedites
(disposable electrodes, dimly lit room, two techs, etc.).
You may need to wait to add some sensors until child
is asleep.
A “tape test” and “goo test” are still good ideas at this
age.
Use both end-tidal and transcutaneous CO2 if possible.
Allow them to help when possible.
Let parents know that the sensors around the face are
the most important ones to keep on. Most parents
will help you if they understand this.
Older children and adolescents are easily
embarrassed about their body. Give them
plenty of privacy and address personal privacy
issues immediately when they arrive.
Explain all the procedures in age-appropriate
language.
Speak primarily to the child rather than the
parent.
Speak plainly and avoid technical words even
with adolescents unless you define the term.
Offer a mirror if a child wants to see what is going on,
but realize that many do not want to see what you are
doing.
Discourage parents from taking a picture of their child
with the electrodes on; this is embarrassing to many
children.
Explain in age-appropriate language what each sensor
is used for.
Allow them to help you.
Give teens the option of sending the parent home
after getting settled. Keep in mind that it is not
uncommon even for 16 year olds to want a parent to
stay but they may be embarrassed to ask.
Control of breathing
Young infants hypoventilate in response to
hypoxia (adults hyperventilate).
The age in which the hypoxic ventilatory
response occurs is controversial and may be
altered by disease.
Exposure of the peripheral and central
controllers to hypoxia or hypercarbia in infancy
may permanently alter ventilatory responses.
Angle of neck and relationship to snoring.
Parent behavior in response to child’s
movement.
Child’s behavior in response to parent
movement or other sounds in room.
Be alert for confusional partial awakenings and
attempts to sleep-walk.
Listen to what the child says about his/her
sleep problem and document it.
Be certain that you understand the rules and
the specific differences in scoring PSGs in
children vs. adults.
Examples:
Event duration (duration of 2 breaths)
Scoring of hypopnea requires >50% fall in amplitude of NP
signal + arousal, awakening, or >3% desat
RERA scoring requires snoring, noisy breathing, elevation in
PCO2, or visual evidence of increased work of breathing
Central apneas have to be either 20 seconds OR 2 missed
breaths plus arousal, awakening or >3% desat
Hypoventilation rule is based on TST not TIB (>25% at or
above 50 mmHg)
Examples:
Normal heart rate parameters: see Archbold K et. al
JCSM 2010;6:47-50.
No difference in arousal criteria for children vs.
adults.
DPR is slower than alpha and indicates wakefulness.
Occipital sharp waves are common and normal.
Hypnagogic hypersynchrony is present in 95% of
children age 6-8 months and gradually decreases,
but is still often seen in children up to about age 12.
Pediatric sleep technology is enjoyable,
interesting, and has unique challenges.
Pediatric sleep technology requires the ability
to establish good rapport with children and
their parents.