Pediatric Sleep Studies: A Sleep Tech’s Guide
When conducting pediatric sleep studies in your sleep lab, remember that you will not treat children the same way you would adults. Children have distinct needs based on their stage of development and age, spanning from when they're newborns to their adolescence.
Children's sleep problems can range from bedtime settling problems, insufficient sleep, sleep apnea, sleepwalking, and even to narcolepsy. The physician orders a pediatric sleep study based on what sleep issues these young patients are experiencing.
Up to 50 percent of kids will have some type of sleep issue. Identifying sleep problems early can prevent negative consequences like:
- Daytime sleepiness
- Learning difficulties
- Behavioral problems
- Poor academic performance
- Vehicle crashes in teens
Sleep is how your body conserves energy, promotes physical growth, restores normal processes, and supports mental development. To ensure these important functions, sometimes a sleep study is necessary to diagnose and treat sleep disorders.
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Why Does a Child Need a Sleep Study?
Sleep issues in children often maintain themselves with time. Because of this, pediatric studies are a good way to identify prevailing sleep disorders in young patients. Diagnosing and treating these disorders is imperative to the health of a child.
In children, there are two basic types of sleep issues — physiological and behavioral. These issues often occur in a young patient simultaneously. For example, when a child has a sleep disorder, it can lead to other health issues. While behavioral problems tend to go away eventually on their own, physiological issues are more involved, and a sleep study may be necessary.
Common Sleep Disorders in Children
Be aware that there are several types of sleep disorders children can experience.
Obstructive Sleep Apnea (OSA)
An upper airway obstruction characterizes OSA. This upper airway obstruction is characterized by interrupted breathing, despite continued respiratory effort, that disrupts normal sleep patterns. OSA is often associated with:
- Decreased upper airway lumen size
- Failure of pharyngeal dilator muscles
- Excessive upper airway soft tissue
In children, however, this obstruction typically occurs due to enlarged adenoids and tonsils. The onset of OSA often occurs when the child is between two and eight years old, in accordance with peak tonsil growth. However, OSA can occur at any age. There is an overall one to five percent prevalence of OSA in children, occurring equally in females and males. It tends to have a higher prevalence in ethnic minorities, though.
Classic symptoms of OSA are witnessed apneas and snoring, however, not all children who snore have OSA. Up to 27 percent of kids habitually snore, and this can complicate identifying OSA.
Other symptoms of OSA may include:
- Sleep-related paradoxical breathing
- Unusual sleeping positions like a hyper-extended neck
- Excessive daytime sleepiness
- Morning headaches
- Nighttime enuresis or diaphoresis
Results of the child's physical examination and medical history alone poorly correlate with objective findings of obstructive sleep apnea, and there's only 78 percent sensitivity shown in questionnaires. Therefore, many children suspected of having OSA should go in for a polysomnography.
Around 50 percent of children have parasomnias. Parasomnias include:
- Sleep terrors
- Confusional arousals
- Sleep talking
Parasomnias are displeasing events that occur with sleep and often occur during a child's (or adults) sleep-wake transitions. They're characterized by awake-like, complex activity that lacks meaningful interaction in the child's environment but appears purposeful.
Other parasomnias features may include:
- Automatic behaviors
- Difficulty awakening
- Quick return to deep sleep following the event
Parasomnias usually occur during slow wave sleep in the child's first half of sleep. Your patient will likely not even remember the event. On the other hand, nightmares occur during REM sleep in the child's last half of sleep and the child remembers the event. Timing and symptoms of nocturnal seizures may overlap with parasomnias. You should ask about any odd posturing and stereotypic behaviors that may represent nocturnal seizures.
By adolescence, parasomnias typically resolve themselves spontaneously, but four percent of people will have a repeat episode.
Delayed Sleep Phase Disorder
In your young patient's suprachiasmatic nucleus is their master circadian clock that controls the timing of their cycles and their sleep approximately every 24 hours.
The conflict between the external world and the internal clock continues to "reset" by different time cues like:
- Body temperature
- Physical activity
When your young patient has a delayed sleep phase disorder, there's a delay in their habitual sleep-wake times by a minimum of two hours opposed to the socially acceptable times. Delayed sleep phase disorder is more common when patients are in their adolescence when the child is more sociable and their circadian rhythm is thought to lengthen. This disorder has seven to 16 percent prevalence in adolescents. The sleep physician utilizes sleep diary documentation of wake and sleep times and patient history to make a diagnosis of delayed sleep phase syndrome.
Restless Legs Syndrome (RLS)
It's unclear what the prevalence of restless legs syndrome is in kids, however, some studies suggest it's around two percent. Unpleasant leg sensations make the child have the urge to move their legs, typically beginning in the evening. When your patient rests, their symptoms worsen. Getting up and moving around can offer relief.
Other RLS symptoms include:
- Bedtime resistance
- Difficulty falling asleep
- Similar symptoms to those of ADHD
- Growing pains
RLS in children is more common when they have ADHD and is associated with decreased attention and cognition as well as negative mood and behavior.
Genetics, dopamine dysfunction, and iron deficiency all play a role in the development of RLS. Also, symptoms can worsen with inadequate or excessive physical activity, antihistamines, caffeine, tricyclic antidepressants, selective serotonin, and nicotine.
Prepping the Sleep Center for Children
You will use the same tests that you use in adults for children to diagnose and rule out any other types of sleep disorders. But, since young patients are more likely to remove the sensors, performing pediatric studies in the sleep clinic is better than home monitoring.
Therefore, there are certain things you need to do to prep the sleep center for pediatric sleep studies, including:
- Ensure you provide a family-friendly environment
- Have equipment ready that's smaller in size
- Have an area for parents
- Provide games, toys, etc.
If your patient is under the age of 18, a parent must stay overnight.
Being well prepared and ensuring you prep your sleep center appropriately is important. It may take some advanced preparation and forethought to make this step simpler.
How to Prepare the Child & Their Parent or Guardian for the Study
You should know how to communicate with both the child and parents for all age groups so you can ease their anxiety properly and ensure the study is successful.
Children Under Two Years
Communicating with this age group is primarily between you and the parents. The infant will most likely sleep through most of the night with only a few brief interruptions for diaper changes and feedings. Toddlers and infants are too young to know what's going on and expressing their needs. They depend on their parents/caregiver completely for assistance. You'll calm the anxious parent by explaining the test procedure so they can get a better understanding of the entire sleep study process.
The parent's cooperation can be your biggest asset for this age group. They can help assist you by keeping their infant's hands away from equipment and electrodes, holding the infant, and distracting them.
Ages Two to Five
You should initiate an introduction and communicate with your young patient and their parents before their scheduled appointment for this age group. Sleep facility staff can help assist you in preparing the child properly by supplying a video and giving a tour of the sleep lab so they know what to expect. Both you and the parents should use words to explain the sleep study procedure that is age-appropriate. This can help ease the child's anxiety.
Your young patient will probably fall asleep more naturally if you make them comfortable in the sleep study environment. Give both the child and parents time to get used to their surroundings.
Encourage the parents to continue with regular nightly routines such as:
- Providing snacks
- Reading a book
- Putting on pajamas
- Bringing a teddy bear
Anything that can simulate a homelike environment is helpful. Put your young patient in a bed that has bed rails so they remain safe. Establish a "lights out" time ahead of time so your patient knows what their bedtime will be.
Ages Six through 18
Although adolescents might be similar to adults, there are some important, subtle differences. There are certain techniques you can use that can help make the sleep study successful. You can gain insight about the patient and gain rapport by identifying their presenting behavior.
For instance, by observing the teen patient looking down, wearing headphones, or not making eye contact, you can probably assume they're bored, angry at their parents for making them do this study, or a little anxious. By doing this, you get the opportunity to talk with the patient and assure them you understand the situation may be difficult for them, you realize they would rather be somewhere else, and that you're there to help them. By being perceptive, observant, and empathic, you should have no problem coaxing a cooperative patient so you can get a recording that's of good quality.
Remember, you need to respect the teen patient’s privacy. Before entering their room, be sure to knock. Use age-related terminology that's appropriate to increase compliance.
No matter what the age group your young patient falls under or any other medical conditions, you have the ability to gather up reliable medical data so the doctor can review it, make a diagnosis, and treat your patient. But, you also play an important role in providing care for your pediatric sleep patients.
- Pediatric patients need to be treated differently than adult patients.
- Up to 50 percent of children have a sleep disorder.
- Pediatric studies help in identifying the type of sleep disorder the young patient has.
- Proper prepping of the sleep lab is important.
- You need to know how to communicate with your young patient no matter what age they are.
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