Overview of polysomnography in infants and children
- Madeleine Grigg-Damberger, MD
Madeleine Grigg-Damberger, MD
- Professor of Neurology
- University of New Mexico School of Medicine
Polysomnography (PSG) is a diagnostic sleep medicine tool during which multiple different physiologic parameters are continuously and simultaneously recorded across a sleep period to characterize sleep and identify sleep disorders. Through simultaneous recording of multiple physiologic parameters, particular changes in sleep/wake state or specific abnormalities in one parameter can be correlated with other signals. PSG is thereby a much more powerful diagnostic tool than what can be provided by recording only one or two simultaneous measurements.
Younger and younger children are being referred to sleep specialists and sleep laboratories for evaluation of sleep disorders, which often require PSG for diagnosis, and sometimes treatment. While PSG is considered a painless, noninvasive procedure by most adults, it can be challenging and even frightening for children and therefore requires special considerations.
This topic will provide an overview of PSG in infants and children, including indications for testing, derived information, techniques for obtaining useful data, and scoring and interpretation. An approach to the assessment and classification of specific sleep disorders in children is discussed separately. (See "Assessment of sleep disorders in children".)
TYPES OF SLEEP STUDIES
The American Academy of Sleep Medicine (AASM)  and the Centers for Medicaid and Medicare Services (CMS)  identify four classes of sleep studies based upon how channels are recorded and whether a sleep technologist is present throughout the recording to provide oversight ("attended" or "unattended").
●A level 1 polysomnography (PSG) is performed in a sleep laboratory with a sleep technologist present, recording a minimum of seven channels including electroencephalography (EEG), electrooculography (EOG), submentalis (chin) electromyography (EMG), electrocardiogram (ECG)/heart rate, and pulse oximetry (SpO2).
- Collop NA, Anderson WM, Boehlecke B, et al. Clinical guidelines for the use of unattended portable monitors in the diagnosis of obstructive sleep apnea in adult patients. Portable Monitoring Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2007; 3:737.
- Phurrough S, Jacques L, Stiller J, Brechner R. Coverage decision memorandum for sleep testing for obstructive sleep apnea (OSA) testing. CAG-00405N, US Centers for Medicare and Medicaid Services, Washington, DC 2009.
- Boss EF, Benke JR, Tunkel DE, et al. Public insurance and timing of polysomnography and surgical care for children with sleep-disordered breathing. JAMA Otolaryngol Head Neck Surg 2015; 141:106.
- Konka A, Weedon J, Goldstein NA. Cost-benefit analysis of polysomnography versus Clinical Assessment Score-15 (CAS-15) for treatment of pediatric sleep-disordered breathing. Otolaryngol Head Neck Surg 2014; 151:484.
- Horwood L, Brouillette RT, McGregor CD, et al. Testing for pediatric obstructive sleep apnea when health care resources are rationed. JAMA Otolaryngol Head Neck Surg 2014; 140:616.
- Kotagal S, Nichols CD, Grigg-Damberger MM, et al. Non-respiratory indications for polysomnography and related procedures in children: an evidence-based review. Sleep 2012; 35:1451.
- Wise MS, Nichols CD, Grigg-Damberger MM, et al. Executive summary of respiratory indications for polysomnography in children: an evidence-based review. Sleep 2011; 34:389.
- Aurora RN, Zak RS, Karippot A, et al. Practice parameters for the respiratory indications for polysomnography in children. Sleep 2011; 34:379.
- Aurora RN, Lamm CI, Zak RS, et al. Practice parameters for the non-respiratory indications for polysomnography and multiple sleep latency testing for children. Sleep 2012; 35:1467.
- Roland PS, Rosenfeld RM, Brooks LJ, et al. Clinical practice guideline: Polysomnography for sleep-disordered breathing prior to tonsillectomy in children. Otolaryngol Head Neck Surg 2011; 145:S1.
- Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012; 130:e714.
- Kushida CA, Littner MR, Morgenthaler T, et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep 2005; 28:499.
- Zaremba EK, Barkey ME, Mesa C, et al. Making polysomnography more "child friendly:" a family-centered care approach. J Clin Sleep Med 2005; 1:189.
- Committee on Hospital Care and Child Life Council. Child life services. Pediatrics 2014; 133:e1471.
- Primeau M, Gershon A, Talbot L, et al. Individuals with Autism Spectrum Disorders Have Equal Success Rate But Require Longer Periods of Systematic Desensitization than Control Patients to Complete Ambulatory Polysomnography. J Clin Sleep Med 2016; 12:357.
- Bowmer N. Therapeutic play and the impact on anxiety in hospitalized children. Ky Nurse 2002; 50:15.
- Drake J, Johnson N, Stoneck AV, et al. Evaluation of a coping kit for children with challenging behaviors in a pediatric hospital. Pediatr Nurs 2012; 38:215.
- Moore M, Russ SW. Pretend play as a resource for children: implications for pediatricians and health professionals. J Dev Behav Pediatr 2006; 27:237.
- William Li HC, Lopez V, Lee TL. Effects of preoperative therapeutic play on outcomes of school-age children undergoing day surgery. Res Nurs Health 2007; 30:320.
- Uman LS, Birnie KA, Noel M, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev 2013; :CD005179.
- Berry RB, Gamaldo CE, Harding SM, et al for the American Academy of Sleep Medicine. The AASM Manual for the Scoring of Sleep and Associated Events : Rules, Terminology, and Technical Specifications, Version 2.2, American Academy of Sleep, Darien, IL 2015.
- Berry RB, Brooks R, Gamaldo CE, et al. The AASM Manual for the Scoring of Sleep and Associated Events: Rules, Terminology and Technical Specifications, version 2.4, American Academy of Sleep Medicine, Darien IL 2017.
- Fernandes do Prado LB, Li X, Thompson R, Marcus CL. Body position and obstructive sleep apnea in children. Sleep 2002; 25:66.
- Oksenberg A, Arons E, Nasser K, et al. REM-related obstructive sleep apnea: the effect of body position. J Clin Sleep Med 2010; 6:343.
- Frauscher B, Iranzo A, Högl B, et al. Quantification of electromyographic activity during REM sleep in multiple muscles in REM sleep behavior disorder. Sleep 2008; 31:724.
- Foldvary-Schaefer N, De Ocampo J, Mascha E, et al. Accuracy of seizure detection using abbreviated EEG during polysomnography. J Clin Neurophysiol 2006; 23:68.
- Foldvary N, Caruso AC, Mascha E, et al. Identifying montages that best detect electrographic seizure activity during polysomnography. Sleep 2000; 23:221.
- Aldrich MS, Jahnke B. Diagnostic value of video-EEG polysomnography. Neurology 1991; 41:1060.
- Schenck CH, Milner DM, Hurwitz TD, et al. A polysomnographic and clinical report on sleep-related injury in 100 adult patients. Am J Psychiatry 1989; 146:1166.
- Blatt I, Peled R, Gadoth N, Lavie P. The value of sleep recording in evaluating somnambulism in young adults. Electroencephalogr Clin Neurophysiol 1991; 78:407.
- André M, Lamblin MD, d'Allest AM, et al. Electroencephalography in premature and full-term infants. Developmental features and glossary. Neurophysiol Clin 2010; 40:59.
- Grigg-Damberger MM. The Visual Scoring of Sleep in Infants 0 to 2 Months of Age. J Clin Sleep Med 2016; 12:429.
- Grigg-Damberger M, Gozal D, Marcus CL, et al. The visual scoring of sleep and arousal in infants and children. J Clin Sleep Med 2007; 3:201.
- Berry RB, Budhiraja R, Gottlieb DJ, et al. Rules for scoring respiratory events in sleep: update of the 2007 AASM Manual for the Scoring of Sleep and Associated Events. Deliberations of the Sleep Apnea Definitions Task Force of the American Academy of Sleep Medicine. J Clin Sleep Med 2012; 8:597.
- Burg CJ, Montgomery-Downs HE, Mettler P, et al. Respiratory and polysomnographic values in 3- to 5-year-old normal children at higher altitude. Sleep 2013; 36:1707.
- Uliel S, Tauman R, Greenfeld M, Sivan Y. Normal polysomnographic respiratory values in children and adolescents. Chest 2004; 125:872.
- Marcus CL, Omlin KJ, Basinki DJ, et al. Normal polysomnographic values for children and adolescents. Am Rev Respir Dis 1992; 146:1235.
- Brockmann PE, Poets A, Poets CF. Reference values for respiratory events in overnight polygraphy from infants aged 1 and 3months. Sleep Med 2013; 14:1323.
- Brockmann PE, Schaefer C, Poets A, et al. Diagnosis of obstructive sleep apnea in children: a systematic review. Sleep Med Rev 2013; 17:331.
- Ross KR, Rosen CL. Sleep and respiratory physiology in children. Clin Chest Med 2014; 35:457.
- Caples SM, Rosen CL, Shen WK, et al. The scoring of cardiac events during sleep. J Clin Sleep Med 2007; 3:147.
- Scholle S, Scholle HC, Kemper A, et al. First night effect in children and adolescents undergoing polysomnography for sleep-disordered breathing. Clin Neurophysiol 2003; 114:2138.
- Coble PA, Reynolds CF 3rd, Kupfer DJ, Houck P. Electroencephalographic sleep of healthy children. Part II: Findings using automated delta and REM sleep measurement methods. Sleep 1987; 10:551.
- Li AM, Wing YK, Cheung A, et al. Is a 2-night polysomnographic study necessary in childhood sleep-related disordered breathing? Chest 2004; 126:1467.
- Verhulst SL, Schrauwen N, De Backer WA, Desager KN. First night effect for polysomnographic data in children and adolescents with suspected sleep disordered breathing. Arch Dis Child 2006; 91:233.
- Katz ES, Greene MG, Carson KA, et al. Night-to-night variability of polysomnography in children with suspected obstructive sleep apnea. J Pediatr 2002; 140:589.
- Kolla BP, Lam E, Olson E, Morgenthaler T. Patient safety incidents during overnight polysomnography: a five-year observational cohort study. J Clin Sleep Med 2013; 9:1201.
- Kothare SV, Vendrame M, Sant JL, et al. Fall-prevention policies in pediatric sleep laboratories. J Clin Sleep Med 2011; 7:9.
- Razmus I, Wilson D, Smith R, Newman E. Falls in hospitalized children. Pediatr Nurs 2006; 32:568.
- Tung TH, Liu MC, Yang JY, et al. Useful methods in preventing accidental falls from the bed in children at the emergency department. Eur J Pediatr 2009; 168:1323.
- Marcus CL, Brooks LJ, Draper KA, et al. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics 2012; 130:576.
- TYPES OF SLEEP STUDIES
- INDICATIONS FOR POLYSOMNOGRAPHY
- CHILD-FRIENDLY TECHNIQUES
- Electrode application
- RECORDED SIGNALS
- Evaluation of sleep/wake state
- Respiratory monitoring
- Detection of movements and behaviors
- Expanded EEG montages
- SCORING AND INTERPRETATION
- SAFETY CONSIDERATIONS
- ALTERNATIVE STUDIES
- INFORMATION FOR PATIENTS