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... 12 This discovery soon led to the recognition of REM sleep and its association with dreaming in adults by Dement and Kleitman in 1957. 13 Beginning in the late 1950s, neonatal electroencephalographers [14][15][16][17] and infant sleep researchers [18][19][20][21][22][23][24] systematically studied the EEG, PSG and behaviors of sleep and wake in full-term infants. Dreyfus-Brisac et al., 14 Dreyfus-Brisbac and Monod, 15 Monod and Pajot, 16 and Parmalee et al. 17,25 identified REM and NREM sleep states, respectively, terming them active sleep (AS) and quiet sleep (QS). ...
... 13 Beginning in the late 1950s, neonatal electroencephalographers [14][15][16][17] and infant sleep researchers [18][19][20][21][22][23][24] systematically studied the EEG, PSG and behaviors of sleep and wake in full-term infants. Dreyfus-Brisac et al., 14 Dreyfus-Brisbac and Monod, 15 Monod and Pajot, 16 and Parmalee et al. 17,25 identified REM and NREM sleep states, respectively, terming them active sleep (AS) and quiet sleep (QS). Infants during QS/NREM were "very quiet" with regular respiration and heart rates, preserved chin electromyography (EMG) activity, and no or rare vertical eye movements. ...
... They recognized that normal infants had many periods (or epochs) of sleep that were not easily categorized as a particular sleep state because of discordant features between the physiological markers of sleep/wake states (EEG, EOG, chin EMG, respiration, and body movements). 16,26,29 These were variously called transitional, indeterminate, or intermediate sleep. ...
Unlabelled:
In March 2014, the American Academy of Sleep Medicine (AASM) Board of Directors requested the Scoring Manual Editorial Board develop rules, terminology, and technical specifications for scoring sleep/wake states in full-term infants from birth to 2 mo of age, cognizant of the 1971 Anders, Emde, and Parmelee Manual for Scoring Sleep in Newborns. On July 1, 2015, the AASM published rules for scoring sleep in infants, ages 0-2 mo. This evidence-based review summarizes the background information provided to the Scoring Manual Editorial Board to write these rules. The Anders Manual only provided criteria for coding physiological and behavioral state characteristics in polysomnograms (PSG) of infants, leaving specific sleep scoring criteria to the individual investigator. Other infant scoring criteria have been published, none widely accepted or used. The AASM Scoring Manual infant scoring criteria incorporate modern concepts, digital PSG recording techniques, practicalities, and compromises. Important tenets are: (1) sleep/wake should be scored in 30-sec epochs as either wakefulness (W), rapid eye movement, REM (R), nonrapid eye movement, NREM (N) and transitional (T) sleep; (2) an electroencephalographic (EEG) montage that permits adequate display of young infant EEG is: F3-M2, F4-M1, C3-M2, C4-M1, O1-M2, O2-M1; additionally, recording C3-Cz, Cz-C4 help detect early and asynchronous sleep spindles; (3) sleep onsets are more often R sleep until 2-3 mo postterm; (4) drowsiness is best characterized by visual observation (supplemented by later video review); (5) wide open eyes is the most crucial determinant of W; (6) regularity (or irregularity) of respiration is the single most useful PSG characteristic for scoring sleep stages at this age; (7) trace alternant (TA) is the only relatively distinctive EEG pattern, characteristic of N sleep, and usually disappears by 1 mo postterm replaced by high voltage slow (HVS); (8) sleep spindles first appear 44-48 w conceptional age (CA) and when present prompt scoring N; (9) score EEG activity in an epoch as "continuous" or "discontinuous" for inter-scorer reliability; (10) score R if four or more of the following conditions are present, including irregular respiration and rapid eye movement(s): (a) low chin EMG (for the majority of the epoch); (b) eyes closed with at least one rapid eye movement (concurrent with low chin tone); (c) irregular respiration; (d) mouthing, sucking, twitches, or brief head movements; and (e) EEG exhibits a continuous pattern without sleep spindles; (11) because rapid eye movements may not be seen on every page, epochs following an epoch of definite R in the absence of rapid eye movements may be scored if the EEG is continuous without TA or sleep spindles, chin muscle tone low for the majority of the epoch; and there is no intervening arousal; (12) Score N if four or more of the following conditions are present, including regular respiration, for the majority of the epoch: (a) eyes are closed with no eye movements; (b) chin EMG tone present; (c) regular respiration; and (d) EEG patterns of either TA, HVS, or sleep spindles are present; and (13) score T sleep if an epoch contains two or more discordant PSG state characteristics (either three NREM and two REM characteristics or two NREM and three REM characteristics). These criteria for ages 0-2 mo represent far more than baby steps. Like all the other AASM Manual rules and specifications none are fixed in stone, all open for debate, discussion and revision with the fundamental goal to provide standards for comparison of methods and results.
Commentary:
A commentary on this article appears in this issue on page 291.
... Estes estudos foram realizados a partir da descoberta da eletroencefalografia feita em 1929, por Hans Berger e, posteriormente, pelos estudos em bebês prematuros realizados por Dreyfus-Brisac et col. [48][49][50][51][52][53] . ...
... Dreyfus-Brisac e Monod, 1965 realizou um estudo de polissonografia em bebês nascidos prematuros, e à termo (48). Em um adulto o que normalmente se observa é um ciclo de sono composto por ondas lentas mais tranquilo (NREM), seguido por ciclos rápidos de sono ativo, movimentos rápidos dos olhos, pobre atividade muscular e aumento do padrão respiratório, os quais correspondem a 20% do sono total 49,69,70 . ...
Resumo Introdução: As pesquisas neurocientíficas têm proporcionado grandes descobertas no que concerne ao entendimento sobre o funcionamento cerebral e seus circuitos neurais. Com os avanços nos estudos sobre o comportamento fetal novas discussões têm surgido acerca da existência de um possível aparelho psíquico rudimentar. Questionar a existência de um psiquismo no feto, torna-se duplamente desafiador. Primeiro pela controvérsia que existe no âmbito da neurociência sobre os estudos dos epifenômenos. Segundo, pela própria dificuldade que a psicanálise tem em aceitar a existência de uma estrutura psíquica antes do nascimento. Este estudo foi realizado considerando todas estas controvérsias e limitações científicas, e por este motivo deve ser entendido como uma hipótese teórica e um convite para uma ampla e transdisciplinar visão sobre a complexidade do comportamento humano. A partir de uma extensa revisão sobre o desenvolvimento do sistema nervoso e da sinaptogênese fetal, e associando as pesquisas neurofisiológicas e da neurofísica, foi possível criar uma articulação com a teoria Freudiana da energia psíquica descrita no Projeto para uma psicologia científica. A partir destas articulações, levantou-se questionamentos sobre o desenvolvimento fetal, especialmente na fase pré-termo, o qual seria composto por atividades sinápticas intensas, especialmente nas regiões somatossensoriais e talamocorticais que receberiam estímulos exógenos e endógenos, ambos atuando para gerar um acúmulo de energia psíquica. Desta forma, criou-se uma hipótese de que este intenso fluxo de energia seria o primeiro sinal do desenvolvimento do aparelho psíquico primitivo no feto. Assim, foi possível supor que durante o período pré-termo esta descarga de energia catexizada poderia se projetar diretamente sobre as estruturas cerebrais límbicas e motoras e deixar traços de memória inconscientes das experiências da vida intrauterina. Seriam estas influências de natureza psíquica em conjunto com os fatores epigenéticos, que contribuiriam para o aparecimento de certos transtornos comportamentais e do neurodesenvolvimento. Sendo assim, sugerir uma abordagem transdisciplinar precoce em bebês de risco expostos a fatores estressores ambientais ou epigenéticos durante o período gestacional, especialmente durante a janela de plasticidade sináptica, proporcionará uma oportunidade terapêutica através da reorganização psíquica e da integração sensoriomotora. Palavras-chave: psiquismo fetal, sinaptogênese, neurofísica, psicanálise, neurociência comportamental, desenvolvimento fetal.
... For this reason, it is essential to understand more about CNS electrophysiology in the fetal development period. These studies were carried out based on the discovery of electroencephalography made in 1929, by Hans Berger, and later on by the studies on premature babies carried out by Dreyfus-Brisac et al., [48][49][50][51][52][53] . ...
... In an adult what is normally observed is a sleep cycle composed of quieter slow waves (NREM), followed by rapid cycles of active sleep, rapid eye movements, poor muscle activity and increased breathing pattern, which correspond to 20 % of total sleep 49,69,70 . ...
Backgroung: Neuroscientific research has provided great discoveries regarding the understanding of the brain functioning and its neural circuits. With advances in studies on fetal behavior, new discussions have arisen about the existence of a possible rudimentary psychic apparatus. Questioning the existence of a psychism in the fetus becomes doubly challenging. First, because of the controversy that exists in the field of neuroscience about the studies of epiphenomena. Second, because of the difficulty that psychoanalysis has in accepting the existence of a psychic structure before birth. This study was carried out considering all these controversies and scientific limitations, and for this reason it should be understood as a theoretical hypothesis and an invitation to a broad and transdisciplinary view on the complexity of human behavior. From an extensive review on the development of the nervous system and fetal synaptogenesis, and combining neurophysiological and neurophysical research, it was possible to create a link with the Freudian theory of psychic energy described in the Project for a scientific psychology. From these joints, questions were raised about fetal development, especially in the preterm phase, which would be composed of intense synaptic activities, especially in the somatosensory and thalamocortical regions that would receive exogenous and endogenous stimuli, both acting to generate an accumulation of psychic energy. Thus, it was hypothesized that this intense flow of energy would be the first sign of the development of the primitive psychic apparatus in the fetus. Thus, it was possible to assume that during the preterm period this cathected energy discharge could project directly onto the limbic and motor brain structures and leave unconscious memory traces of intrauterine life experiences. These influences of a psychic nature, together with epigenetic factors, would contribute to the appearance of certain behavioral and neurodevelopmental disorders. Therefore, suggesting an early transdisciplinary approach in at-risk infants exposed to environmental or epigenetic stressors during the gestational period, especially during the synaptic plasticity window, will provide a therapeutic opportunity through psychic reorganization and sensorimotor integration.
... The recognition of sleep states in newborns and infants was initially based on differences in respiratory rate. The breathing rhythm was more irregular during active and more regular during quiet sleep segments (92,93). Related changes in these respiratory patterns were first noted when sleep state differentiation was recognized (94). ...
Serial neonatal and infant electroencephalographic (EEG)–polysomnographic studies document the ontogeny of cerebral and noncerebral physiologic behaviors based on visual inspection or computer analyses. EEG patterns and their relationship to other physiologic signals serve as templates for normal brain organization and maturation, subserving multiple interconnected neuronal networks. Interpretation of serial EEG-sleep patterns also helps track the continuity of brain functions from intrauterine to extrauterine time periods. Recognition of the ontogeny of behavioral and electrographic patterns provides insight into the developmental neurophysiological expression of neural plasticity. Sleep ontogenesis from neonatal and infancy periods documents expected patterns of postnatal brain maturation, which allows for alterations from genetically programmed neuronal processes under stressful and/or pathological conditions. Automated analyses of cerebral and noncerebral signals provide time- and frequency-dependent computational phenotypes of brain organization and maturation in healthy or diseased states. Research pertaining to the developmental origins of health and disease can use these computational phenotypes to design longitudinal studies for the assessment of gene–environment interactions. Computational strategies may ultimately improve our diagnostic skills to identify special-needs children and to track the neurorehabilitative care of the high-risk fetus, neonate, and infant.
... Monod and Pajot (21), who performed polygraphic recordings in human neonates born near term, could distinguish between two different sleep states: active sleep with flat or rhythmic EEG tracing and quiet sleep with a tracé alternant on the EEG pattern. These investigators recorded the electrooculogram in addition to the EEG and noted that during quiet sleep, eye movements are absent, whereas during active sleep, rapid eye movements are continually present. ...
Adverse perinatal events affecting cerebral functions are a major cause of neonatal mortality, morbidity, and long-term neurologic deficit. Intrapartum fetal EEG, which records fetal brain electrical activity, provides a monitoring modality for evaluating the fetal CNS during labor. In this study, we describe a new approach to such monitoring that is based on real-time spectral analysis of the fetal EEG during labor. Fourteen pregnant women with uncomplicated term pregnancies who went into labor participated in the study. Two suction-cup electrodes were applied to the fetal scalp at the occipitoparietal or parietal region after rupture of membranes. Real-time spectral analysis was used to determine the frequency and amplitude of the fetal EEG signal. The spectral edge frequency (SEF) was calculated as the frequency below which 90% of the power in the power spectrum resides. The average EEG amplitude and the SEF were displayed using the density spectral array technique. Fetal heart rate and intrauterine pressure were also measured. Two fundamental EEG patterns were identified: high-voltage slow activity and low-voltage fast activity. The SEF was found to be an excellent index of cyclic EEG activity. Fetal heart rate demonstrated increased variability and an elevated baseline during low-voltage fast activity, whereas both parameters decreased during high-voltage slow activity. During episodes of variable decelerations in the fetal heart rate, a decrease in the SEF was observed, accompanied by an increased EEG voltage. The results obtained substantiate the presence of sleep cycles in the human fetus. This kind of cortical activity monitoring may enable rapid alertness to cerebral hypoxia and allow for prompt intervention, thereby decreasing the risk for birth asphyxia and subsequent brain damage.
Sleep is essential for human life. It has different characteristics in the early stages of life compared to later periods: during development, qualitative and quantitative changes in sleep features occur such as the onset of REM/NREM sleep at 3 months, the progressive increase of night sleep duration, and the reduction of total sleep time. Sleep seems to be essential in the cognitive functions' development, especially in the first period of life. Indeed, higher rates of night sleep at the age of 12 and 18 months are associated with higher executive functions' performance. Furthermore, memory consolidation occurs during sleep and sleep contributes to children's learning not only in retaining information but also in organizing memories most efficiently. Therefore, sleep problems could cause negative effects on some features of cognitive development like memory, executive functions, and learning process. There is also an intimate relationship between sleep and regulation of emotional brain functions, with a link between sleep disturbance and behavioral problems.
Patience and adequate time allotment are required for neonatal EEG work. At least two hours should be allowed for the entire procedure. Patience and diligence yield many benefits. It is strongly recommended that the electroencephalographer not only accompany the technologist as often as possible to the cribside, but that the electroencephalographer perform the entire procedure on a newborn infant at least once. There is no finer way to become enlightened about the many unusual difficulties which might arise during the recording. It is further advised that the records be reviewed by the electroencephalographer with the EEG technologist present. This is very helpful when problem areas contained in the EEG are called into question. Also, new ideas can be acquired for the next neonatal EEG procedure with the joint reading sessions. There are many considerations, complications, modifications and challenges involved in performing EEG records on newborn infants. But the delight of obtaining an informative, beautiful EEG can far outweight the aggravations which might have occurred. The most fascinating aspect of the neonatal period is the realization the the most dramatic electrical and physiological changes take place during this single stage of life. Being involved in neonatal EEG work is not merely challenging, but is rather immensely interesting and rewarding for the technologist and for the electroencephalographer. The ultimate hope is that the information provided by a well-run and a well-read EEG will assist the clinician in the care of the patient. As far as long-term prognostic projection is concerned, serial EEG recordings, rather than single EEG records, should be stressed.
This chapter delineates the evolution of the infancy, childhood, and adolescence sleep research in the past decades. The process of the unveiling of infants and children sleep disorders is depicted since its beginning in the nineteenth century, with the increasing awareness of the existence of specific pediatric sleep disorders that need specialized attention and treatment. The contribution of the observation of infant sleep to the discovery of rapid eye movement sleep is also reported, followed by the process that led to the definition of sleep architecture during development. This chapter also briefly lists the contribution by outstanding researchers from different countries and tells the tale of the establishment of the scientific associations now active in the field of pediatric sleep medicine. As a conclusive remark, the chapter shows that almost all studies have demonstrated that practically all sleep disorders have a negative impact on the child health. The field of pediatric sleep medicine is a growing field of research with great possibilities of expansion and dynamic evolution.
The aim of this chapter is to depict the discovery of sleep physiology in infants and the emergence of the discipline of pediatric sleep as relatively autonomous entity.
The gradual awareness regarding sleep disorders in infants and children begins in the nineteenth century when the first doctors and pediatricians begin to classify infants and children sleep disorders. The process that leads to the increasing understanding and knowledge of pediatric sleep disorders was not easy. Children’s sleep has been neglected until the end of the last century with the main textbook of pediatrics reporting no chapters or only few paragraphs devoted to pediatric sleep.
It is interesting to note that the first observation that leads to the discovery of rapid eye movement (REM) sleep was made on neonates and infants, and the first study on the negative behavioral consequences of sleep apnea has been reported in children.
The story of the infants’ and children’s sleep behavior during the antiquity is briefly delineated, and subsequently the first recommendations on the sleep time duration are reported with surprisingly data.
This chapter also briefly lists the fundamental contribution of researchers from different countries and their role in the development of pediatric sleep medicine.
Finally, the history and the establishment of the scientific associations related to the pediatric sleep medicine are delineated.
This historical overview has limitations, and some fundamental researchers that greatly contributed to the birth of pediatric sleep medicine as an independent field probably have been forgotten. However the last few years have acknowledged the growing interest on pediatric sleep, and different health providers (pediatric pulmonologists, otolaryngologists, neurologists, orthodontists, and psychologists) become interested in recognizing the negative consequence of sleep disorders for child health and development.
We have long understood sleep as an active, not passive, process that serves many functions, some of which vary in importance across the human lifespan. Ontogeny is the study of how a living organism develops from conception to birth and across its lifespan. This chapter reviews the ontogeny of sleep and its functions from infancy through adolescence. Sleep in humans serves many functions including: (1) fostering optimal brain growth and development; (2) enhancing learning, attention, memory, synaptic efficiency, and plasticity; (3) regulation of emotion, appetite, feeding, body weight, risk-taking, and pleasure-seeking behaviors; (4) strengthening immune function; and (5) providing optimal time for clearing the brain of cellular debris and neurotoxins. The chapter provides summaries of growing evidence for each of these. Sleep/wake states are scored in polysomnography using electroencephalography (EEG), electromyography (EMG), and electrooculography (EOG), and the ontogeny of these is also reviewed here.
In a group of 14 infants the behavioral arousal threshold (BAT) for a cold thermal stimulus was found to be significantly higher in the second quiet sleep epoch than in the first quiet sleep epoch. This finding points to the importance of the time effect concerning the BAT in infant sleep. The BAT in quiet sleep versus active sleep was not significantly different for the same stimulus. The role of different modalities of stimulation and individual differences as determinants of responsiveness during neonatal sleep states is discussed.
The goal of this study was twofold: at which conceptional age do the spontaneous skin potential responses (SPRs) appear in premature infants; are they related to the sleep cycle as they are in human adults. Twenty nine sleeping infants, conceptional age (CA) 24 to 41 weeks, were investigated with polygraphic recordings. SPRs first appeared at 28 weeks. Their number increased rapidly after 30 weeks CA. They appeared mostly simultaneously with slow wave EEG activity which in premature infants is the EEG pattern of active sleep. Unlike the spontaneous SPRs which in adults occur mainly in NREM sleep, they are in premature and full term newborns well correlated with active (or REM) sleep. The relationships between spontaneous SPRs and autonomic or phasic events of sleep are also studied.
The ontogenesis of sleep was studied in prematures from 32 to 41 weeks of gestational age The characteristics of the EEG, the patterns and rate of respiration, the cardiac rate, body motility comprised of localized and diffuse movements, localized and diffuse jerks, clonic movements and electromyo-graphic activity of the chin, as well as periods of total quietness were observed and correlated with the progressive organization of behavior in these infants. The data obtained at each gestational age, i.e., at 32–34 weeks, 35–37 weeks, and 38–41 weeks, were compared to those obtained in full-term newborns. The relationships between the different events and the features of the EEG and of the respiratory patterns were ascertained and compared to similar data obtained in the full-term newborn. This comparison shows that the premature at 40 weeks of gestational age has not attained a level of organization as high as that of the full-term newborn. An hypothesis suggesting a possible mechanism of this discrepancy is presented.
It has been postulated that the sudden infant death syndrome (s.i.d.s.) may sometimes be due to abnormal maturation or injury
to the brain stem centres that regulate respiration. This functional abnormality of the brain stem respiratory centres may
result in the interruption of the automatic inspiratory/expiratory cycle by recurrent periods of apnoea. There is a subgroup
of infants known as ‘near-miss’ for s.i.d.s., who survived a prolonged apnoeic episode during sleep which may have resulted
in death. In a number of recent studies, the near-miss infant has been clearly identified as an infant at high risk for s.i.d.s.
Clinical studies conducted by using polygraphic and behavioural monitoring of near-miss infants have revealed numerous apnoeic
episodes during sleep. Consequently, the clinical necessity of monitoring these babies in a paediatric care unit has become
well established both for diagnostic purposes and for subsequent outpatient care. In view of these findings, it has become
increasingly more important to develop advanced sophisticated computer methods for the on-line detection and processing of
apnoeas during in-hospital monitoring of infants. This paper describes a digital computer method of on-line apnoea processing
for application during the in-hospital monitoring of infants. The method is based on the application of Walsh transformations
to the expired CO2 signal measured in infants using a Beckman CO2 analyser.
Polygraphic sleep cycle studies--comprising simultaneous recording of electroencephalogram (EEG), electrocardiogram (ECG), electro-oculogram (ECOG), phasic body activity and respiration--were performed on 19 term newborn babies born to severely undernourished mothers, and results compared with 19 healthy newborn babies. The sleep cycle in babies of undernourished mothers showed disorganisation during active rapid eye movement (REM) sleep and quiet nonrapid eye movement (NREM) sleep. The sleep disorganisation was more pronounced during quiet NREM sleep when frequent phasic activity and ocular movements were registered, thereby leading to a significant increase in the content of intermediate sleep. Furthermore, the duration of total sleep cycle and its components, active REM and quiet NREM sleep, were significantly shortened.
Jugular venous occlusion plethysmography was performed on sleeping babies. Cranial blood flow (CBF) was calculated by correcting for noncompressible drainage pathways. Sleep state of the baby was monitored using clinical and EEG criteria. In 20 babies CBF was consistently higher in rapid eye movement (REM) sleep compared with nonREM sleep (mean difference 24.2%). In 7 babies systolic blood pressure was consistently higher in REM sleep (mean 20.2%). There was no correlation between the degree of change in blood pressure and CBF. In 11 babies in whom CBF was measured at known times after feeding, there was a consistently lower flow rate during the first hour compared with 2 hours later (mean difference 34.5%). The degree of change was unrelated to amount of feed taken, despite the method of test weighing being demonstrably accurate.
Thirty-five healthy, premature infants, ranging from 30–39 weeks postconceptional age, were observed continuously for 6 to 24 hr. Behavioral state and electroencephalographic patterns were coded for each minute. Using these data, three questions regarding coding of states of sleep were addressed: What is the concordance between behavioral codes and specific EEG patterns? Does the concordance between behavioral codes and EEG patterns change with postconceptional age? What range of error can be expected when observation periods shorter than 24-hr are used to estimate the daily distribution of quiet sleep (QS) and active sleep (AS)?
With behavioral codes as the standard, concordances of EEG patterns for QS and AS were 72.5 and 92.1% respectively. With EEG patterns as the standard, behavioral codes for QS and AS agreed 83.0 and 88.9%. Agreement between behavioral codes and EEG patterns for QS increased with age. Finally, variation in estimates of the daily distribution of QS and AS decreased dramatically as the length of observation increased from 3 to 24 hr.
Age is probably the single most crucial factor determining how humans sleep. Age and level of vigilance significantly influence the electroencephalogram (EEG) and the polysomnogram (PSG). The Pediatric Task Force provide an evidence-based review of the age-related development of the polysomnographic features of sleep in neonates, infants, and children, assessing the reliability and validity of these features, and assessing alternative methods of measurement. We used this annotated supporting text to develop rules for scoring sleep and arousals in infants and children. A pediatric EEG or PSG can only be determined to be normal by assessing whether the EEG patterns are appropriate for maturational age. Sleep in infants at term can be scored as NREM and REM sleep because all the polysomnographic and EEG features of REM sleep are present and quiet sleep, if not NREM sleep, is at least "not REM sleep." The dominant posterior rhythm (DPR) of relaxed wakefulness increases in frequency with age: (1) 3.5-4.5 Hz in 75% of normal infants by 3-4 months post-term; (2) 5-6 Hz in most infants 5-6 months post-term; 3) 6 Hz in 70% of normal children by 2 months of age; and 3) 8 Hz (range 7.5-9.5 Hz) in 82% of normal children age 3 years, 9 Hz in 65% of 9-year-olds, and 10 Hz in 65% of 15-year-old controls. Sleep spindles in children occur independently at two different frequencies and two different scalp locations: 11.0-12.75 Hz over the frontal and 13.0-14.75 Hz over the centroparietal electrodes; these findings are most prominent in children younger than 13 years. Centroparietal spikes are often maximal over the vertex (Cz), less often maximal over the left central (C3) or right central (C4) EEG derivation. About 50% of sleep spindles within a particular infant's PSG are asynchronous before 6 months of age, 30% at 1 year. Based on this, we recommend that: (1) sleep spindles be scored as a polysomnographic signature of NREM stage 2 sleep (N2) at whatever age they are first seen in a PSG, typically present by 2 to 3 months post-term; (2) identify and score sleep spindles from the frontal and centroparietal EEG derivations, especially in infants and children younger than 13 years. NREM sleep in an infant or child can be scored if the dominant posterior rhythm occupies <50% of a 30-second epoch, and one or more of the following EEG patterns appear: (1) a diffuse lower voltage mixed frequency activity; (2) hypnagogic hypersynchrony; (3) rhythmic anterior theta of drowsiness; (4) diffuse high voltage occipital delta slowing; (5) runs or bursts of diffuse, frontal, frontocentral, or occipital maximal rhythmic 3-5 Hz slowing; (6) vertex sharp waves; and/or (7) post-arousal hypersynchrony. K complexes first appear 5 months post-term and are usually present by 6 months post-term, whereas clearly recognizable vertex sharp waves are most often seen 16 months post-term. Vertex sharp waves are best seen over the central (Cz, C3, C4) and K complexes over the frontal (Fz, F3, F4) electrodes. Slow wave activity (SWA) of slow wave sleep (SWS) is first seen as early as 2 to 3 months post-term and is usually present 4 to 4.5 months post-term. SWA of SWS in an infant or child often has a peak-to-peak amplitude of 100 to 400 microV. Based on consensus voting we recommended scoring N1, N2, and N3 corresponding to NREM 1, 2, and SWS whenever it was recognizable in an infant's PSG, usually by 4 to 4.5 months post-term (as early as 2-3 months post-term). Epochs of NREM sleep which contain no sleep spindles, K complexes, or SWA would be scored as N1; those which contain either K complexes or sleep spindles and <20% SWS as N2, and those in which >20% of the 30-second epoch contain 0.5 to 2 Hz >75 microV (usually 100-400 microV) activity as N3. The DPR should be scored in the EEG channel that is best observed, (typically occipital), but DPR reactive to eye opening can be seen in central electrodes. Because sleep spindles occur independently over the frontal and central regions in children, they should be scored whether they occur in the frontal or central regions. Because sleep spindles are asynchronous before age 2 years, simultaneous recording of left and right frontal and central activity may be warranted in children 1-2 years of age. Simultaneous recording of left, right, and midline central electrodes may be appropriate because of the asynchronous nature of sleep spindles before age 2 years, but reliability testing is needed. Evidence has shown that the PSG cannot reliably be used to identify neurological deficits or to predict behavior or outcome in infants because of significant diversity of results, even in normal infants. Normal sleep EEG patterns and architecture are present in the first year of life, even in infants with severe neurological compromise. Increasing evidence suggests that sleep and its disorders play critical roles in the development of healthy children and healthy adults thereafter. Reliability studies comparing head-to-head different scoring criteria, recording techniques, and derivations are needed so that future scoring recommendations can be based on evidence rather than consensus opinion. We need research comparing clinical outcomes with PSG measures to better inform clinicians and families exactly what meaning a PSG has in evaluating a child's suspected sleep disorder.
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