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.