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Summary Sleep Staging Rules for Infants and Children
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Sleep Staging Rules for Infants and Children notes from the AASM scoring manual, version 3.0.
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Sleep Staging Rules for Children Notes Use the pediatric rules for children 2 months post term or older
For infants less than 2 months post-term, use the Sleep Staging Rules for Infants
Post-term: at least 40 weeks after conception
o For babies born full-term, this means using the pediatric rules starting 2 months after birth
o For babies born a month premature (36 weeks after conception), use the pediatric rules starting 3 months
after birth
Children under the age of 6 months, scoring of sleep stages may be difficult
o This is because the waveforms we rely on for staging have not yet developed
Waveform Age
Sleep Spindles 6 weeks to 3 months
K complexes 3-6 months
Slow Wave Activity 2-5 months
Rules for general scoring of pediatric sleep stages follow:
1. Scoring of sleep in the very young adds a stage N (NREM), because sleep waveforms develop at different rates
after birth and may not all be present. Otherwise, terminology for the stages is the same.
2. If the child is not in W or R and there are no sleep spindles, K complexes without arousals or slow wave activity,
score stage N.
3. If there are sleep spindles of K complexes but not slow wave activity, score epochs with sleep spindles or K
complexes as N2 and other epochs that are not W or R as Stage N.
4. If there are no sleep spindles or K complexes and some epochs have more than 20% slow wave activity, score
those as N3 and other epochs that are not W or R as stage N.
5. If there are sleep spindles, K complexes and slow wave activity, score N1, N2, and N3 as in adults.
For children under 2-3 months of age, it may be difficulty to make the distinction between sleep stages.
Based on the polygraph recordings alone, it may be difficult to determine if the child is awake or asleep.
It may be difficult to tell the difference between N1, N2, and N3.
Rules 1-5 above say that we can lump all of these together as N if the patient has no K complexes, spindles or slow
wave activity.
Young Children do not have the same kind of posterior dominant or alpha rhythm that adults have.
This makes scoring of sleep onset very difficult
Infants often transition from W to R rather than the adult pattern of W to NREM to R.
Detailed notes on the behavior of the child are very important
Scoring Pediatric Stage W
Definitions for pediatric stage W are mostly the same as for adults
Posterior dominant or alpha rhythm, eye blinks, reading eye movements and rapid eye movements are all the same
as for adults and used in the scoring of W
PDR is the equivalent of alpha rhythm for infants and young children
The frequency changes with age, but 2 things are the same: it is most prominent in the occipital channel, and it
goes away when the patient’s eyes are open.
, The PDR is used in infants and children in the same way as alpha rhythm is used in adults.
Frequency Age
3.5-4.5 Hz 3-4 months
5-6 Hz 5-6 months
7.5-9.5 Hz 3 years
Rules for Scoring W in children follow:
1. Score W in accordance with the definitions of alpha, eye blinks, reading eye movements, rapid eye movements and
posterior dominant rhythm.
2. PDR in children is the equivalent of alpha rhythm in adults.
3. Score W in epochs where PDR or alpha rhythm is more than 50% of the epoch.
4. If there is no alpha rhythm or PDR, score W when any of the following are present:
a. eye blinks
b. reading eye movements
c. Rapid eye movements with normal or high EMG tone
If you are recording a 6 month old child, you should look for 5-6 Hz sinusoidal EEG in the occipital channel
If you see it for more than half of the epoch, score W
We know that around 10% of adults will have no alpha rhythm
Almost all infants under 3 months of age will have no PDR or alpha rhythm
This means you would score W when there are eye blinks or rapid eye movements
Rapid eye movements may occur in W when tracking a mobile or the face of a parent
Young children often go from W to R, so the rapid eye movements can be misleading
Chin EMG is not a very reliable measure and may drop only a little bit in the transition to R
Detailed notes on the behavior of the child are very important
The most important observation is eyes open or eyes closed
Infants don’t spend a lot of time awake with their eyes closed
o If they close their eyes score N1 as eye closure is a sign of drowsiness
o When they occur, reading eye movements in children are defined in the same way as reading eye
movements in adults
Technologist notes are so important when running pediatric sleep studies!
Scoring Pediatric Stage N1
Definitions for pediatric stage N1 are mostly the same as for adults
Slow eye movements, LAMF, vertex sharp waves and sleep onset are all defined in the same way
Hypnagogic Hypersynchrony are bursts of very large waves that look abnormal
Frequency is 3-4.5 Hz
Very sinusoidal and the amplitude can be as high as 350uV
Seen in all channels, but they are usually smallest in the occipital channel and maximal in the central, frontal or
frontocentral regions
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