Ray McCrea puts the finishing touches on Gabriel’s turban. There are a dozen different leads attached underneath.
Gabriel nods off for a moment while still in the chair.
Gabriel is a shy 4-year-old who isn't sleeping well. He snores heavily and wakes up in the middle of the night coughing and choking. He complains of headaches and pain down his leg when he wakes. As a consequence, his dad, Julio, reports he's often moody and angry. Lack of sleep will do that to anyone.
An electroencephalogram (EEG) was performed to determine if there was a neurological problem. Fortunately it was negative, so doctors suggested a sleep study. Thus the presence of dad and son, pajamas in hand, at Children's Hospital & Research Center Oakland's Sleep Lab one October evening. Gabriel is about to go on a journey, a journey into the world of sleep, a mysterious, little understood world, under the watchful gaze of Children's registered pediatric polysomnographers who understand that world as well as anyone in the business.
Sleep studies can make a huge contribution to both the mental health and the physical well-being of a child, says Jim Ghiron, coordinator of Children's Sleep Lab. Jim, who came up through the ranks as a respiratory therapist and pulmonary function technician and is now a registered pediatric polysomnographer, sees their value nightly.
"Here's the beauty of this work: in pediatric polysomnography you are gaining information that will dramatically improve the life of the child immediately. Because if you are able to document severe sleep apnea [blocked night breathing] or hypercardia [too much carbon dioxide in the blood], the kid can be treated right away, in fact the next day they can be admitted to the hospital and treated. That dramatically improves their sleep, their life, and everyone's life around them. The improvement is really thrilling to see, really enjoyable."
Ray McCrea, also a registered pediatric polysomnographer in Children's Sleep Lab, brings Gabriel and his dad into one of the three sleep rooms in the lab. It has two beds, one so Dad can spend the night comfortably. Ray gets Gabriel settled in a chair and talks him through a sometimes tedious, sometimes challenging process. "No owies," he assures the 4-year-old. "I promise, no owies."
Ray starts by showing Gabriel an electrode that will be attached to his forehead. "See, it's gold," he says, "real gold." With a swab, he cleans a spot of skin, "Scrub-scrub-scrub-scrub!" Ray says. "Does it tickle?" Gabriel neither smiles nor reacts, so Ray continues to coach him. "It's kind of cold, isn't it, the liquid is cold." He places the electrode on the spot, and attaches it with tape. "We're just gonna keep doing this until we run out of electrodes," he says.
"How many are you going to put on?" Dad wonders.
"About 13 of these," Ray explains, "every one of them has its purpose." Electrodes will monitor the airflow at Gabriel's nose and mouth, his heart rate, and his oxygen and carbon dioxide levels. Others will measure his chest expansions and abdominal movements. His chin will be monitored for snoring, his brain waves for sleep stages and his eyes for REM state (see related article: The Architecture of Sleep). Because Gabriel has complained of leg pain, Ray will also add leg leads. "Sometimes, kids just kick themselves awake," Ray says.
Through it all, Gabriel maintains his shy, quiet demeanor. "Boy, you sure are brave," Ray tells him. "I wish all my kids were as brave as you."
They're not all as accommodating. In room two, Jim Ghiron is going through the same process with a 9-month-old boy. His cries can be heard in Gabriel's room.
"Looks like I won the lottery tonight," Ray acknowledges. He does, however, have a second study coming in shortly (the lab does three studies a night, Monday thru Thursday), so he still may have his work cut out for him.
Pediatric pulmonologist Karen Hardy, MD, is the medical director of Children's Sleep Lab. "With the data from a sleep test," Dr. Hardy says, "we can determine whether or not a child has normal sleep, or whether they have disruptive sleep, and if they have disruptive sleep, if it's disrupted by some type of apnea or some other cause."
It turns out most of the kids who come to the lab with sleep problems do have respiratory issues, Dr. Hardy explains. "About 10 percent of children have obstructive sleep apnea (OSA), which is an under-recognized condition. Most people think of adults as having sleep apnea but they don't realize kids can have it, too."
OSA occurs when enough air cannot flow into or out of the person's nose or mouth, although efforts to breathe continue. Often, tonsils and adenoids are the culprits in kids, in which case the treatment is rather simple. "We send them to surgery and take out their tonsils and adenoids, which gives them physically more space," says Dr. Hardy. "It works for 75 to 80 percent of kids with OSA."
The effects of OSA, or any disruption of sleep patterns, on a child's life can be dramatic.
"Unlike adults, if a child does not sleep well at night and they don't take naps during the day, they tend to do the 'I'm overactive-hyperactive thing,'" Dr. Hardy says. "So most of them become wild. They act out. We get kids referred here from Psychiatry because they have behavior abnormalities, not because they have a mental illness. They just aren't sleeping at night; they are sleep-deprived."
Not all kids come to the sleep lab with OSA, however. Some suffer parasomnias like sleepwalking, night terrors or narcolepsy. Others have congenital medical conditions or craniofacial abnormalities or illnesses that effect their breathing and sleeping. In these latter cases, the solution is often mechanical breathing support, from a C-PAP (Continuous Positive Airway Pressure) or Bi-PAP (Bilevel Positive Airway Pressure) machine. The sleep study helps to determine which non-invasive, positive pressure ventilation solution is best for a child and what the machine's settings should be.
"If we apply oxygen using a C-PAP or Bi-PAP to a child, there's usually a dramatic payback," says Jim Ghiron. "Very often children will go right to sleep and in fact go directly to REM sleep to make up their deficit." Jim calls this phenomenon REM-rebound, or catch-up sleep.
"Once again, by morning, they're already better. You have puzzled out what they need with respect to sleep at night, with respect to mechanical support. You know their night sleep following your work is going to be greatly improved, their school work will get better, sometimes they gain weight because they no longer burn all their calories at night, their relationship with their parents gets better, and daytime cognition improves. It has a direct correlation to schoolwork and sociability. All this happens with one night's work. It's exhausting and draining emotionally, but you know by morning that you've done a good job."
While Ray wraps the multitude of wires into a braid that will hang from the back of Gabriel's turbaned head (the turban holds all the wires and electrodes in place), the four-year-old is already droopy-eyed. Ray and Dad help tuck him into bed, wires safely out of harm's way. By the time Ray makes it to the lab's control room down the hall and sits at his desk, the EEG vector on his computer screen reports that Gabriel is sleeping soundly; a dream case for a pediatric polysomnographer. All of the leads on Gabriel are now reporting data on a single screen. To its left is a TV monitor where Ray can watch Gabriel in cozy slumber thanks to an infrared camera mounted in the room's ceiling.
Across the room, Jim is monitoring his 9-month old, who is quiet now, but whose eyes are still open. For the rest of the night, the polysomnographers will chronicle and note any anomalies in sleep patterns, respiration and arousals of their clients. The data should allow them to trace the arousals to their source. Help, if it's needed, is right around the corner.
The new American Academy of Pediatrics (AAP) guidelines suggest that any child with chronic snoring or sleep problems should be a candidate for a sleep study. Children's now has a Sleep Clinic to screen candidates. Ask your physician for a referral.