PSG Scoring
for the Pediatric Patient
Jennifer Chen Hopkins, M.D.
D. ABP, ABIM & Sleep Medicine
Texas Society of Sleep Professionals
October 28, 2011
Objectives
 Indications for pediatric sleep study
 Normal sleep and EEG changes during childhood
development
 Differences between adult and pediatric PSG scoring
and interpretation
Kids who may need
a sleep study
 Suspected OSA (snoring + “ADHD”/behavior problems,
tonsillar hypertrophy, Down syndrome, craniofacial
malformation, obesity, HTN)
 Suspected Narcolepsy
 Suspected PLMD
 Suspected seizure disorder
 Congenital neuromuscular disorder
 Suspected central hypoventilation
 Infants: apnea of prematurity, severe GER, ALTEs/SIDS
Normal sleep in kids
 Birth to 1 year:
 Sleep 50-75% of day, gradually decreases
 Circadian rhythm begins by 6 mo., still 2-3 naps
 NREM-REM cycles shorter (50 min/50 wga), gradually
increases
 More REM: 40-50% of TST
 Preschool kids:
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

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12-14 hours sleep/24h
Usually phase advanced
Take 1-2 naps
Behavioral sleep problems start
Normal sleep in kids
 School-age kids:





9-11 hours sleep/24h
No nap
90 minute NREM-REM cycle
Increase in slow wave sleep
More phase-delayed, towards puberty
Normal sleep
When to use
Pedi Scoring Rules
2 months to 12 yrs – use pedi rules
13 yrs to 17 – can use either adult or pedi
rules
 Better to use 3% desat if use adult rules
(C. Marcus, SLEEP v33, n10, 2010)
Normal Pediatric
Sleep EEG
Normal EEG in kids
 ODR (“alpha”)
present at birth
 Spindles
2 to 3 mo
 Delta waves
4 to 5 mo
 K-complex
4 to 6 mo
Occipital Dominant Rhythm
(ODR)
- AKA: Dominant Posterior Rhythm (DPR)
- Their “alpha” rhythm
- Occipital leads during eyes closed
Occipital Dominant Rhythm
(ODR)
Development of EEG
Characteristics
 Spindles
2 to 3 mo
 Delta waves
4 to 5 mo
 K-complex
4 to 6 mo
Infants:
- May have to stage sleep as Quiet (N) vs.
Active (R) sleep.
- Use other parameters to help stage: eye
movements, chin tone, RR, HR, etc.
Things that look funny but really
are quite normal…
 Tracé alternans
 Hypnagogic
hypersynchrony
Trace Alternans
- NREM sleep
- Seen in full term newborns (until 3 mo)
Hypnagogic hypersynchrony
- Synchronous, high voltage theta
waves associated with sleep onset
- Seen in infants and children
Pediatric Scoring:
Respiratory Events
Respiratory Events
 OA
 90% decreased flow
 At least 2 missed breaths
 OH
 50% decreased nasal pressure for at least
2 breaths
 Associated with arousal or 3% desaturation
Respiratory events
 RERA
 Discernable fall or flattening of nasal pressure, but
<50%
 Snoring or increase in pCO2
 Increased respiratory effort
 At least 2 breaths
 Central Apnea
 Absence of respiratory effort for 2 breaths +
arousal or 3% desaturation
 20 sec or longer without arousal or desat
Pedi Diagnostic Criteria
for OSA
 Mild
AHI 1 to 5
 Moderate
AHI 5 to 15
 Severe
AHI >15
Only need 7 events during a 7 hour PSG to earn
a diagnosis of Sleep-disordered breathing!!!
Other respiratory
considerations
 Hypoventilation: >25% of TST with CO2 >50
mm Hg
 Periodic breathing: >3 episodes of central
apnea lasting >3 sec, separated by no more
than 20 sec of normal breathing. (Physiologic in
infants)
Non-invasive CO2
 End Tidal CO2 (more common)
 Transcutaneous CO2
Periodic Limb Movements
 PLMS in kids are scored the same way as in
adults.
 Only need PLMAI ≥ 5 for diagnosis of PLMD.
 Can support a diagnosis of RLS.
Take-Home Points
 Kids need sleep studies for some of the reasons that
adults do but also for some reasons specific to
Pedatrics (hyperactivity/behavior problems, tonsillar
hypertrophy, dysmorphic features).
 EEG characteristics and sleep staging vary
dramatically with age from birth to age 17. Pay
attention to ODR and be able to recognize normal EEG
patterns commonly seen in pedi patients.
 Respiratory scoring in pediatrics: NOT the same as
adults. Being meticulous is paramount because every
event counts!
References
 The AASM Manual for the Scoring of Sleep and
Associated Events, 2007.
 Sheldon SH, Ferber R, Kryger MH. Principles and
Practice of Pediatric Sleep Medicine, 2005.
 C. Marcus, “Differences in Overnight PSG Scores
using Adult and Pediatric Criteria for Respiratory
Events in Adolescents”, SLEEP v33, n10, 2010.
 http://naraamt.or.jp/Academic/kensyuukai/2005
 Google images
Questions?