The Pediatric Sleep Technologist Is This the Future for You ?

1. The Pediatric Sleep TechnologistIs This the Future for You? Cynthia D. Nichols, PhD, FAASM, CBSM Munson Sleep Disorders Center Traverse City, MI

2. Objectives • Describe the unique challenges and rewards of working with children and their families in the sleep center • Discuss methods to protect the safety of children in the sleep center • Understand basic differences in recording and scoring sleep in children vs. adults • Explain effective methods of communication with children of different ages • Discuss legal issues specific to evaluating children in the sleep center

3. I do not have any potential conflicts of interest to disclose.

4. Why specialize in pediatric sleep? • Children are never boring, always changing. • Observing the development of sleep in children of different age levels is very interesting. • It is a rapidly growing area of sleep medicine, with opportunities for creative, innovative people. • When you help a child, you help the whole family. • When you improve a child’s sleep, you have the potential to change their entire future.

5. Why specializing in pediatric sleep has its challenges • Children are fragile and it is easy to hurt them. • Children can become very sick, very quickly, and with little warning. • Working with children is more time-consuming than working with adults. • Children have parents. • Children are less cooperative and less predictable than adults during PSG.

6. Why specializing in pediatric sleep has its challenges • Many children are on state-funded programs and reimbursement is poor. • Young or very challenging children often require 1:1 which is cost-ineffective for many centers. • Job security or the desire to increase the number of PSGs in your sleep center is not a good reason to specialize in pediatric sleep.

7. Legal issues • When parents are divorced, it is important to determine who has the right to seek non-emergent medical treatment for the child • The custodial parent is not always the one who pays the bill. • The specific laws regarding consent vary from state to state. • Best to obtain both parental informed consent and child assent for the test in children age 8 and older.

8. Safety considerations • Abduction • Potential for child to walk out if unsupervised • Chemicals • Electrical outlets • Things that a toddler can put in the mouth • Keep bed at setting closest to the floor • Abusive parents • Inattentive parents

9. Medications in the sleep lab • Medications must be listed and specifically ordered by the attending physician, including inhalers, Tylenol, and breathing treatments. • Medications must be brought to the sleep center in the original package/bottle; each medication must inspected and verified by a pharmacist or a technologist with specific training in comparing the medication to the picture in your medication database. • Each medication that was administered to the child in the sleep lab must be witnessed and documented by the sleep technologist.

10. Sleep hygiene in the sleep center • “Screens” including television, video games, etc. • Phones and texting (parents also) • Co-sleeping • Parent in room • Parent in bed • The sleep environment is VERY different in the lab as compared to the home. • Be prepared for anxiety in the child and the parent; some private time may help.

11. Common medical conditions seen in the pediatric sleep center • Syndromes of many types • Muscular dystrophy • Seizure disorder • Cerebral palsy • Spina bifida • Arnold Chiari malformation • Apnea of prematurity • Apnea associated with gastroesophageal reflux

12. Always keep these things in mind when interacting with children • Children and their parents do not always have the same goals. • A phone call by the attending technologist to the parents prior to the study is helpful. • Children (and even adolescents) are often very concrete in their understanding. • A child may not tell you the really important things unless you ask directly. • It is important to adapt your communication to the child’s level of comprehension.

13. Skills that differentiate between inadequate vs. excellent pediatric sleep techs • Genuinely like children • Empathy • Patience • Adaptation • Curiosity • Creativity • Ability to demonstrate respect for the child as a unique individual

14. Communicating with infants and very young children • It is difficult or impossible for them to express their needs with words. • They are dependent on the caregiver for assistance. • They are more often (but not always) calmed when being held by a parent or familiar caregiver. • Explain the test procedures to the parent; the parent will be able to communicate their calmness to the infant.

15. Electrode application in infants and toddlers • Babies are not just small but are also fragile. • Keep little hands away from electrodes by wrapping the head or using splints or mittens. • Distance between EMG chin electrodes or distance from eye for EOG often needs to be reduced by 50%. • Do a “tape test” and “goo test” with all materials for at least 10 minutes, then check skin for irritation.

16. Electrode application in infants and toddlers • A crib should be available even when the child is sleeping in a toddler bed at home. • Use both end-tidal and transcutaneous CO2 if possible. • OK to put pulse oximeter on foot in infants and small children, but use hand when possible in children age 1 or older.

17. Age 2-5 communication • Children in this age group should almost always have an orientation to the sleep lab. • Allow extra time for the child and parent to acclimate to the room before initiating the hook up. • Start by gaining trust. Avoid scrubs and white coats. • You may need to say “no shots” for some children. • Young children respond very well to distraction with a special movie or a new toy.

18. Electrode application age 2-5 • This is usually the most challenging age to obtain a PSG. • In difficult hookups, use anything that expedites (disposable electrodes, dimly lit room, two techs, etc.). • You may need to wait to add some sensors until child is asleep. • A “tape test” and “goo test” are still good ideas at this age. • Use both end-tidal and transcutaneous CO2 if possible. • Allow them to help when possible. • Let parents know that the sensors around the face are the most important ones to keep on. Most parents will help you if they understand this.

19. Age 5-18 communication • Older children and adolescents are easily embarrassed about their body. Give them plenty of privacy and address personal privacy issues immediately when they arrive. • Explain all the procedures in age-appropriate language. • Speak primarily to the child rather than the parent. • Speak plainly and avoid technical words even with adolescents unless you define the term.

20. Electrode application age 5-18 • Offer a mirror if a child wants to see what is going on, but realize that many do not want to see what you are doing. • Discourage parents from taking a picture of their child with the electrodes on; this is embarrassing to many children. • Explain in age-appropriate language what each sensor is used for. • Allow them to help you. • Give teens the option of sending the parent home after getting settled. Keep in mind that it is not uncommon even for 16 year olds to want a parent to stay but they may be embarrassed to ask.

21. A few comments on control of breathing in infants: They are not “small adults” Control of breathing • Young infants hypoventilate in response to hypoxia (adults hyperventilate). • The age in which the hypoxic ventilatory response occurs is controversial and may be altered by disease. • Exposure of the peripheral and central controllers to hypoxia or hypercarbia in infancy may permanently alter ventilatory responses.

22. Behavioral observations during PSG in children • Angle of neck and relationship to snoring. • Parent behavior in response to child’s movement. • Child’s behavior in response to parent movement or other sounds in room. • Be alert for confusional partial awakenings and attempts to sleep-walk. • Listen to what the child says about his/her sleep problem and document it.

23. PSG scoring in children • Be certain that you understand the rules and the specific differences in scoring PSGs in children vs. adults. • Examples: • Event duration (duration of 2 breaths) • Scoring of hypopnea requires >50% fall in amplitude of NP signal + arousal, awakening, or >3% desat • RERA scoring requires snoring, noisy breathing, elevation in PCO2, or visual evidence of increased work of breathing • Central apneas have to be either 20 seconds OR 2 missed breaths plus arousal, awakening or >3% desat • Hypoventilation rule is based on TST not TIB (>25% at or above 50 mmHg)

24. More examples • Examples: • Normal heart rate parameters: see Archbold K et. al JCSM 2010;6:47-50. • No difference in arousal criteria for children vs. adults. • DPR is slower than alpha and indicates wakefulness. • Occipital sharp waves are common and normal. • Hypnagogic hypersynchrony is present in 95% of children age 6-8 months and gradually decreases, but is still often seen in children up to about age 12.

25. Conclusions: Is pediatric sleep technology in your future? • Pediatric sleep technology is enjoyable, interesting, and has unique challenges. • Pediatric sleep technology requires the ability to establish good rapport with children and their parents.