Knowing how to properly score a polysomnogram (PSG) is a must for the sleep technologist, and understanding pediatric and infant scoring rules is crucial for those who work with this population as sleep issues can greatly impact growth and overall health as infants and children age into adulthood.
While PSG conducted in both adults and children is similar, there are differences in scoring rules. Children are not “mini-adults” and when PSG is conducted in the pediatric patient a specific set of scoring rules are used in order to accurately interpret test findings.
Accurate scoring is important as it impacts diagnosis, treatment, viable comparable data for future testing and assists with correlating findings with outcomes. It is also critical that everyone overseeing the pediatric patient’s care is following the same set of scoring rules.
As mentioned in Module 2 of the AAST Advanced Pediatrics Module Series, scoring pediatric and infant sleep studies is an acquired skill and can take time to successfully master. For accurate information on technical specifications and scoring for pediatrics, it’s imperative that the most updated version of the AASM Scoring Manual is being used.
As Laree J. Fordyce, CCRP, RPSGT, RST, CCSH, notes in the module, “Pediatric sleep staging rules apply to children two months post-term or older. There is no precise upper limit boundary for using pediatric staging rules.”
Determining Staging Rules
The scorer will want to work with their sleep laboratory medical director to determine which staging rules should be used for children as they age, so that everyone is working with the same set of rules:
- Use pediatric rules for those less than 18 years of age
- Use adult scoring rules for individuals over 13 years of age
For patients 37-48 weeks conceptual age through two months post-term, sleep technologists should use sleep staging rules for infants. These stages are as follows:
- Wakefulness (W)
- Rapid Eye Movement sleep (R)
- Non-REM sleep (N)
- Transitional sleep (T)
Child sleep staging varies from infants in that the rules are similar to those of adults, generally being defined as N1, N2, N3 and REM (R). Children less than six months of age who do not have a defined N2 non-REM sleep stage should be scored as N.
Dominant Alpha Rhythm
In infants and children who have not developed alpha rhythm activity, sleep and medical professionals should look for a dominant posterior rhythm (DPR). The DPR develops by age three to four months post-term and increases in frequency with age.
DPR Ranges by Age:
- 3-4 months: DPR ranges between 3.5 to 4.5 Hz
- 5-6 months: DPR increases to 5 to 6 Hz
- 3 years: DPR increases to 7.5 to 9.5 Hz
The DPR continues to increase in frequency until it meets criteria for alpha.
In order to accurately score pediatric PSG, sleep technologists must use the most recent scoring rules for both infants and children and have a thorough understanding of the sleep stages and how their characteristics differ with age.