GUIDELINE

American Clinical Neurophysiology Society Guideline 5: Minimum

Technical Standards for Pediatric Electroencephalography
John Kuratani,* Phillip L. Pearl,†‡ Lucy Sullivan,§ Rosario Maria S. Riel-Romero,k Janna Cheek,¶
Mark Stecker,# Daniel San-Juan,** Olga Selioutski,†† Saurabh R. Sinha,‡‡§§ Frank W. Drislane,kk¶¶
and Tammy N. Tsuchida##***†††
*
The Permanente Medical Group, Department of Pediatric Neuroscience, Kaiser Permanente, Santa Clara, CA, U.S.A.; †Department of Epilepsy and Clinical
Neurophysiology, Boston Children’s Hospital, Boston, MA, U.S.A.; ‡Department of Neurology, Harvard Medical School, Boston, MA, U.S.A.; §RSC Diagnostic
Services, Richardson, TX, U.S.A.; kDepartments of Neurology and Pediatrics, Ark-La-Tex Epilepsy Monitoring Unit, Louisiana State University Health Sciences
Center, School of Medicine in Shreveport, Shreveport, LA, U.S.A.; ¶NeuroLinks Group, LLC in Tulsa, OK, U.S.A.; #Winthrop University Hospital, Mineola, NY,
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U.S.A.; **Clinical Neurophysiology Department, National Institute of Neurology and Neurosurgery, Mexico City, Mexico; ††Strong Epilepsy Center, Department
of Neurology, University of Rochester, Rochester, NY, U.S.A.; ‡‡Department of Neurology, Duke University Medical Center, Durham, NC, U.S.A.;
§§
Neurodiagnostic Center, Veterans Affair Medical Center, Durham, NC, U.S.A.; kkDepartment Neurology, Harvard Medical School, Boston, MA, U.S.A.;
¶¶
Comprehensive Epilepsy Center, Beth Israel Deaconess Medical Center, Boston, MA, U.S.A.; Departments of ##Neurology and ***Pediatrics, George
Washington University School of Medicine and Health Sciences, Washington, DC, U.S.A.; and †††Division of Neurophysiology, Epilepsy and Critical Care in
Center for Neuroscience and Behavioral Health, Washington, DC, U.S.A.

Summary: This revision to the EEG Guidelines is an update to use current American Academy of Pediatrics term
incorporating the current electroencephalography technology “postmenstrual age” rather than “conceptional age.” Finally,
and practice. It was previously published as Guideline 2. Similar because therapeutic hypothermia alters the prognostic value of
to the prior guideline, it delineates the aspects of Guideline 1 neonatal EEG, the necessity of documenting the patient’s
that should be modified for neonates and young children. temperature at the time of recording is emphasized.
Recording conditions for photic stimulation and hyperventilation
Key Words: Electroencephalography, EEG, Guideline, Technical,
are revised to enhance the provocation of epileptiform discharges.
Neonate, Children, Pediatric, Hyperventilation, Photic Stimula-
Revisions recognize the difficulties involved in performing an EEG
tion, Montage, Electrode, Filter, Postmenstrual Age, Concep-
under sedation in young children. Recommended neonatal EEG
tional Age, Therapeutic Hypothermia.
montages are displayed for the reduced set of electrodes only
since the montages in Guideline 3 should be used for a 21-
electrode 10-20 system array. Neonatal documentation is updated (J Clin Neurophysiol 2016;33: 320–323)

T hese Guidelines for clinical EEG recording in children should

be considered in conjunction with the more general ACNS
Guideline 1: Minimum Technical Requirements for Performing 1. CHILDREN
Clinical Electroencephalography (MTR), which covers primarily 1.1 [MTR 2.1]
EEG recording in adults. Because children, especially young children, have a tendency
The basic principles of clinical EEG outlined in Guideline 1 to move a good deal during EEG recordings, electrode application
also apply to the very young and are reaffirmed here. Special should be performed with great care. Electrodes may be applied with
considerations pertinent to pediatric recordings are discussed paste or collodion, according to the preference of the laboratory, but
below, with emphasis on the EEG in neonates, infants, and their positions and impedances should be monitored carefully
young children. EEG recording in older children and adolescents throughout the study. Needle electrodes should not be used.
differs little from recording the EEGs of adults. Because EEG
recording in the newborn presents a number of special problems;
this Guideline is divided into two parts, setting forth recom- 1.2 [MTR 2.3]
mendations for children and for neonates separately. [Notation in All 21 electrodes of the International 10-20 system1 should
brackets in this Guideline refers specifically to sections of be used for most purposes. The standard montages used for
Guideline 1 which must be modified for pediatric recordings. adults should be used for children.
For situations not covered here, the recommendations of
Guideline 1 remain appropriate and should be consulted.] 1.3 [MTR 2.4, 3.2]
Recommendations of MTR 2.4 and 3.2 should be followed.
Particularly active children may require more frequent review of
Address correspondence and reprint requests to John Kuratani, MD, Department electrode recording quality during the recording.
of Pediatric Neuroscience, The Permanente Medical Group, Inc., 710
Lawrence Expressway, No. 470 Santa Clara, CA 95051, U.S.A.; e-mail:
[email protected]. 1.4 [MTR 3.1]
Copyright Ó 2016 by the American Clinical Neurophysiology Society
ISSN: 0736-0258/16/3304-0320 Before recording the EEGs of young inpatients, especially
DOI 10.1097/WNP.0000000000000321 those in so precarious a condition that the recordings must be

320 Journal of Clinical Neurophysiology Volume 33, Number 4, August 2016 clinicalneurophys.com
 ACNS Guideline 5: Pediatric EEG J. Kuratani, et al.

done at the bedside, the technologist should consult with the Whenever available, linking video to the EEG to capture these
nursing staff concerning the patient’s condition and about any events may be helpful.
necessary limitations on recording procedures. In stuporous or comatose patients and in those showing
invariant EEG patterns of any kind, visual, auditory, and
1.5 [MTR 3.3] somatosensory stimuli should be applied systematically during
The voltage of EEG activity in many young children is the recordingdbut only toward the end of the recording period,
higher than that of older children and adults, and appropriate lest normal sleep cycles be disrupted, or unexpected arousal-
reduction of sensitivity (to 10 mV/mm, or even 15 mV/mm) could related artifact render the tracing unreadable. The stimuli and
be used as needed. At least a portion of the record should be run the patient’s clinical responses or failure to respond should be
at a sensitivity (such as 7 mV/mm) adequate to display low- noted on the recording as near as possible to their point of
voltage fast activity. Otherwise, for patients beyond infancy, the occurrence.
same instrument control settings can be used as for adults in the
same laboratory.

2. NEONATES AND YOUNG INFANTS (UP TO 4–8

1.6 [MTR 3.8]
It is advised to perform hyperventilation at the beginning
WEEKS POSTTERM)
and photic stimulation at the end of the recording to maximize 2.1 [MTR 1.1]
spontaneous sleep.2 If hyperventilation fails to elicit diagnostic Recordings with at least 12 cerebral channels should be
findings in patients with suspected absence or other primary used, in addition to two, and often more, channels devoted to
generalized seizures, a second trial of hyperventilation (done at recording non-EEG “polygraphic” variables, such as electrocar-
least 10 minutes after the first trial) may have a higher yield.3 diogram and respiration. Sixteen or more channels facilitate the
Photic stimulation over the frequency range of at least 1 to 30 necessary flexibility.
flashes per second should be used during wakefulness in Because EEG patterns seen in the neonate are not as clearly
appropriate patients.4 related to stages of the wake–sleep cycle as are those of adults
and older children, it is usually necessary to record polygraphic
1.7 [MTR 3.8] (non-EEG) variables along with the EEG to assess accurately the
Whenever possible, recordings should include periods when baby’s state during the recording. Polygraphic recording is also
the eyes are open and when they are closed. In infants over helpful in identifying physiologic artifacts. For example, appar-
3 months of age, passive eye closure (by placing the technolo- ent monomorphic delta activity often turns out to be respiration
gist’s hand over the patient’s eyes) is often successful in artifact, as babies may have respiratory rates of up to 100/min.
producing the dominant posterior rhythm, as is playing a game Moreover, variables other than the EEG may be directly pertinent
such as “peek-a-boo.” to the patient’s problems, for example, in children with apneic
episodes, breathing and heart rate changes are often very
important.
1.8 [MTR 3.9] The parameters most frequently monitored along with EEG
Sleep recordings should be obtained whenever possible, in infants are heart rate, respirations, and eye movements.
but not to the exclusion of the awake record. Recording the Recording muscle activity by submental electromyography or
patient’s EEG during drowsiness, initiation of sleep, and movement transducer can also be very helpful.
arousal is important, and this is best obtained with continuous Electrocardiogram should be recorded routinely and is
EEG acquisition rather than pausing the recording in between particularly necessary when there are cardiac or respiratory
states. Natural sleep is preferred, but sleep deprivation or problems, or when rhythmic artifacts occur.
melatonin may be helpful.5 Discretion is required in choosing Respirogram can be recorded by any of the following
candidates for sleep deprivation as it may exacerbate prob- means: (1) abdominal and/or thoracic strain gauges, (2) changes
lematic behavior in developmentally challenged patients. Use in impedance between thoracic electrodes (impedance pneumo-
of sedation is the decision of the individual institution and gram), or (3) airway thermistors/thermocouples. In infants with
physicians. The benefits of a sedated sleep recording must be respiratory problems, it is necessary to devote three or four
weighed against the potential risks of sedation and/or its effect channels to respiration to monitor both abdominal and thoracic
on the EEG. movements, as well as airflow in the upper airway. In infants
without respiratory problems, one channel of abdominal or
1.9 [MTR 3.10] thoracic respirogram may be sufficient.
The patient’s clinical state (waking vs. drowsy vs. sleep) Eye movements can be recorded by placing one electrode
should be indicated clearly at the beginning of the recording and 0.5 cm above and slightly lateral to the outer canthus of one eye
with each montage change. Continuous observation by the and another electrode 0.5 cm below and slightly lateral to the
technologist, with frequent notation on the recording, is partic- outer canthus of the other eye. They can be designated E1 and
ularly important when recording young patients. This is espe- E2. Both lateral and vertical eye movements can be detected by
cially true in situations during which the typical events or linking (i.e., referring) the eye movement electrodes to auricular
behaviors concerning for seizures are displayed by the patient. electrodes: E1 to A1 and E2 to A1 (or E1-A2, E2-A2).

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 J. Kuratani, et al. ACNS Guideline 5: Pediatric EEG

2.2 [MTR 2.1] TABLE 1. Neonatal Montage Examples

Electrodes may be applied with either collodion or paste.
For neonates, the fumes of acetone and ether may not be Channel Montage A Montage B Montage C
acceptable, and disk electrodes with electrolyte paste are 1 Fpl-T7 (T3) Fp1-C3 Fpl-T7 (T3)
preferable. Needle electrodes should never be used. 2 T7 (T3)-O1 C3-O1 T7 (T3)-O1
3 Fp2-T8 (T4) Fpl-T7 (T3) Fp1-C3
2.3 [MTR 2.3] 4 T8 (T4)-O2 T7 (T3)-O1 C3-O1
5 Fp1-C3 Fp2-C4 Fp2-T8 (T4)
It is a matter of individual preference whether a reduced
6 C3-O1 C4-O2 T8 (T4)-O2
electrode array is acceptable for neonates. Some electroencepha-
7 Fp2-C4 Fp2-T8 (T4) Fp2-C4
lographers prefer the full 21 electrodes of the International 10-20 8 C4-O2 T8 (T4)-O2 C4-O2
system; others prefer a reduced array. It is generally agreed that 9 T7 (T3)-C3 T7 (T3)-C3 T7 (T3)-C3
a reduced array is acceptable in premature infants with small 10 C3-Cz C3-Cz C3-Cz
heads or where (as in neonatal intensive care units) time 11 Cz-C4 Cz-C4 Cz-C4
considerations or other circumstances may not allow application 12 C4-T8 (T4) C4-T8 (T4) C4-T8 (T4)
of the full electrode array. If 20 channels are available, it is 13 ECG ECG ECG
possible to use standard adult 16-channel montages plus poly- 14 Respiration Respiration Respiration
graphic variables. 15 E1-A1 or A2 E1-A1 or A2 E1-A1 or A2
16 E2-A1 or A2 E2-A1 or A2 E2-A1 or A2
If a reduced electrode array is used, the following electrodes
17 EMG EMG EMG
(10-10 system nomenclature, with 10-20 system nomenclature in
10-10 system nomenclature, with 10-20 system nomenclature in parentheses.
parentheses) are suggested as a minimum: Fp1, Fp2, C3, Cz, C4, ECG, electrocardiogram; EMG, electromyography.
T7 (T3), T8 (T4), O1, O2, Al, and A2. If a baby’s earlobes are
too small, mastoid leads may be substituted for A1 and A2 and
can be designated Ml and M2. Acceptable alternative frontal
placements in the reduced array are AF3 and AF4 instead of Fp1 taken into account when interpreting voltages in a bipolar
and Fp2 (10-10 system nomenclature; see Guideline 2); AF3 is montage.
halfway between the Fp1 and F3 positions and AF4 halfway The montages above are not the only permissible ones (for
between the Fp2 and F4 positions. additional neonatal montages, see Ref. 6). Rather, they should
Determining electrode sites by measurement is just as be considered standard montages, and at least one of them
important in infants and children as in adults. Deviation from should be used for at least a portion of a neonate’s EEG
this principle is permissible only in circumstances in which it is recording in all laboratories, to provide some standardization
impossible or clinically undesirable to manipulate the child’s among laboratories. Cz is always included because positive
head to make the measurements. If an electrode placement must “rolandic” sharp waves (a common abnormal finding) and
be modified because of intravenous lines, pressure bolts, scalp some seizures may only be detected at Cz in this population.
hematomas, and others, the homologous contralateral electrode Electrodes Fz, Cz and Pz are also used to visualize positive
placement should be modified similarly. If approximate rather “rolandic” sharp waves.7 Various other montages can be
than precise lead placement is done, the technologist should note devised for special purposes, such as a montage combining
this on the recording. referential and bipolar derivations.
The use of a single montage throughout the recording of
a neonate may be, and often is, sufficient and is preferred in many
2.4 [MTR 2.4]
laboratories. Nevertheless, a single montage is not always
Electrode impedances of less than 10 kOhms are allowed to
adequate. Even in laboratories preferring single montages,
avoid excessive manipulation or excessive abrasion of tender skin.
additional montages should be used when the need arises, for
It is still important that marked differences in impedances among
example, to delineate focal abnormalities better.
electrodes be avoided. Further details are in the [MTR 2.1] section.
For recording polygraphic variables, the following derivations
are recommended: (1) for electrocardiogram, lead 1 (right arm-left
2.5 [Guideline 3] arm) is preferred; (2) for respiration, chest wall or abdomen
If a 21-electrode 10-20 system array is used, Guideline 3 movement (strain gauge or impedance pneumogram); (3) for eye
recommendations should be followed as long as Cz is included. movements (electrooculogram): E1-A1 and E2-A1 or E1-A2 and
If a reduced array is used, a single montage that includes both E2-A2; (4) for submental electromyography: two electrodes under
longitudinal and transverse montages is recommended below the chin, each 1 to 2 cm on either side of the midline.
(10-10 system nomenclature, with 10-20 system nomenclature in
parentheses) (Table 1).
Note that channels 9 to 12 are a transverse bipolar chain 2.6 [MTR 3.1]
with standard interelectrode distances rather than the double Before recording the EEGs of young inpatients, especially
distances in channels 1 to 8. AF3 and AF4 (per 10-10 system those in so precarious condition that the recordings must be done
nomenclature; see Guideline 2) may be substituted for Fp1 and at the bedside, the technologist should consult with the nursing
Fp2, and M1 and M2 may be substituted for A1 and A2. If AF3 staff concerning the patient’s condition and about any necessary
and AF4 are used, the reduced interelectrode distance must be limitations on recording procedures.

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 ACNS Guideline 5: Pediatric EEG J. Kuratani, et al.

The baby’s gestational age at birth, chronologic age, and change. When there is EEG variability, adequate sampling of
postmenstrual age on the day of recording, stated in weeks, are both major sleep states is important. The initial sleep state in the
absolutely essential to interpretation and must be included in the neonate is usually active sleep, which may last a very short time
information available to the electroencephalographer (Postmenst- or continue for many minutes. An adequate sleep tracing must
rual age is gestational age plus chronological age.8 Gestational include a full epoch of quiet sleep. It is never necessary or
age is the time elapsed between the first day of the last menstrual desirable to use sedation to obtain a sleep recording in a neonate.
period and the day of delivery. Chronological age is the time Repetitive photic stimulation is rarely, if ever, clinically
elapsed since birth. Neonatal studies (past and present) some- useful in neonates and is not recommended.
times use the term conceptional age when postmenstrual age is
being measured. Some studies do not define the term concep- 2.9 [MTR 3.10]
tional age. This is an important distinction since conceptional age The child’s condition, including head and eyelid position,
is the time elapsed between the day of conception and day of should be clearly indicated at the beginning of every montage.
delivery, and therefore an infant with conceptional age of 24 Continuous observations by the technologist, with frequent
weeks would have a gestational age of 26 weeks. To avoid notation on the recording, are particularly important when
confusing terminology, the American Academy of Pediatrics recording from neonates.
recommends using postmenstrual age and never using concep-
tional age.). All other available relevant clinical information
(including blood gas results, serum electrolyte values, and
current medications) should be noted for the electroencephalog- DISCLAIMER
rapher. If hypothermia is present, therapeutic or otherwise, it This statement is provided as an educational service of the
should be documented along with the patient’s body temperature. American Clinical Neurophysiology Society (ACNS). It is based
on an assessment of current scientific and clinical information. It
2.7 [MTR 3.3, 3.4] is not intended to include all possible proper methods of care for
In young infants’ EEGs, the most appropriate sensitivity is a particular problem or all legitimate criteria for choosing to use
usually 7 mV/mm, but adjustments up or down should be a specific procedure. Neither is it intended to exclude any
appropriately used to facilitate EEG interpretation. At least reasonable alternative methodologies. ACNS recognizes that
a portion of the recording should be run at a sensitivity adequate specific patient care decisions are the prerogative of the patient
to display low-voltage fast activity. The low-frequency filter and the physician caring for the patient, based on all of the
setting should be between 0.3 and 0.6 Hz (23 dB) (time circumstances involved. The clinical context section is made
constants of 0.27–0.53 second), not the commonly used 1 Hz available in order to place the evidence-based guidelines into
(0.16 second). perspective with current practice habits and challenges. Formal
For electrooculogram, a sensitivity of 7 mV/mm and the practice recommendations are not intended to replace clinical
same time constant as for the concomitantly recorded EEG judgment.
derivations are recommended. For respirogram, amplification
should be adjusted to yield a clearly visible vertical deflection. A
low-frequency filter setting of 0.3 to 0.6 Hz, but not direct
current, should be used. For the submental electromyography REFERENCES
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