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, 12 (3), 429-45

The Visual Scoring of Sleep in Infants 0 to 2 Months of Age


The Visual Scoring of Sleep in Infants 0 to 2 Months of Age

Madeleine M Grigg-Damberger. J Clin Sleep Med.


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.

Keywords: infant sleep scoring; neonatal polysomnography; neonatal sleep scoring; polysomnography; sleep scoring criteria.


Figure 1
Figure 1. Electroencephalogram (EEG) patterns of sleep in infants 0–2 mo of age.
Thirty-second epochs of each of the four sleep EEG patterns seen in infants between ages 0–2 mo: (A) mixed (M) EEG pattern characterized by both high voltage slow (HVS) and low voltage polyrhythmic components intermingled with little periodicity; (B) high voltage slow (HVS) EEG pattern characterized by continuous synchronous symmetrical predominantly high voltage (100–150 μV) 1–3 Hz delta activity, which often has an occipital or central predominance; (C) trace alternant (TA) pattern characterized by ≥ 3 alternating runs of bilaterally symmetrical synchronous high voltage (50–150 μV) bursts of 1–3 Hz delta activity lasting 5–6 sec (range, 3–8 sec) alternating with periods of lower amplitude (25–50 μV) 4–7 Hz theta activity (range, 4–12 sec); and (D) low voltage irregular (LVI) EEG pattern characterized by continuous low voltage mixed-frequency activity with delta and predominantly theta activity. The only EEG pattern distinctive of a particular sleep/wake state is trace alternant (TA) which when present suggests NREM sleep. The other three EEG patterns can be observed in more than one sleep/wake state. The (M pattern can be seen in W or R, rarely N; LVI in either R or W; and HVS most often in N, rarely R. The EEG pattern of R sleep before a period of R is often M, and LVI after a period of N (respectively termed AS1 and AS2).
Figure 2
Figure 2. Polysomnographic (PSG) montage for recording infants 0–2 mo of age.
Eye channels (left eye [E1], right eye [E2]) are referenced to the midline frontopolar electrode (FPz). Electroencephalogram (EEG montage is left frontal-right mastoid (F3-M2), right frontal-left mastoid (F4-M1), left central-right mastoid (C3-M2), right central-left mastoid (C4-M1), left occipital-right mastoid (O1-M2), right occipital-left mastoid (O2-M1), left central-midline central (C3-CZ), and midline central-right central (CZ-C4). This EEG montage allows easy recognition of low voltage 12–14 Hz sleep spindles, which may be seen as early as 43 w, usually present by 45–48 w CA. Other PSG signals recorded include: EKG, chin electromyogram (EMG), left and right anterior tibialis (L Leg, R Leg) muscles, snore microphone, nasal pressure (NP), thermal sensor, respiratory inductance plethysmography (RIP) thoracic, RIP abdomen, RIP SUM, pulse oxygen saturation (SpO2), R-R interval, pulse waveform, endtidal carbon dioxide (EtCO2), capnogram, and transcutaneous carbon dioxide (tcCO2).
Figure 3
Figure 3. Hypnogram showing rapid eye movement (REM) sleep onset in an infant.
Sleep onsets more often are REM sleep in healthy infants until 2–3 mo postterm. Note sleep onset (purple arrow) is REM sleep (black bars). Note more than half the sleep time is spent in REM sleep, typical for infants this age.
Figure 4
Figure 4. Representative examples of polysomnographic patterns of sleep in infants 0–2 mo of age.
(A) 30-sec epoch of rapid eye movement (REM) sleep with mixed (M) electroencephalogram (EEG) pattern, REMs and low chin electromyogram (EMG) tone typically seen following a period of wakefulness; (B) 30-sec epoch of NREM sleep with high voltage slow (HVS) EEG pattern, no eye movements, preserved chin EMG, and regular respiration, which often precedes longer period of trace alternant (TA) in infants at 38–42 w conceptual age (CA); (C) 30-sec epoch of nonrapid eye movement (NREM) sleep with trace alternant (TA) EEG pattern, no eye movements, regular respiration; and (D) 30-sec epoch of REM sleep with a low voltage irregular (LVI) EEG pattern, rapid eye movements (REMs), irregular respiration, and low chin EMG tone.
Figure 5
Figure 5. A 30-second epoch of sleep best scored as transitional sleep (T).
The discontinuous EEG pattern of trace alternant, absence of eye movements and the regular heart rate suggest stage N, but irregular respiration and body movements are more consistent with REM sleep (stage R). The AASM Scoring rules for scoring sleep in infants recommend scoring stage T if 3 NREM + 2 REM characteristics or 2 REM and 3 NREM characteristics are discordant. See Figure 2 for explanation of the various channels displayed in the montage.
Figure 6
Figure 6. A 30-second epoch of sleep best scored as wakefulness (W).
The technologist noted eyes open, moving head and crying. The EEG is continuous mixed EEG frequencies, rapid eye movements are present, chin muscle tone is high, respiration irregular and rapid, and movement and muscle artifact mar the tracing. See Figure 2 for explanation of the various channels displayed in the montage.

Comment in

  • Infant Scoring: The Force Awakens.
    Tapia IE, Marcus CL. Tapia IE, et al. J Clin Sleep Med. 2016 Mar;12(3):291-2. doi: 10.5664/jcsm.5566. J Clin Sleep Med. 2016. PMID: 26857048 Free PMC article. No abstract available.

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