Ov

erv
iewofpol
ysomnogr
aphyi
ninf
ant
sandchi
l
dren
Author
:Madelei
neGrigg-Damberger
,MD,SectionEdi
tor:
RonaldDChervi
n,MD,MS
DeputyEdi
tor
:Apri
lFEichler
,MD,MPH
Li
terat
urer
evi
ewcur r
entt hr
ough:
 Nov2020.
 |
 Thist
opiclastupdat
ed:
 
Jun22,2020.

INTRODUCTI ON: Pol

ysomnogr aphy( PSG)i sadiagnosticsleepmedi cinetoolduri
ng
whichmul t
ipledif
fer
entphy siologicpar amet ersarecontinuouslyandsi multaneously
recordedacrossasleepper iodt ochar act er
izesleepandi dentif
ysl eepdisorders.
Throughsimul t
aneousr ecordingofmul tiplephysiol
ogicpar amet ers,changesin
sleep/wakestateoralterat
ionsi nonepar amet ercanbecor rel
atedwi thothersignal
s.
Thus, PSGisamuchmor epower f
ul diagnost i
ctoolthancanbepr ovidedbyr ecor
ding
onlyoneort wosimultaneousphy siological measures.

Youngerandy oungerchil
drenarebei
ngr eferredt
osleepspeci
ali
stsandsleep
l
abor atori
esforevaluat
ionofsleepdisorders;PSGisoft
enrequi
redfordiagnosis,
and
somet imest r
eatment.WhilePSGisconsi deredarel
ati
vel
ypainl
ess,noninvasi
ve
procedur ebymostadul t
s,itcanbechall
engi ngandevenfr
ight
eningforchil
drenand
thereforerequi
resspecialconsi
derat
ions.

TYPESOFSLEEPSTUDI ES:TheAmer i
canAcademyofSl eepMedicine(AASM)[ 1]and
theCenter
sf orMedi
cai
dandMedi careServices(CMS)[2]ident
if
yfourclassesofsleep
studi
esbaseduponhowchannel sarerecordedandwhet herasleeptechnologi
stis
presentt
hroughoutt
herecordi
ngtoprovideov er
sight(
"att
ended"or"unatt
ended").

●Al evel1pol
ysomnogr aphy( PSG)i
sperformedinasleeplaborat
orywithasleep
technologi
stpresent,r
ecordingaminimum ofsevenchannelsincl
uding
electr
oencephalography(EEG),el
ect
rooculogr
aphy(EOG),submentali
s(chin)
electr
omy ogr
aphy( EMG),electr
ocar
diogr
am (ECG)/
heartrate,andpulseoximetr
y
(SpO2).

●Alev
el 2PSGissi
mpl
yal
evel
1PSGwhi
chi
srecor
dedunat
tended,
inoroutoft
he
sl
eeplabor
ator
y.

●Alevel
3studyrecor
dsami ni
mum off
ourchannel
s,incl
udingvent
il
ati
on,oxi
metry,
ECG,orhear
trat
e,andisdoneathomeorout
sideofthesleeplabor
ator
y,unat
tended.

●Alevel
4studyr ecor
dstwotot
hreecar
dior
espi
rator
ysignal
s(mostof
tenai
rf
low,
SpO2,
andheartr
ate)andistypi
cal
l
ydoneathome,unatt
ended.

Compr ehensi
vein-
laboratoryoverni
ghtPSG(i
e,lev
el1PSG)issti
ll
regar
dedasthegol
d
standardmethodforrecor di
ngsleep/wakest
atesandfordi
agnosi
ngobstr
uct
ivesl
eep
apnea( OSA)andothersleepdisordersi
nchil
dren,f
orsever
alr
easons:

●At echnologi
stispresentt
hroughoutt
oident
if
y,r
epai
r,r
epl
ace,
int
erv
ene,
prot
ect
,and
testtreat
ment(s)ifneeded.
●Thesever
it
yofsleep-
disorder
edbreathi
ng(ie,t
heapneahypopneaindex[AHI]
,mean
numberofapneasandhy popneasperhour)canbederi
vedfrom sl
eeptime,r
atherthan
ti
meinbed.AHIbasedont imeinbedmaybef al
sel
ylow,under
esti
matingOSAsev eri
ty
i
ftoomuchoft heni
ghtisspentawake.

●Nonr
espi
rat
orysl
eepdi
sor
der
sandot
herdi
srupt
orsofsl
eepcanal
sobei
dent
if
ied.

However,
Level1PSGi sexpensiveandt
ime-andlabor
-i
ntensiv
etorecor
d,score,
and
r
ead.Avai
labi
li
tyisoft
enlimit
ed,andwaitt
imescanbelongi nsomeregi
ons,especi
all
y
f
orinf
antsandy oungchi
ldren[3-
5].

Forthesereasonsandother
s,l
evel3studi
es(i
e,homesleepapneatest
ing)are
i
ncreasingl
yusedinadul
tstodiagnoseOSA.Therearemorel
imiteddat
aonl evel
3
studi
esinchil
dren,andt
hishasnotyetbecomestandar
dpract
ice.

INDICATIONSFORPOLYSOMNOGRAPHY: Poly
somnography(PSG)playsarol
einthe
diagnosi
sandtreat
mentofavari
etyofrespi
rator
yandnonrespi
rat
orysleepdi
sordersi
n
chil
dren[6-
11]
.Specif
ici
ndi
cat
ionsforPSGinchildr
eni
ncludethefol
lowing[
8,9,
12]:

●Diagnosisofsl
eep-
rel
atedbreat
hingdi
sorders(SRBD)suchasobstr
ucti
vesleepapnea
(OSA),centr
alsl
eepapnea(CSA),orsl
eep-
relat
edhy pov
enti
l
ati
ondisor
ders.

●Preoperati
veassessmentbeforeupperairwaysurgery( eg,adenotonsil
lect
omy ),
part
icul
arlyi
nchildr
enwithsnori
ng,signsandsy mptomsofOSA, orotherhigh-ri
sk
th
feat
ures(eg,obesit
ywit
habodymassi ndex[BMI]≥95 per centil
e,Downsy ndr
ome
[
DS],craniof
aci
alabnormali
ti
es,neuromusculardisorders,si
cklecelldisease).

●Ti
tr
ati
onofposi
ti
veai
rwaypr
essur
e(PAP)t
her
apyf
orSRBD.

●Evaluati
onoft r
eatmenteffi
cacyofPAP, or
alappl
iances,weightloss,orupperair
way
surgeri
esinpatientswithSRBD.●Evaluat
ionanddiagnosi
sofsuspect ednarcolepsy
type1or2, i
diopathichyper
somnia,andothercent
ralhypersomnias,foll
owedbya
multipl
esleeplatencytest(
MSLT).

●Di
agnosi
sofrapi
dey emovementsl
eepbehav
iordi
sor
der(
RBD)and/
orr
api
dey
e
movementsl
eepwithoutat
oni
a(RWA).

●Eval
uati
onofpar oxysmalnoctur
nalev
entswithexpandedelectr
oencephal
ogr
aphy
(EEG)andvideo-PSGinselect
edpati
ents,
suchast hosewit
hat y
picalf
eatur
es,
cli
nical
suspi
cionforsleep-
rel
atedsei
zures,
orpotent
ial
lyi
njuri
ousbehavior
s.

●Assessmentofselectedchildrenwit
hsuspectedrestl
essl
egssyndr
ome( RLS),
when
addi
ti
onalsupport
ivedata( eg,demonstrati
onofperi
odicl
egmovements)aredesir
edt
o
hel
pconfir
mt hediagnosis.Inotherchi
ldrenwit
houtRLS,PSGcanbeusefulto
di
agnoseperiodi
climbmov ementdisorder(PLMD).
●Suspect
edsl
eep-r
elat
edepi
lepsywhenthei
nit
ial
cli
nical
eval
uat
ionandst
andar
dEEG
ar
einconcl
usi
ve,
tohelpdi
sti
nguishf
rom par
asomnias.

●Confi
rm andt
reatcongeni
tal
cent
ral
alv
eol
arhy
pov
ent
il
ati
onsy
ndr
ome,
incl
udi
ngl
ate-
onsett
ypes.

PSGi snott hebestf i

rsttestforev al
uati
nginsomni a,RLS,circadianrhythm sleep-
wake
disorders,t
ypicaluncompl icatedparasomnias,sleep-rel
atedepilepsy,depression,
chroniclungdi sease,sl
eep- r
elatedbruxi
sm, orbehavioral
ly-basedinsomni a[9,12]
.
AlthoughPSGi snotrout i
nelyindicat
edintheev aluat
ionofsl eepwalkingandsl eep
terror
s,itshouldbeper formedwhent hereiscli
nicalsuspicionforanot hersl
eep
disorder(eg,OSA)t hatmaybepr eci
pit
ati
ngpartialarousalsfrom sleep.

CHILD-FRI ENDLYTECHNI QUES: Alt

houghnoninvasiv
e, pol
ysomnogr aphy(
PSG)canbe
i
ntrusi
v e,onerous,
andev enfri
ghteni
ngf orchi
ldr
en.Adopt i
ngandr outi
nel
yemployi
ng
chi
ld-f
riendly,
family
-cent
eredPSGpr act
icescanincr
easet hel
ikel
ihoodofobtai
ningan
i
nterpretablePSGandofhav ingthepat i
entret
urnforfoll
ow-up[13].

Chil
d-f
ri
endlyPSGt echni
quesbegi
nwit
hpreparati
onandeducationofthechil
dand
famil
y,i
deall
ybeforetheycometothel
aborat
ory.Thetechni
quesr ev
iewedbel
owar e
deri
vedfrom exper
texperi
enceinr
ecor
dingover1000sleepstudiesinchi
l
dren[14]
.

Preparati
on — 
Preparingthechildandcar egi
verbef
orethePSGlessensanti
cipator
y
anxiet
yandpr oceduraldi
stress,i
ncreasescooperat
ion,i
mprov
espar ent
alsati
sfacti
on,
andhel psthechi
ldtoler
atef ut
uremedi calpr
ocedures.

●Whenasleepst
udyi
sindi
cat
ed,
thecl
i
nici
anshoul
ddescr
ibetheprocedur
einage-
appr
opr
iat
e,posi
ti
vet
ermsandpr
ovi
deanexpl
anati
onofwhythestudyisneeded.

●Wri
tt
enandv i
sualpr
eparat
orymateri
alcanbev
eryhel
pful
.Thismayincl
ude
pamphl
ets,ani
ntr
oductor
yvideoshowinghowPSGisdone,andatouroft
hesleep
l
abor
ator
y .

●Encour
agethechil
dtobr
ingper
sonal
itemsf
rom home(
eg,
fav
ori
tet
oy,
blanket
,
st
uffedani
mal,dol
l
,paj
amas).

●Cli
nici
ansandstaffshoul
didenti
fypati
ent
swhomayneedaddi ti
onalassi
stanceand
supportaheadofti
me, i
nordertoarr
angefor1:1st
affingifneeded.Suchpatient
smay
i
ncludethosewhoar emedical
lyfr
agil
e,dev
elopmentallydel
ayed,orwhohav ehad
dif
fi
cult
ytoler
ati
ngotherpr
ocedures.Examplesofscreeningquesti
onsincl
ude:

•Howeasil
ydoesyourchi
l
dtol
erat
etest
s,sur
ger
ies,
medi
cal
procedur
es,
orev
ensi
tt
ing
sti
l
lforhai
rcut
s?

•
Doesy
ourchi
l
dhav
esensor
ysensi
ti
vi
ti
es(
noi
se,
touch,
smel
l
,text
ures)
?
•
Doesy ourchi
ldhaveanyhomemedicalequi
pmentorspeci
ali
zedmedical
needs(
eg,
f
eedingtubes,
sucti
oningdev
ices,
per
it
onealdi
aly
sis,
mechanical
vent
il
ator
,
t
racheostomycaps)
?

●All
owatl east90mi nut
esbeforeusualsleeponsetinchil
drenyoungerthansixyear
s
ofage( oranychi
ldr
enwi thspeci
alneeds)topermitadjustmenttothelabor
atoryand
hook-
up; twohourslead-
timeisneededf oraPSGt hati
ncludesexpanded
el
ectroencephal
ography(EEG)mont ages.

●Longertechnologistshift
sar eneededtor
ecordPSGinchildrenbecauseoftheir
l
ongersleeptimes: 11t o12hour sfort
oddl
ersandpreschoolers,9to10hoursfor
school
-agedchildren.Itisusefult
oextendthesl
eeprecordi
ngt imetocaptur
esuffici
ent
rapi
deyemov ement( REM)sl eepinthemorni
ng(whenapneai sof t
enworse).

●Ifi
tseemsl i
kelyt
hechildwi l
lhav
egreatdiffi
cul
tycooperati
ngforPSG( orhasf
ail
edit
before),andt hePSGi scrucial f
ormedicaldecisi
on-
making,considerinvolvi
ngachil
d
l
ifespeci ali
sttopreparethechi ldf
orPSG[ 15].Afor
mal desensi
tizati
onpr ot
ocol
,in
whichchi ldrenaregraduallyexposedtopor t
ionsofthePSGequi pmentathomei nthe
weeksl eadingupt oast udy ,canbetaughttocaregi
versandmayi ncreasethe
l
ikeli
hoodofasuccessf ul studyinchil
drenwithauti
sm spectrum disorderor
development aldel
ay[16].

●Avoi
dperformingaPSGwhenapati
entisacutel
yunwelloronthesamedayas
i
mmuni zat
ion[17]
.Acut
eil
l
nessmayexacerbat
esleep-
disor
deredbreat
hingorot
her
sl
eepproblems.

●Unl
esst
hePSGisperf
ormedf
oraspeci
alpur
pose(eg,
suspect
ednarcol
epsyor
par
asomni
a),
pat
ient
sshoul
dmaint
aint
hei
rusualsl
eephabi
tspr
iort
othestudy. 

●Chi
l
drenshoul
dav
oidcaf
fei
nat
edorener
gydr
inkst
hedayoft
hePSG.

●Medi cati
onsthechi l
dt akesshoul dberev i
ewed.Hy pnotics,sedat i
ves, andopi oi
d-
basedanal gesi
cscanwor senori nducesleep-disorderedbr eathingandmayal tersl
eep
archit
ectureandar ousal thr
eshol ds[17]
.Ant i
depr essants, antipsy chot i
cs,
benzodiazepines,andbar bi
turat
escanal tersleepar chitecture, arousal t hresholds,
sleepspindles,musclet one, andlegmov ement s.Thecl i
nicianor deringt hePSGneeds
todecidewhet herclonidine,caffeine,melatonin,nasal steroids, antihistami nes,
met hyl
phenidateanddexamphet ami neshouldbecont inuedt heni ghtoft hest udy.I
n
somecases, wit
hdrawal ofachr onicmedi cati
onorsubst ancemayf ur t
herdi sturbsleep.

●Sedat
iont
oobt
ainsl
eepi
napedi
atr
icPSGi
sbestav
oided.

El
ect
rodeappl
i
cat
ion

●Chi
ldr
enyoungerthansi
xyear
sofagehav el
i
mit
edabili
tyt
ocooperatewit
hthePSG
pr
ocedureandsetup,andev
enolderchi
l
drenmayregr
essunderst
ressful
condi
ti
ons.
Youngerchil
drenneedshort
,concr
eteexpl
anat
ions.Pat
ience,
flexi
bil
i
ty,
andapl
ayf
ul
andposit
iveatti
tudecangoalongway.

●Avoidlay
ingchi
ldr
endownorr estr
aini
ngthem t oapplysensor
s.Inst
ead,posi
ti
onthe
chil
d(whocansit)i
nt heparent'
slap(chest
-to- chesthuggi
ng,si
tti
ngsidewaysor
for
ward).Chi
ldr
enfeel l
essvulner
ablewhenpl acedinthese"posi
tionsofcomfort
"and
arebett
erablet
omai ntainasenseofcont r
ol andcooper ati
on.

●Seekoutt
hepar
ent
'shel
pandadv
ice.Whathashel
pedthechi
l
dmanagehar
dthi
ngs
i
npast?Whatmayhel
pthechi
l
dcooperat
ewiththeset
up?

●Usechi
l
d-f
riendl
yter
minol
ogyf
ort
hePSGsensor
sandexpl
anat
ionsf
ort
heset
upand
pr
ocedur
e[14].

●Medi
cal
playcanhel
pthechi
l
dcooper
ate[
18-
21]
:

•Demonst
rat
ehowandwher
easensori
sappl
i
edont
hei
rdol
lorst
uff
edani
mal
bef
ore
placi
ngi
tonthechi
l
d.

•
Encour
aget
hechi
l
dtot
oucht
hesensor
sandequi
pment
.

•
Askt
hechi
ldtobl
owbubblesupi
ntheai
rwhi
l
eattachingt
hechi
nelectr
omyogr
aphy
(
EMG),
orputt
heplayel
ect
rodeont
hedol
lwhi
ley
oupl aceoneonthechil
d.

•
Givethechi
ldchoi
ces:DoIputonthelegorchi
nsti
ckyfi
rst
?Whichfi
ngerf
ory our
f
ingerni
ghtl
i
ght?Wouldli
ketohol
dt hemir
rorandwatchmeputsti
cker
sony ourchi
n?

●All
owextr
ati
meandt
ime-
out
sforchi
l
drenwhobecomef
ri
ght
ened,
emot
ional
l
ylabi
l
e,
orover
whel
med.

●Provideadi
str
act
ionbox(eg,
sti
ckers,
musical
andli
ght-uptoys,pop-
upbooks,
bubbles)t
oengagethechi
l
dwhi l
esensorsar
eappl
ied[22].Pr
aisethechi
l
dev er
yst
ep
oftheway.

●Nasalai
rfl
owsensor sarepart
icularl
yodi oustochi l
dren,
andthetechnol
ogi
stmay
needtowaitunti
lthechil
disdeepl yasleept oapplythem.Sometimes,thecl
i
nici
anmay
havetoacceptrecordi
ngonlypulseoxi met r
y(SpO2),respi
rat
oryi
mpedance
pl
ethysmography(RIP),
andelectrocardiogram (ECG)anddependuponsuppl ement
al
dataf
rom quali
tyvideoanddir
ectobser vati
onsbyt hetechnol
ogi
st.

RECORDEDSI GNALS:Polysomnography(PSG)dataarerecorded,scored,andanalyzed
i
nchi ldrenusingcri
ter
ia,
recommendat i
ons,andtechni
calspecifi
cati
onsdet ail
edinthe
Amer icanAcademyofSl eepMedi ci
ne(AASM)Manual fortheScor i
ngofSl eepand
Associ atedEvent
s,whichisupdatedregular
ly[
23].Whi
lemostaspect sofPSG
recordingaresimil
arforadult
sandchi l
dren,t
herearemajordif
ferencesint hescori
ng
rulesforsleep/wakestat
esandr espi
rati
on.
Eval
uationofsleep/wakestat
e — Sleep/wakest
atesandarousal
sareidenti
fi
edand
cl
assifi
ed(scored)usi
ngthreebiologicalpar
ameter
s:el
ect
roencephal
ography(EEG)
,
el
ectroocul
ography(EOG),andsubment al
is(
chi
n)surf
aceelect
romyography(EMG)
acti
vi
ty.

●EEGrecor
dedfrom thefr
ontal
,cent
ral
,andocci
pit
alscal
pregi
onsper
mit
srecogni
ti
on
ofsl
eep/wakest
ate,asfol
lows:

•Wakeful
ness(W)isi
ndi
cat
edbyt hepr
esenceofadominantpost
eri
orr
hyt
hm ov
ert
he
occi
pit
alregi
ons,
whichi
sattenuat
edbyeyeopeni
ng(f
igure1).

•Sl
oweyemov ementsoverthefr
ontalr
egionsaretypical
l
ythef
irstsignofnon-
rapi
d
eyemovement(NREM)st ageN1sleep(fi
gure2);v
ertexwaves,
typicall
ymaximalover
thecent
ral
regi
ons,appearlat
eri
nstageN1( butarealsoseeni
nst ageN2)(fi
gure3).

•Sleepspi ndl
esofst ageN2sl eep(whichmaylingerint
oear l
yN3)fir
stappearov erthe
mi dl
inecent r
al r
egioni ninfant
sat44t o48weekspost -concept
ionalage.Until13y ear
s
ofage, sleepspindlesar emaxi maloverthefr
ontalandcentralr
egions( f
igur
e4) .After
age13, sl
eepspi ndlesar emostprominentandofhi ghestampli
tudeov ercentr
al
regions( f
igure5).Occasi onall
y,f
ront
al sl
eepspindl
esar eseeninyoungadul t
si n
transit
iont ostageN2sl eep.

•
K-complexesofstageN2sl
eep(
fi
gur
e6)ar
eof
tenofhi
ghestampl
i
tudeov
ert
he
f
rontal
EEGr egi
ons.

•
Highvol
tageslowwaveacti
vi
tyofstageN3sleepi
stypi
cal
l
yofhi
ghestampl
i
tudeov
er
t
hefront
alregi
onsandscor
edinthesechannel
s(fi
gur
e7).

•Saw-
toothwavesofREM sl
eepar
ebestseenovercent
ralregions,
typi
cal
ly
accompaniedbyrapi
deyemovement
s,alow-v
olt
agemi xedfrequencyEEG,andchi
n
EMGat oni
a(fi
gur
e8).

●EOGdet ect
schangesinelectr
icalf
ieldsgeneratedbythemov ementoftheey
ebal
ls,
whichhaveahorizont
aldipol
ewi thast r
ongpositivechargeint
hecorneaandaminor
negati
vechargeattheret
ina.Twodifferentmont agesarerecommendedbytheAASM
forscor
ingEOG[23].EOGdat aareusedi nseveralways:

•
Eyemovement
sarepar
ticular
lyusefuli
nident
if
yingsl
eeponsetandr
api
dey
e
movement(
REM)sl
eep(stageR)(figur
e9).

•
Slowey
emov
ement
sar
ethemostdependabl
emani
fest
ati
onofst
ageN1sl
eep.

•
Rapi
dey
emov
ement
sar
eacar
dinal
signofREM sl
eep(
fi
gur
e8)
.

●Chi
nEMGisusedtoassessaxi
alskel
etal
musclet
oneandacti
vi
ty.Mostaxi
alskel
etal
muscl
esar
eacti
vel
yinhi
bit
edduri
ngREM sleep(
savet
heext
raocul
armusclesandthe
di
aphr
agm)
,ther
ebypr
event
ingdr
eam enact
ment
.

•
ChinEMGt endst
odecreaseatsl
eeponset,f
urtherdi
mini
sheswit
hincr
easi
ngdept
hof
NREM sl
eep,andr
eachesit
slowestl
evelofacti
vit
yinREM sl
eep.

•Theonset,
presence,andof
fsetofREM sleepi
sidenti
fi
edandscoredwhent
hechi
n
EMGi sabsentoratit
slowestampli
tudeintherecor
ding(wav
efor
m 1).

•Ar
ousal
sfr
om sl
eepar
eoftenaccompani
edbyt
ransi
enti
ncr
easesi
nmuscl
etone,
evi
dentont
hechi
nEMG( f
igur
e2).

•
TheAASM scor
ingmanual
requi
resatr
ansienti
ncr
easei
nchi
nEMGl ast
ing>1second
t
oscor
eanEEGar ousal
dur
ingREM sl
eep(butnoti
nNREM sl
eep)[
23]
.

Respir
atorymonitoring —  Al
mostalloft hesensorsusedt omonit
orbreathingandgas
exchangeduringsleeppr ovi
dequalit
ative,notquantit
ativ
e,dat
a.Becauseoft hi
s,
redundantmeasuresofr espirat
ionduringsleepareneeded.Thispermitscorrel
ati
onof
changesinrespir
ation, pulseoximetry
,car bondioxi
de( CO2)
,andel
ectrocardi
ogram
(ECG)withthreeaddi ti
onal measures:bodyposi t
ion,sl
eep/wakestages,andarousal
s.
Thesecross-corr
elationsar enecessaryf orsev
eralreasons:

●Sl
eep-
disor
der
edbr
eat
hingof
tendi
srupt
ssl
eep,
causi
ngar
ousal
sorawakeni
ngs.

●Sleep-
disor
der
edbreat
hingismor
eoftenworsewhensl
eepi
ngsupi
ne(
andsomet
imes
proneinyoungchi
l
dren[24]
)ordur
ingREM sl
eep[
25].

●Desat
urati
onsrel
atedtosleep-
disor
deredbreat
hingar
eof t
enworsedur
ingREM sl
eep,
andrel
atedcar
diacarr
hythmiasorsinuspausesarepar
ticul
arl
ycommonduringt
his
ti
me.

●Sleepingthroughsuchdesaturat
ions(wi
thoutanarousalorawakeni
ng)i
san
i
mpor t
antcli
nicalobser
vat
ion,i
ncreasi
ngthepotent
ialser
iousnessoft
hesleep-
rel
ated
breathi
ngdisor der(
SRBD).

Multi
plesensorsareusedduri
ngPSGt omonit
orforsleep-
disor
deredbr eathi
ng.These
vari
ablesareusedtodetectr
espir
atoryevent
s,suchasapneasandhy popneas,andto
cal
culatesummar ymeasures(eg,apneahypopneaindex,r
espir
atorydistressi
ndex)
(t
able1).

●Or onasalt
hermalandnasalpressuresensors–Thesesensorsmoni t
orairfl
ow
throughthenoseandmout h;thethermalsensorbesti
denti
fi
esapnea,andt henasal
pressuresensorbesti
denti
fi
eshy popneasandrespir
ator
yeventrel
atedarousals
(RERAs) .

●Snori
ngmi
crophone–Asnor
ingmi
crophonedet
ect
sthepr
esenceandv
olumeof
snor
ing.
●Respirator
yinduct
anceplet
hysmography(RIP)–RIPprovi
desameasureof
respir
atoryeff
ortasmanif
estedbyexpansionandrel
axati
onoft
hethor
axandabdomen
duringinspi
rat
ionandexpi
rati
on,r
especti
vely
.

●Pulseoximetr
y–Asensorpl
acedov
erthefinger
,ear
lobe,
ortoecont
inuousl
y
measurespulseoxy
hemogl
obi
nsatur
ati
on,heartr
ate,
andpulseampli
tudetodet
ect
hypoxemia.

●ECG–PSGtypi
cal
l
yrecordsasingl
eECGchannel(
leadI
).SRBDcanaf
fectcardi
ac
rat
eandr
hyt
hm (
oft
enbradycar
diaduri
nganapnea,
tachy
cardi
auponar
ousal).

●CO2monit
ori
ng–Monitori
ngCO2isusedtoi
dentif
ysleep-
rel
atedhypoventi
lat
ion.End-
ti
dal
CO2ismeasur
edusinganasalcannul
apl
acedi nt
henostri
ls.Tr
anscutaneousCO2
i
smeasuredusi
ngsensorsatt
achedt
oupperarm ortr
unk.

Duri
ngadiagnosti
cstudy
, ei
therend-ti
dalCO2ort ranscut
aneousCO2canberecorded.
Duri
ngapositi
veair
waypr essure(PAP)t i
tr
ati
onst udyoruseofsuppl
ementaloxygen,
tr
anscut
aneousCO2isoftenpr ef
erred,becausetheef f
ecti
venessoft
heend-t
idal
CO2
cannul
aisreducedwhenoxy genorPAPi sdeli
vered.

●Esophagealpr
essuremonit
ori
ng–Anesophagealpressuresensori
susedi
nsome
sl
eeplaborat
ori
est omeasur
echangesi
nint
rat
horaci
cpr essur
eandassesswor
kof
breat
hingdur
ingsleep.

●Bodyposit
ionmonitor–Abodyposi
ti
onmoni t
ordetect
schangeinbodyposi
ti
on.
Obstr
ucti
vesleepapneamaybeworsewhent hechi
l
di sl
yingsupi
neordur
inga
par
ti
cularsl
eepstate(mor
eoft
enREM sleep)
.

●Conti
nuouspositi
veair
waypr essure(CPAP)f l
owandleak–WhenPSGi sbei
ngused
toti
tr
ateposit
iveai
rwaypr essuretherapy,nasalpr
essur
eandend-
ti
dalCO2sensor
sare
tur
nedoff.CPAPairfl
ow, pressure,andleakfrom t
heCPAPmaskar et
henmeasured.

Det
ecti
onofmov
ement sandbehavi
ors 
— EMGact i
vi
t yf
rom t
helef
tandri
ghtant
erior
t
ibi
ali
smuscl
es(
lef
tleg,r
ightl
eg)wi
thti
me-lockedvideoisr
outi
nel
yrecor
dedinorder
t
o:

●Ident
ifyperi
odi
cli
mbmov ementsdur
ingwakeandsl
eep,whichcanbeamar kerof
peri
odicli
mbmov ementdi
sorder(
PLMD)orrest
lessl
egssyndrome/Wi
ll
i
s-Ekbom
di
sease( RLS/WED)
.

●Identif
yinappropri
atemuscl eactivi
tyduringREM sleepwhenmuscleat oniashouldbe
present(so-cal
ledREM sl eepwithoutatonia[RWA],asseeninREM sleepbehav i
or
disorder[RBD]).Ofnote,RWAandsomeoft hemovement sofRBDmaybemi ssedon
PSG, astheyoccurmor ecommonl yi
nthechi nandwr i
stext
ensors(whichar enot
routi
nelyrecorded)thanint heanteri
orti
biali
s[26]
.TodetectRWAi nREM sl eep,t
he
AASM scor ingmanual recommendsopt ionalpl
acementofleftandri
ghtflexor
di
git
orum super
fi
cial
i
sandext
ensordi
git
orum communi
ssur
faceEMG[
23]
.

●Confi
rm anarousal
ori
dent
if
yexcessi
veori
nappr
opr
iat
efor
msofmuscl
eact
ivi
ty
dur
ingsleep.

Inourexperience,
5t o10percentofpediatri
cPSGs( perfor
medatat er
ti
arycent er)ar
e
request
edf orthepurposesofident
if
yingandcl assi
fyi
ngunusual,paroxysmal ,
excessi
ve,orinappropri
atemotororcompl exbehav i
orsduri
ngsleep.Thesei nclude
peri
odicli
mbmov ement s,
RWA, RBD,sleep-r
elatedepil
epsy,andotherparasomni as.

ExpandedEEGmont ages — ThenumberofEEGchannel suseddur ingastandardPSG

(t
hreeorsix)i
snotgenerall
ysuffi
cientt
odetectorf ul
lycharacterizemostinteri
ctal
epi
lepti
for
m acti
vi
ty,
alt
houghi tmayshowsei zures.Whennoct urnalsei
zures,epi
lepsy
,
oratypi
calpar
asomniasaresuspect edandr
out i
neEEGhasy ettoi dent
if
ythem, vi
deo-
PSGwi t
hexpandedEEGmont agescanbeausef ul nextstepint heev al
uati
on.

Wet ypicallyr ecord18channel sofEEGi nthisset ti

ng.Ev enwi th18channel s,howev er,
somesei zur esmaynotbei dent i
fied,parti
cul arl
ywhent heyor i
ginatef r
om t hef r
ontal
l
obe[ 27,28] .Inonest udyi nwhi chbl indedrev iewerswer epr ovidedwi thPSGr ecordings
oftempor al l
obesei zuresrefor mat t
edi n4,7, or18channel s,thesensi ti
vityfor
detecti
ngt empor al l
obesei zuresi mpr ovedast henumberofchannel sincreased( 67,82,
and86per centsensi t
ivit
yfor4, 7, and18channel s,respecti
v ely)[28]
.Howev er,the
sensit
ivit
yf orfrontall
obesei zur eswasf arloweranddi dnoti mpr ovewi t
hahi gher
numberofchannel s.Anotherpot enti
al l
imitationisthatt hehabi tualnocturnal event
maynotbecapt uredbyoneni ghtofi n-l
abor atoryvideo-PSG, par t
icul
arlyiftheev ents
areNREM ar ousalpar asomni as[ 29-31].

SCORI NGANDINTERPRETATION:Foll
owingtherecordi
ng,sl
eep/wakestatesand
arousalsar
emanual
lyscor
edin30-secondsequenti
alepochsfr
om "LightsOff
"to
"Li
ghtsOn"byasl
eeptechnol
ogi
stbasedonpubl i
shedscoringcr
iter
ia[23].

●Sleepininf
ant
szer otot
womonthsofagei
sscor
edasei
thernon-
rapi
deyemov ement
(NREM)sleep(stageN),r
api
dey
emov ement(
REM)sl
eep(
stageR),ort
ransi
ti
onal
sleep(st
ageT)[23,32,
33]
.

●Betweenagestwot ofivemont hs,sl

eepisoftenscoredsimplyasstageNorstageR,
al
thoughrecognizablesleepspindlesofstageN2sl eepareusuall
yseenbytwotothree
months,N3isidentifi
ablebyfourt osi
xmont hs,andK-complexesbysixmonthsofage
[
34].Whensleepspi ndlesarepresent,epochscontaini
ngthem canbescoredasstage
N2;whenslowwav eact i
vi
tyispresent,epochsarescoredasstageN3.

Respirat
oryeventsar
escoredbythet echnol
ogistusi
ngpubli
shedcri
teri
ainchi
l
dren[35]
andt aki
ngint
oaccountnormsforsleep-rel
atedventi
l
ationi
nchil
dren[36-
41]
.The
presence,t
ype,anddurat
ionofr
espiratoryabnormali
ti
esarescor
ed,incl
udi
ng(t
able1):

●Apneas,
hypopneas,
respi
rat
oryev
entr
elat
edar
ousal
s[RERAs]
,oxy
gendesat
urat
ions,
i
ncreasedworkofbreat
hing,hy
percapni
a,hypoxemi
a,andhy
pov
ent
il
ati
on(
tabl
e1)
.
Thesearedef
inedandreviewedseparat
ely
.

●Dist
urbi
nghear
trhy
thmsandr
ates,
andt
hei
rrel
ati
ont
ohy
poxemi
aandr
espi
rat
ory
event
s[42].

Thetechnologistal
soscoresand/ort
agsperi
odi
cli
mbmov ements,
par
oxysmalmotor
behavi
ors,parasomnias,
inter
ict
aldi
schar
ges(I
EDs)
,andREM sl
eepwit
houtat
onia
(RWA)[23].

Oncescor ed,thedigi
talpol
ysomnogr aphy(PSG)sy stem progr
am tabul
atesand
collat
essummar i
esofthedat aandgener atesavisualsummar yofthePSG( cal
l
eda
hypnogram) .Thescoredsleepstudyist henrevi
ewed, r
evised,
andinterpr
etedbya
sleepspeciali
st.Asleepstudyreportistypi
call
yaccompani edbytablessummar i
zi
ng
thedata,ahy pnogram,andani nt
erpretati
onofthef i
ndings.

Exampl
esofabnor
mal
i
tiesorsi
gni
fi
cantf
indi
ngsof
tenr
epor
tedi
ncl
ude:

●Sl
eep-
disor
der
edbr
eat
hing(
eg,
apneas,
hypopneas)
.

●Fr
equentar
ousal
s(andt
hei
rcauses,
ifappar
ent
).

●Shor
tordel
ayedsl
eeponsetl
atenci
es(
someofwhi
chmayr
epr
esentf
ir
st-
night
ef
fect
s).

●RapidonsetREM sleeplat
enci
es(ie,entr
yintoREM sleep<15mi nut
esaf
tersl
eep
onsetininf
ants)
.Sleeponseti
nhealthyinfant
sy oungerthanthreemonthsisty
pical
l
y
REM sleep.REM sl
eeponsetisrar
elyseeni nhealt
hyinfantsaft
ersixmonthsofage.

●Absenceofst
ageRorN3sl
eep(
someofwhi
chmaybemedi
cat
ionorf
ir
st-
night
ef
fects)
.

●Excessi
vel
ossofnormal
skel
etal
atoni
adur
ingREM sl
eepandREM sl
eepbehav
ior
di
sordermot
orevent
s.

●Excessi
veposi
ti
onshif
ts,sl
eepstageshi
ft
s,l
i
mbmov
ement
s,andexcessi
vemot
or
act
ivi
tyduri
ngNREM and/orREM sl
eep.

●Excessi
veamount
soft
ransi
ti
onal
ori
ndet
ermi
nat
esl
eep.

●Abnormal
elect
roencephal
ogr
aphy(
EEG)backgr
oundori
ndet
ermi
nat
esl
eep/
wake
st
ates.

●Per
iodicli
mbmov ement
swhi
l
eawakeandasl
eepandt
heper
cent
aget
hatcause
ar
ousals/awakeni
ng.
●Otherparasomni
as,
sei
zur
es,
int
eri
ctal
epi
l
ept
if
orm di
schar
ges,
EEGv
ari
ant
s,orPSG
ar
ti
facts.

Intheappr opri
ateclini
cal context,PSGoftenprov i
desdiagnost iccertaintyforar angeof
sleepdi sordersinchi l
dren, i
ncludi
ngobst r
ucti
vesleepapnea( OSA) ,centralsleepapnea
(CSA), narcolepsyt y
pe1andt ype2( i
ncombi nati
onwit hthemul t
iplesleeplatencyt est
[MLST] ),andper iodi
climbmov ementdisorder(PLMD).Howev er,
thesi gnif
icanceofany
PSGf indingmustbeconsi deredwithint
hecont extofthecl i
nicalhistoryand
exami nationf i
ndings.Thedi agnost i
ccri
teri
aforthesedi sorders,whi chincorporateboth
cli
nical andpol ysomnogr aphicf i
ndings,
arereviewedindividually.

LIMITATI ONS: Whi l

elevel1pol y
somnogr aphy(PSG)pr ovidesextensive,
mul t
icomponenti nf
ormationonsl eep,
ther earesomel imitati
ons.Asleepst udy
typi
cal l
yrecordsonl yoneni ghtofsl
eepint hearti
fi
cialenv i
ronmentoft hesleep
l
abor atory,whichprov i
desatbestanar rowv iewofhowachi l
dnaturall
ysleeps.Thi
s
resultsinso-calledfi
rst-
nighteffect
s:mor eti
mesupi ne,lessr api
deyemov ement(REM)
andst ageN3sl eep,andmor ewakeaftersleeponset(WASO)andst ageN1sl eepon
thefirstnight
.

Ali
mitednumberofprospect
ivest
udi
esevaluati
ngfir
st-
nightef
fect
sinchi
l
drenand
t
heiri
mpactonPSGr esul
tssuggestt
hef
ollowing[11,
43-47]:

●Childr
enandadol
escent
s(butper
hapsnotyoungi
nfant
s)exhi
bitf
ir
st-
nightef
fect
s
thatarecompar
abl
etothosedescr
ibedi
nadult
s

●Chi
l
drenwithandwi
thoutobst
ructi
vesleepapnea( OSA)exhi
bitsi
gnif
icantni
ght
-t
o-
ni
ght
-var
iabi
l
ityi
nsl
eepparametersbutnotinrespi
rator
yparameters

●Anadaptati
onnighti
snecessaryifaPSGisdonetostudysl
eepar
chi
tect
ure,
butnot
whenonlythenoctur
nalr
espir
atorypatt
erni
sinvest
igat
ed

●OnenightofPSGi
susual
l
ysuf
fi
cientt
oconf
ir
m OSAbuti
snotr
eli
abl
eforsl
eep
ar
chi
tectur
e

Theselimit
ati
onsarealsorelevanttoPSGr ecor
dingsperformedonchi l
drenwhoar e
medicall
ysickorunstabl
e.Resul t
sinsuchcasesar eunli
kelytorepr
esentthebaseli
ne
condi
tionandshouldnotgener all
ybeusedt omakel ong-
ter mtr
eatmentdecisi
ons.I
fa
bedsi
del evel
1PSGi sabsolutelynecessar
ybeforeachi l
di sdi
schargedfr
om the
hospi
tal,i
tshoul
dbet helasttestbeforedi
scharge,whent hechil
dismedicall
ystabl
e.

SAFETYCONSI DERATIONS: Level1pol y

somnogr aphy( PSG)isarelati
v el
ysafe
procedure,al
thought herearefewsy stematicstudi
es.Onesi ngl
e-centerretrospecti
ve
revi
ewi denti
fi
edanadv erseeventreportedin58of36, 141PSGsper f
ormedov erafive-
yearperiod(0.16percent;1outofev ery623PSGs)[ 48].Themostcommonadv erse
eventswer eacutechestpai nordistur
bingcar di
acar r
hy t
hmias(29per cent)andfall
s
(21percent;fi
vewer einpat i
entswhohadt akenzolpidem) .
Asur v
eyofpediatri
csleepcent ersalsoidentif
iedf
al l
soutofacr i
borbedast hemain
safet
yconcern[49].Mostt oddler
scancl imboutofacr ibwhent heyar eabout35
i
nchest al
landbetween18and24mont hsofage.Ri skfact
orsforf all
sthathavebeen
i
dentif
iedinpediatr
ici
npatientsincl
udeepi sodesofdi sori
entati
on,al t
eredmobili
ty,
hist
oryoffal
li
ngathome, agey oungerthant hreeyears,andantisei
zur emedicati
on
[50,
51].Onestudyproposedaf al
lpreventi
onal gor
ithm insleepcent ers,whi
chincl
uded
thefoll
owingguidance[49]:

●I
dent
if
ypat
ient
satr
isk(
eg,
chi
l
drenwhohav
efal
l
eni
nlastmont
h)

●I
dent
if
ytheappr
opr
iat
ebedt
ypef
ort
hechi
l
d'sageandcondi
ti
on

●Useno-
ski
dfoot
wearwhent
hechi
l
disoutofbed

●Provi
dedir
ectsuper
visi
onoft
hechi
l
datal
lti
mes,
par
ti
cul
arl
ywhenget
ti
ngupt
ouse
thebat
hroom

Pati
entswit
hknownorsuspect edsl eep-r
elat
edv i
olence,par
asomni as,orseizuresare
ati
ncreasedri
skf orinjurywhensl eeping,andint
erventi
onstrategiesshouldbei nplace
i
nthesleeplaboratory.Weandot hershav erarel
yobservedinstancesofphy sicalchil
d
abusebyparentorcar egiver,
ev enafterparent
sar eadvisedthattheentir
epr ocedureis
bei
ngv i
deorecorded[ 48].Wer eportsuchcasest ochildprot
ect i
veservi
ces,andt he
vi
deoev i
denceiscitedi nthereport.

Traini
ngstafftorecogni
zeandhandleabnormal
i
tiesi
nvit
alsi
gnsismandat ory
.In-
l
abor at
ory
,out -
of-
hospit
alsleepst
udi
esrequi
rer
eadyaccesstoage-appr
opriat
e
resusci
tat
iveequipment,tr
ainingi
ncar
diopul
monaryr
esusci
tat
ion(CPR),andeasy
accesstopar amedicsupport.

ALTERNATI VESTUDI ES:Alt

houghcompr ehensivein-
labor ator
ypolysomnogr aphy(PSG)
remainsthepref
erredandappr opri
atestudyf ortheevaluat i
onofbot hrespi
ratoryand
nonrespi
rat
orysleepdisordersi
nchi l
dren,alt
ernati
vest udiesfordiagnosingobstructi
ve
sleepapnea(OSA)maybeconsi deredifPSGi snotav ailable.Theseincl
udenoct urnal
homeaudi oorvi
deor ecordi
ngs,nocturnaloximet r
y,daytimenapPSG, andhomesl eep
apneatesti
ng.

Theseapproachesdonotcompl etel
yrepli
cateresultsofPSG[ 11]
.Nonetheless,the
Amer i
canAcademyofPedi atr
ics(AAP)cli
nicalpracti
ceguidelinesuggestsor deri
ngan
al
ternati
vetest(orref
err
altoasl eepspecial
istorotolar
yngologist)i
fPSGi snot
avail
abl
e,withtherati
onalethatsomeobj ecti
vetesti
ngi sbetterthannone[52] .Therol
e
ofthesetestsintheeval
uationofsuspectedOSAi nchil
drenisr evi
ewedsepar at
ely.

SUMMARY

●Comprehensi
vei
n-l
aborat
oryov
ernightpoly
somnogr
aphy(
PSG) ,
alsoknownaslevel
1
PSG,i
sthegoldst
andardmethodforrecordi
ngsl
eep/
wakestat
esandf ordi
agnosi
ng
obst
ruct
ivesl
eepapnea(
OSA)andot
hersel
ect
edsl
eepdi
sor
der
sinchi
l
dren.

●Themostcommoni ndicationforPSGi nchil

drenisasuspect eddiagnosisofOSAor
othersleep-
relatedbreathi
ngdi sorder(SRBD).Inaddi t
iontoitsdiagnosti
cr ole,PSG
pl
ay sani mportantroleinthetit
rationofposit
iveairwaypr essure(PAP)t herapyforOSA
andint hepreoperativ
eev aluati
onbef oreupperairwaysur gery(eg,adenotonsill
ect
omy )
.
PSGi salsoindicatedfortheev aluati
onofatypicalorpot enti
all
yinj
uriouspar asomnias,
andf orsuspectednar col
epsyt ypes1or2orot hercent r
aldisorder
sof
hypersomnol ence,incombi nati
onwi thamul t
iplesleeplatencytest(MSLT) .

●PSGcanbef ri
ghteni
ngforchi
ldr
en.Adopt i
ngandrout
inel
yemploy
ingchi
ld-f
riendly,
fami
l
y-center
edPSGpr acti
cescanincreasethel
ikel
i
hoodofobt
aini
nganinterpretabl
e
PSGandt hepati
entret
urni
ngforfol
low-up.

●Sleep/wakest atesar escoredinaPSGbyr ecor

dingel ectr
oencephalography( EEG) ,
eyemov ements(electrooculogr
aphy[ EOG] ),
andsubment al
is(chin)sur
face
electr
omy ography( EMG) .I
naddit i
on,multipl
esensor sareappl i
edtocharacterize
ventil
ati
onandcar diacrhyt
hms, includi
ngasnor i
ngmi crophone,nasalpressureai rfl
ow,
oronasal t
hermal sensors,respi
rat or
yimpedancepl ethysmogr aphy,el
ectrocardiogram
(ECG, oneortwol eads) ,
pulseoximet ry
,bodyposition,andcar bondioxi
demoni toring.
SurfaceEMGact i
v i
tyfrom theant eri
orti
biali
smuscl esisrouti
nelyrecordedt odet ect
l
egmuscl eacti
v i
tyandmov ement s.

●Foll
owingt herecor
ding,sl
eep/wakestatesandarousalsaremanuallyscoredin30-
secondsequent i
alepochs.Respi
ratoryevent
s,peri
odicl
imbmov ements,paroxysmal
motorbehav ior
s,andothereventsarealsoscored,
tabul
ated,andcoll
ated(table1).The
scoredsleepstudyisthenrevi
ewed, r
evisedwherenecessary,andint
erpr
etedbya
sl
eepspeci ali
st.

●Lev
el1PSGi sarelat
ivel
ysafeprocedure,alt
houghtherearefewsystemat i
cstudi
es.
Themostcommonadv erseevent
sr epor
tedbypediatri
csleepcenter
sar efal
lsoutofa
cr
iborbed,emphasizi
ngt hei
mportanceoff al
lawarenessandotherstandardsafet
y
measuresi
nthesleeplaborat
ory.

●Al t
houghin-laboratoryPSGr emai
nst hepreferredandappropriat
est udyf orthe
evaluati
onofbot hr espir
atoryandnonrespirator
ysleepdisordersinchildren,the
availabi
li
tyofPSGi sli
mitedinsomer egions,especial
l
yforinfantsandchi l
dren.
Alternat
ivestudiesf ordetect
ingOSAmaybeconsi der
edifPSGi snotav ail
able,
recognizi
ngthatsuchst udiesdonotpr eci
selyrepl
icat
eresultsoffull
,in-laborat
oryPSG.

St
agewake
Thisimagedemonst ratesa30-secondr ecording(Compumedi cs)ofstagewakewi theyesclosed,not
abl
e
forthealphaact i
vi
tyoccurri
ngtheocci pit
alleads( label
edO2-M1andO1- M2) .Thetoptwoleads
repr
esentt heeyes(ri
ghtandl eft
),thenextleadi st hechi
n,t
henthefoll
owingsi xl
eadsareEEG( ri
ghtand
l
eftfront
al,central
,andoccipit
al),
ECGwi thheartr atebel
ow(R-R),
andt helegEMGl ead.
EEG: el
ectroencephalogram;ECG: elect
rocardi
ogr am; EMG:el
ectr
omy ography.

St
ageN1sl
eep

Thisimagedemonst ratesa30- secondr ecordi

ng(Compumedi cs)ofstageN1sleep,notabl
eforthetheta
acti
vitythroughoutthef irstt
hreequar tersoftheepoch.Anarousaloccursatthatt
ime( ar
row),wit
ha
ret
urnofal phaact i
vit
y .Thetopt wol eadsr epr
esenttheeyes(r
ightandleft
),t
henextleadisthechin,
then
thefollowingsixleadsar eEEG( r
ightandl eftf
rontal
,cent
ral
,andoccipit
al)
,ECGwithheartratebel
ow( R-
R),andt helegEMGl ead.
EEG: elect
roencephalogr am; ECG: el
ectrocardi
ogram; EMG:el
ectromyography.

Ver
texwav
esandsl
owey
emov
ementofnon-
rapi
dey
emov
ement(
NREM)1sl
eep
30-secondepochofpol
ysomnogr
aphy(PSG)showi
ngver
texwav
esmaxi
mal
overt
hecent
ral
regi
ons
ty
picall
yfi
rstseeni
nlat
erNREM 1sl
eep,commoninNREM 2.

Sl
eepspi
ndl
esofNREM 2sl
eep

30-secondepochofPSGshowi ngsleepspindlesofNREM 2sleep(whichmayli

ngeri
ntoear
lyNREM 3)
maybemor eprominentovert
hef r
ontal
,centr
al,oroccuri
ndependent
lyov
erthefr
ont
alandcent
ral
regionsi
nchil
drenyoungerthan13y ear
s.
PSG: pol
ysomnography;NREM: non-
rapi
dey emov ement.

St
ageN2sl
eep:
Spi
ndl
e

Thisimagedemonst ratesa30- secondr ecordi

ng(Compumedi cs)ofst age N2sl
eep.Mostnot abl
eisthe
beta-fr
equencyspindleactiv
ity( dashedbox) ,maximallyseeninthecent ralEEGleads.Thetoptwoleads
representtheeyes(ri
ghtandl ef t)
,thenextleadist hechin,
thenthef oll
owingsixleadsareEEG( r
ightand
l
eftf r
ontal
,central
,andoccipital),ECGwi thheartratebelow(R-R),andt helegEMGl ead.
EEG: elect
roencephalogram;ECG: elect
rocardi
ogram; EMG: el
ectromy ography.

St
ageN2sl
eep:
K-compl
ex
Thisimagedemonst ratesa30-secondr ecordi
ng(Compumedi cs)ofstageN2sl eep.Mostnot
ablearet
he
K-compl exes(dashedboxes),maxi mall
yseeni nthef r
ont
alandcentr
al EEGleads.Thetoptwoleads
representtheeyes(ri
ghtandl eft
),thenextleadist hechi
n,t
henthefoll
owingsixleadsareEEG(ri
ghtand
l
eftf r
ontal,cent
ral
,andoccipit
al),
ECGwi thheartratebel
ow(R-R),
andt helegEMGl ead.
EEG: electr
oencephalogram;ECG: elect
rocardi
ogram; EMG:el
ectr
omy ography.
Hi
ghv
olt
agesl
owwav
eact
ivi
tyofNREM 3sl
eep

30-
secondepochofPSGshowinghighv ol
tagesl
owwaveact
ivi
tyofNREM 3sl
eep,
whi
chi
sof
tenof
hi
ghestampli
tudeovert
hef
rontal
regions.
PSG:pol
ysomnography;
NREM:non-rapi
dey emovement

Pol
ysomnogr
aphyshowi
ngsaw-
toot
hwav
esofREM sl
eep

30-secondepochofPSGshowingsaw-t
oot
hwavesofREM sleept hatarebestseenovercentr
alregi
ons
ty
picall
yaccompaniedbyrapi
deyemovement
s,al
owv ol
tagemi xedf r
equencyEEGandchi nEMGat oni
a.
PSG: pol
ysomnography
;REM: r
api
deyemovement
;EEG:elect
roencephalography;chi
nEMG: submental
i
s
el
ectromyography
.
St
ageRsl
eep:
Phasi
c

Thisimagedemonst r
atesa30- secondrecordi
ng( Compumedi cs)ofstageRsl eep.Mostnotabl
ei st
he
clust
erofr apideyemov ementsnot edintheeyeleads(backgroundshadi ng)
.Thet opt
wol eadsrepr
esent
theey es( r
ightandlef
t),thenextleadisthechin,
thenthef oll
owingsixleadsareEEG( r
ightandleft
front
al, central
,andoccipit
al)
,ECGwi thheartr
atebelow( R-R),andthelegEMGl ead.
EEG: electroencephal
ogram; ECG: el
ectr
ocardi
ogram;EMG: el
ectromyography.
Tr
ansi
ti
onf
rom NREM 2t
oREM sl
eep

Two30- secondepochsofsl eepr ecordedi na14- year-olddur i

ngov erni
ghtPSG.  
Thesecondepoch
(l
abeled768)i seasi lyscoredasREM sl eep, becausei tcont ai
nsallofthetypical
 PSGf eaturesofREM
sleep(rapidey emov ement s,lowv olt
agemi xedf requencyEEG, andchinmuscl eat onia).Scor i
ngoft he
fi
rstepoch( labeled767)i smor ecompl ex.Intheepochbef ore(notshown),chinmuscl etonewas
preserved, sleepspi ndleswer eseen, andi twasscor edasNREM 2.I nepoch767, a3- second arousal i
s
seen( di
f f
use14Hzact ivi
ty),andt herear enosl eepspi ndles.Beginni
ng3secondsi ntoepoch767, the
chinEMGi ncr easesaf terthear ousal,thendr opst oi tslowestampl i
tudeinthesleepst udy.Epoch767i s
theref
orebestscor edasNREM 1sl eep, andepoch768asREM sl eep.Anar ousal suchast hisone often
occursint het ransitionfrom NREM 2t oREM sl eep.
REM: rapidey emov ement ;EEG: elect
roencephal ography ;NREM: non-REM;PSG: pol ysomnogr am;LEOG:
l
ef tel
ect r
oocul ography ;REOG: r
ightelect r
ooculogr aphy ;
EMG: surf
aceelectromyogr aphy ;EKG:
electr
ocar diography .

Pol
ysomnogr
aphi
cvar
iabl
esi
nchi
l
dren

  Def
ini
ti
on Comment
s
Event
s
>90per centdecreasei nairf
low
signalt
hatl asts≥90per centof  Apneaisobstr
uctiveifther
e
thedurationofatl easttwo i
scontinuedori
ncreased
Apnea
normal breaths,asdetermined i
nspir
atoryef
fortduringthe
from t
hebasel inebreathing ent
ir
eper i
odofdecr eased
patter
n. ai
rf
low.
  Apneaiscent ral ifinspirator
y
eff
ortisabsentdur i
ngt he
enti
reperiodofai rfl
ow
cessati
on.*
 Apneaismi xedi fthereis
absentrespiratoryef fort
duri
ngonepor tionoft he
eventANDt hepr esenceof
i
nspirat
or yefforti nanot her
port
ion,regardlessofwhi ch
port
ioncomesf i
r st.

 Hy popneasmaybecl assi
fi
ed
asei t
herobstructi
veor
central,
dependingont he
≥30per centdecreasei nai rf
low presenceorabsenceof
signalthatlasts≥90per centof snoring,fl
att
eningofnasal
thedurationofatl eastt wo pressuresignal,or
normal breaths,asdet ermined paradoxical
Hy
popnea from t
hebasel inebr eathing thoracoabdomi nalbr
eathi
ng.
 However
,inpr
act
ice,
accur
ate
patter
n.Thedecr easedai rfl
owis
classif
icat
ionoft heeti
ologyof
associatedwi t
hanar ousal,orat
hypopneasi schal l
engi
ng,and
l
east3per centoxyhemogl obin
usuallynotperformed.Ina
desaturati
on.
patientwhohascl ear
obst r
ucti
vesleepapnea,
hypopneasar eusual l
yassumed
tohav eanobst ructi
vebasis.

 RERAscanbedet ectedwi th
routi
nelyusedsensor soni n-
Respir at
or yevent(i
ncreasi ng l
abPSGorbyaddi t
ionof
respiratoryeffort
,fl
atteningof esophageal manomet ry.
theinspi rator
yporti
onoft he  Up perair
wayresist
ance
Respir
atory nasal pressurewav eform, syndr ome(UARS)was
ef
fortrel
ated snoring, oranelevati
oni nthe previousl
yusedt odescr i
be
ar
ousal (
RERA) end-ti
dal PCO2),t
hatleadst o presenceofRERAsi nthe
arousal anddoesnotqual i
fyas absenceofapneasor
¶
anapneaorhy popnea. hypopneas.UARSi snow
subsumedi ntothecat egory
ofOSA.

Sl
eep-
rel
ated Theend-
ti
dal
ort
ranscutaneous
hy
povent
il
ati
on CO2>50mmHgformor ethan25  Somechi
l
drenwi
thbr
eat
hing
 disturbanceduet oi ncreased
upperai rwayresistancehav e
hypov enti
lat
ion,butnot
discreteapneasor
per
centoft
het
otal
sleept
ime. hypopneas.
 Ob str
uct i
vehypov entil
ati
onis
nowsubsumedi ntot he
categor yofOSA.

Ar
ousal
s,snori
ng,changesi
n
Addi
ti
onal
event
sbodyposit
ion,andli
mb  
movements.
Summarymeasures

 Concer nforcl ini

cal
ly
signifi
cantOSAgener all
y
startswi t
hanAHI>1orRDI
>1.
 AnAHI ≥1.5ev ent
sperhour
Thenumberofapneasplus wasconsi deredabnor mal
Apneahypopnea
hypopneast
hatoccurperhourof basedonast udyofagr oup
i
ndex(AHI)
sl
eep. ofheal t
hychi ldrennot
suspect edofhav i
ngsl eep-
relat
edbr eathingdi sorders,
in
whom t hemeanAHIwas0. 2
[
1]
±0. 6event sperhour .

 Concer nf orcl i
nicall
y
signifi
cantOSAgener all
y
startswi thanAHI>1orRDI
>1.
 So meexper tshav e
Respi
rat
ory Thenumberofapneas, adv ocatedsl ightlyhigherRDI
di
stur
bance hypopneas,
andRERAsperhour thresholds, suchas1. 5,2,or
i
ndex(RDI) ofsleep. 3ev entsperhour .
 AnRDI >5ev entsperhourof
sleepi sof tenusedt oidentif
y
anabnor mal RDIi nadul ts,but
i
si nsufficient lysensitivefor
children.

RERA: r
espir
atoryeff
ortrel
atedar ousal
;UARS:upperair
wayr esi
stancesy ndrome;OSA:
obstr
uctiv
esleepapnea; AI:apneaindex;OAI:
obstr
uctiveapneaindex;RDI :r
espi
rator
y
di
sturbanceindex;AHI:apneahy popneaindex;
EEG:electr
oencephalographic.
*Cent r
alapneaalsorequiresoneoft hefoll
owi ngmeasur esofdurat i
on:1)Ther espi
ratory
eventisatleast20secondsl ong;2)Inspi
ratoryef f
ortisabsentf
ort hedur at
ionoftwo
respir
atorycycl
esandisf oll
owedbyacor t
ical ar
ousal,oroxygendesat urati
on≥3percent ;
or3)
Theev entisassoci
atedwi thadecreaseinthehear tr
atetolessthan50beat sperminut eforat
l
east5seconds, orlessthan60beat spermi nutefor15seconds( i
nf antsunderoney earofage
only).
¶Ar ousal
saredeterminedbyel ectr
oencephal ographic(EEG)cri
ter
ia.

Ref
erence:

1. WitmansMB, KeensTG,Davi
dsonWardSL,
Mar cusCL.Obst
ruct
ivehypopneasi
nchi
l
drenand
adolescent
s:nor
malval
ues.Am JRespi
rCr
itCareMed2003;168:1540.

Dat
af r
om: Berr
yRB,QuanSF, Abr
euAR,etalf
ortheAmericanAcademyofSl eepMedici
ne.TheAASM
ManualfortheScor
ingofSl
eepandAssociat
edEv ent
s:Rules,
Ter
mi nologyandTechni
calSpeci
fi
cat
ions,
Ver
sion2.6,www.aasmnet.
org,Amer
icanAcademyofSleepMedicine,Dari
en,I
L2020.

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