Scoring and Sleep Stages (D-49)

Question 1

Adult electrode derivations for EEG, EOG, and chin EMG are acceptable for children except: (x2)

Answer 1

Distance between chin electrodes may need to be reduced from 2 cm to 1 cm
Distance between EOG electrodes may need to be reduced from 1 cm to 0.5 cm.

Question 2

In children 2 months post-term or older, what are the six stages of sleep? (x6)

Answer 2

W, N1, N2, N3, and N (NREM) and R

Question 3

How do we define children in sleep studies? (Age)

Answer 3

2 months post-term or older.

Question 4

Why do children have NREM sleep stages?

Answer 4

If all epochs of NREM sleep contain no sleep spindles, K complexes, or high amplitude 0.5-2 Hz slow wave activity, it’s stage N.

Question 5

How are childrens’ Stage W different from adult Stage W?

Answer 5

Children have a posterior dominant rhythm, meaning that the EEG rhythm in occipital regions in Stage W is slower.
No alpha waves.

Question 6

When should you score a children’s Stage W?

Answer 6

Age-appropriate posterior dominant rhythm over the occipital region
AND/OR
Findings consistent with adult readings

Question 7

How do childrens’ Stage N1 differ from Adults’ stage N1?

Answer 7

Hypnagogic Hypersynchrony (HH) may be present.

Question 8

What’s Hypnagogic Hypersynchrony (HH)?

What is the voltage seen in HH?

Answer 8

High-amplitude, sinusoidal waves begin abruptly in central or frontal scalp regions.
75-350uV, 3-4.5 Hz.

Question 9

In children who generate a PDR, score stage N1 if the PDR is ___ or replaced by low-amplitude, mixed-frequency activity for more than ___% of the epoch.

Answer 9

Attenuated

50%

Question 10

In children who do not generate PDR, score stage N1 if these criteria are met (x5):

Answer 10

1. 4-7 Hz activity with slowing background frequencies by >1-2 Hz from those in Stage W
2. Slow Eye Movements
3. Vertex Sharp Waves
4. Hypnagogic Hypersynchrony
5. Diffuse or occipital predominant, 3-5 Hz activity

Question 11

What are the criteria rules for children?

Answer 11

Use adult rules on children age 13 or older.

Question 12

When measuring event duration, some children have an AHI that’s so high that it’s hard to score. What should you do then?

Answer 12

If the apnea or hypopnea event begins or ends during an epoch that is scored as sleep, you can count it as part of the AHI

Question 13

Scoring apneas: for adults, the period of apnea has to last at least ___ seconds. For children, it has to last for ___ to be obstructive.

Answer 13

10 seconds

Has to last for the duration of two normal breaths.

Question 14

To score central sleep apnea in children, you must meet one of these events: (x3)

Answer 14

1. The event lasts longer than 20 seconds
2. The event lasts at least the duration of two breaths during baseline breathing and is associated with an arousal or a greater than 3% desaturation
3. The event lasts at least the duration of 2 breaths, HR decreases to 50 for at least 5 seconds, or less than 60 for 15 seconds.
   NOTE: Must meet one of these criteria.

Question 15

In children, to score a respiratory event as an apnea, all the following must be met: (x3)

Answer 15

1. A drop in the peak signal excursion by 90% or greater of pre-event baseline
2. Duration of the 90% drop lasts the minimum duration as an obstructive, central, or mixed apnea
3. Event meets criteria of obstructive, central, or mixed apnea.
   NOTE: Must meet all these criteria.

Question 16

To score mixed sleep apnea in children, the episode must meet these criteria: (x3)

Answer 16

1. Apnea criteria is met for the duration of 2 breaths
2. Is associated with absent respiratory effort during one portion of the event
3. Respiratory effort is seen in another portion.
   NOTE: Must meet all these criteria

Question 17

What age is considered an infant?

Include post-term age and conception age

Answer 17

0-2 months post-term

37-48 weeks conception age

Question 18

What are the sleep stages seen in infants? (x4)

Answer 18

W Wakefulness
N NREM
R REM
T Transitional

Question 19

How do you stage infants in T stage of sleep?

Answer 19

If it does not meet the criteria for N stage or R stage, it’s T stage.

Question 20

State the behavioral characteristics of an infant in N stage of sleep. (x3)

Answer 20

Eyes closed
Few movements
Sucking can occur.

Question 21

State the behavioral characteristics of an infant in R stage of sleep. (x6)

Answer 21

Eyes closed
REM seen under closed eyelids
squirming
sucking
grimacing
small movement of the face or limbs.

Question 22

State the breathing characteristics of an infant in N sleep. (x1)

Answer 22

Regular

Question 23

State the breathing characteristics of an infant in R sleep. (x2)

Answer 23

Irregular, some central pauses

Question 24

What characteristics are seen in NREM sleep in infants? (x5)

Answer 24

1. Eyes closed with no eye movements
2. Chin EMG tone present
3. Regular respirations
4. Trace Alternant (TA), High Voltage Slow (HVS), or sleep spindles present
5. Reduced movement relative to wake

Question 25

What characteristics are seen in REM sleep in infants? (x5)

Answer 25

1. Low chin EMG
2. Eyes closed with at least one rapid eye movement
3. Irregular respirations
4. Mouthing, sucking, twitches, brief head movement
5. EEG: Continuous pattern, no sleep spindles
   (Note: 4 or more must be present)

Question 26

If no REM, score as R Stage if all these are present (x3):

Answer 26

EEG shows low or medium mixed frequency activity without trace alternant or sleep spindles
Chin muscle tone is low for majority of epoch
No intervening arousal
(Note: All of these must be present)

Question 27

When should you score Stage T?

Answer 27

Either 3 NREM and 2 REM characteristics
or
2 NREM and 3 REM characteristics