Keywords
Polysomnography - sleep laboratory - design - set up
Introduction
Sleep disordered breathing is a common problem in pediatrics and is probably the most
prevalent sleep disorder affecting children. The prevalence of habitual snoring is
up to 12% of children. A significant number of these children will require overnight
polysomnography (PSG) to diagnose obstructive sleep apnea syndrome (OSAS) which occurs
in up to 5.7% of children.[1] However, there are only a limited number of sleep laboratories that perform PSG
testing on children.[2] Furthermore, for a variety of technical and behavioral reasons, studies cannot be
easily performed on children at home as they can for adults. As a result, more sleep
laboratories that can perform sleep studies on children are required. This need can
be met by building more exclusively pediatric sleep laboratories. However, pediatric-only
sleep laboratories are usually associated with a tertiary hospital and the number
of such laboratories clearly cannot meet the demand for sleep study services of the
population. On the other hand, primarily adult sleep centers are often in an area
where there are no pediatric sleep laboratories and may have a desire to serve younger
patients to provide more comprehensive service. In addition, sleep studies for adults
are now primarily performed in the home. As a result, there is available space in
the adult sleep laboratories and use of such facilities, if appropriately equipped
and staffed, would be a reasonable solution for the space crunch and relative inaccessibility
to sleep studies in children.
Performing sleep studies on children provide unique challenges as compared with adults.
They have different physiological, medical, developmental, behavioral, and cultural
needs than adults. These differences can stress the sleep laboratory from the time
of referral to the process of interpreting the sleep study. Attention to details with
a pediatric focus in mind is required to be successful in providing optimal services.[3] This article is written to assist the reader in either setting up a pediatric sleep
laboratory or expanding from primarily adult service to including children. Specific
details of protocols, equipment, or the performance of sleep studies are beyond the
scope of this article.
Decision to Perform Pediatric Studies
Decision to Perform Pediatric Studies
The first decision to make is whether pediatric sleep studies are needed in the desired
service area. Evaluating the pediatric demographics in the service area is an important
place to start. Other considerations are the availability of existing sleep laboratories
that provide service for children and what ages do the existing laboratories serve?
Many primarily adult laboratories will study adolescents down to 12 years of age,
while others may be comfortable performing studies on children as young as 6 years
of age. Another area to evaluate is the complexity of children other laboratories
are performing studies on? Also, how comprehensive is the service? For example, does
the laboratory perform a multiple sleep latency test (MSLT) on children? Finally,
does an existing laboratory have more of a research focus than a clinical one?
Location
The next decision is the location of the laboratory. This may be predetermined if
the studies will be in an existing adult laboratory. Even so, some adjustments will
likely need to be made to service children. For a new laboratory, location can be
critical in determining success. Factors to consider include whether the laboratory
is part of an existing health care institution and what facilities are available in
the desired service community? For example, is there a hospital in the area? Medical
complexity of the children to be studied is an important factor as well. In otherwise
healthy children, the sleep laboratory can more easily be in a community environment.
However, if sleep studies will be done on children with other significant medical
comorbidities, a sleep laboratory housed within a hospital setting would be more desirable.
Access to parking, food, registration requirements, and emergency support are also
considerations in determining location.
Sleep Laboratory Design
Planning for pediatric sleep studies will have a clear impact on architectural design,
build, and decoration. For pediatric patients to be comfortable the space must be
child friendly. An intimidating space could make the difference of whether a study
can be completed or not. The American Academy of Sleep Medicine (AASM) has recommendations
for room size and these must be kept in mind.[4] However, a room for children may need to be larger to allow for a bed for parent/caregiver
to sleep, access for special needs children or space for other medical equipment,
such as feeding pumps and home ventilators. The room must also be large enough for
emergency personnel to function. Medically complex children may require additional
staffing, such as nurses, child life workers, social workers, and security staff ([Fig. 1]).
Determining how many beds to have in the sleep laboratory is another important decision.
Too few beds and there will be a backlog in the schedule. Too many, and money is wasted
on the space and equipment. Pediatric demographics in the laboratories service area
will help inform this decision too. Other factors include how many days per week the
studies will be done and whether staffing issues impose any limitation. Available
space in the building and whether individual showers and bathrooms are desired may
also affect the number of beds.
The safety and comfort of the staff and regulatory requirements for the staff must
be kept in mind when choosing space and designing the laboratory. Space will be needed
for technical staff to take breaks. Staff restrooms and refrigerators are additional
considerations ([Fig. 2]).
All sleep laboratories need to consider lighting, patient restrooms, handicap accessibility,
and electrical shielding when building a sleep laboratory. Furthermore, children tend
to cry when they are upset. This can be mitigated with room spacing and/or sound proofing.
Overhead paging must also be blocked if the laboratory is a part of a larger institution.
Closets and/or shelves for stocking testing equipment, cleaning supplies, and safety
equipment must also be considered. A final thought is if the space isn't being used
during the day it could also potentially be used as an ambulatory sleep clinic with
some alterations ([Fig. 1]).
Fig. 1 Picture of a study room in the authors’ laboratory. The camera is in the ceiling
(solid black arrow) to allow the best patient viewing even with a crib. Note the shelving
for the PAP machine, end-tidal CO2 monitor and other equipment (dashed black arrow). One bed is for the patient and
the other is for a parent. The bedside stand is low and cannot be tipped over easily.
PAP, positive airway pressure.
Pediatric Safety
Safety is a critical factor when designing, building, and operating any clinical area.
This becomes even more important and brings different considerations when children
are involved. Access to oxygen, air, and suction should be present, as well as child
sized cannulas and suction catheters. A cardiopulmonary resuscitation cart should
be stocked with child appropriate equipment, medications and dosage guides. Transportation
to an emergency facility for children must also be thought through.
Child friendly furniture is important to make them comfortable but must also be safe.
There must be developmentally appropriate beds with rounded corners, bedside stands,
equipment, armoires, and other furniture that cannot be pulled over by a child. Another
thing to keep in mind is buying waterproof mattresses so they can be easily cleaned
in the case of enuresis or emesis. Some children may have medication that requires
refrigeration and how this is handled must be considered by the laboratory personnel.
One thought is to have a medication refrigerator. However, it must be kept in mind
that medication must be kept separate from food and adequately labeled. Another possibility
is to have the parent bring the medication in a cooler.
Once the space is built, it is important to perform a safety walk with child hazards
in mind. These could include checking safety covers for electrical outlets, pull cords
that could strangle a child, water that gets too hot and dangerous equipment in the
reach of young hands. Staff training in pediatric basic life support is critical.
One last step prior to opening the laboratory is to do a “dress rehearsal” to make
sure that everything is present and working properly. Once the laboratory is running,
regular mock emergency procedures should be performed to learn where issues may arise.
A final safety consideration when medically complex children are being studied is
to make the larger hospital aware that such a child is present in the sleep laboratory
in case their underlying condition worsens. For example, at Akron Children's Hospital,
if a child is being studied that has a tracheostomy and/or home ventilator, a respiratory
therapy supervisor evaluates the child as an independent assessment of the child's
stability and also provides input as to what their needs might be if an emergency
occurs.
Technical Concerns
Dealing with children of course generates technical considerations. Their bodies are
smaller, they are physiologically different than adults, and they are developmentally
more challenging. A crib will be required for young children, so beds must be mobile
to allow movement in and out of a room. AASM and other requirements can be different
for children.[3] For example, the AASM recommends that all children have carbon dioxide monitored
due to the increased likelihood of hypoventilation. The placement, size, and type
of leads are often different for children. Examples include different placement for
electrooculogram (EOG) and chin electromyogram (EMG) leads, and the pediatric oxygen
saturation probe may be a wrap as opposed to a clip. Also, nasal cannulas, thermistors,
and respiratory inductance plethysmography bands will all need to be pediatric sized.
When choosing a sleep software/hardware vendor a child's needs must be kept in mind.
The vendor must meet AASM requirements for performing studies in children and if desired,
infants.[5] Technical requirements for doing the study, such as sampling rate, scoring a pediatric
study such as using a two-breath duration for apneas and hypopneas, and the ability
to score periodic breathing are all elements that need to be assessed. Pediatric report
templates must be available from the vendor and support for customizing templates
is very desirable. For example, oxygen for the treatment of central sleep apnea is
more often used in young children than adults. The titration report must be able to
handle this. In this day and age exporting a report to the institution's electronic
medical record and/or with the area's health information exchange system is becoming
a routine requirement. While HL7 interoperability is a must, systems may have differing
versions of this standard and an older version may not handle pediatric specific information
as well as the most recent versions of recommended documentation. Length of time during
which the digital information containing the sleep study is stored may also be different
for children. For example, in the United States the medical liability statute of limitations
is often longer for children leading to larger storage capacity requirements for digital
information.[6]
Given all these considerations, choosing a vendor for pediatric studies can be more
difficult than for adult-only studies. Using a consultant with pediatric experience
can be useful. Even so, it is useful to talk with colleagues that have used the PSG
equipment and have met all the desired technical requirements. Of course, demonstrations
must be done and care taken to verify what a vendor has said is correct. Toward this
end, visiting a pediatric laboratory that has experience in using the equipment can
provide useful insights and prevent potential future problems. If needed, the vendor
should be able to provide references for sleep laboratories using their equipment.
Do not forget to include technical and administrative staff in these visits. Finally,
do not forget to keep vendor technical support in mind. It is vital that they provide
robust support with pediatric experienced staff both day and night once the equipment
has been purchased.
Staffing for Pediatric Patients
Staffing for Pediatric Patients
Pediatric sleep studies call for additional requirements and training when looking
for qualified sleep technologists to staff the sleep laboratory. Personnel must be
trained in pediatric developmental, physiological, and behavioral aspects, and must
have a family centered approach. Beyond that, they must have a desire and temperament
for working with children. Sleep studies are done when a child and their parent are
at their lowest capability for cooperating. Putting a technician that does not want
to work with children and does not have proper training into this mix can be disastrous.
Finding technicians with the above skills can be challenging. Traditionally sleep
technologists have a respiratory therapist or EEG technician background so a local
pediatric hospital or hospital with a pediatric ward may be a source. Developing a
relationship with the closest training school for sleep technologists can be very
useful. Teaching a course at the college or hosting students at your laboratory for
their clinical rotations can assist in this goal and provide valuable exposure to
your laboratory. Another source for technicians is job posting sites at schools, the
AASM or other professional societies, such as the American Association of Sleep Technologists.
Fig. 2 Control room at the authors’ sleep laboratory showing two of the six review stations
(white arrows). The staff lounge is connected to the sleep laboratory (black arrow).
Additional personnel that must have pediatric understanding and/or training includes
the receptionist, the scheduler, registration and billing staff, information technology,
and biomedical support. One of the most important staff in the sleep laboratory is
the operations manager. This person keeps the laboratory running smoothly while also
being a safe and effective place. They are responsible for hiring the right staff
and providing them with resources and a good working environment. They have a critical
role as a go-between for the night and day teams, clinic, and other areas outside
the laboratory, such as durable medical equipment (DME) companies. They will make
sure the staff is adequately trained, evaluate staff and make sure they maintain continuing
education credits. A good operations manager will also make sure the laboratory receives
patient satisfaction feedback and perform quality improvement work.
Policies and Procedures
An important process in the functioning of the laboratory is the creation of a policy
and procedure manual. It creates a consistent and durable body of knowledge under
which the laboratory operates. The development of good policies and procedures does
take time and effort. This can be reduced by starting with sample protocols and then
adjusting them to your sleep laboratory's specific requirements. Sources of protocols
can be obtained from colleagues, the AASM, and other professional societies. Other
important considerations when creating policies are to include staff from the areas
that involve them, make them as direct as possible, teaching the staff about the policies
when created, and reviewing them on a regular basis.
Of course, it is important to have policies and procedures that take pediatric issues
into account. Most pediatric sleep laboratories work closely with a tertiary care
hospital or sleep-specialty clinic which is the primary source of patient referrals
for testing. However, it is our experience that once sleep-related specialty services
are established in a given community, awareness for screening and managing sleep disorders
rapidly increases among area physicians and clinicians. Subsequently, they become
an important source of direct-to-laboratory referrals for testing. Often, such clinicians
will order tests ahead of, or even in lieu of a sleep-specialty consultation. Since
these patients are not evaluated by a sleep specialist prior to testing, good policies
and procedures will ensure that the appropriate order for the study is placed based
on the child's clinical assessment in the referral documents. Along these lines, several
issues become noteworthy. First, the reason for doing the study must meet standards
of care. A test must be ordered for the right reasons and not just to “rule out a
sleep disorder” in a child who “cannot sleep.” Also, many conditions affecting sleep
or involving sleep do not necessarily require a PSG for reaching the diagnosis. For
example, childhood insomnia is a common reason for referral to a sleep laboratory
that does not require a PSG to be done unless symptoms of OSAS or other specific sleep
disorders are present. In the United States, the AASM has published guidelines for
the indications of PSG and other sleep tests in respiratory and nonrespiratory conditions
([Table 1]).[7]
[8] Second, fiscal stewardship with healthcare expenditures demand that the correct
test is ordered. For example, a patient with daytime sleepiness who is also at high
risk for sleep apnea should not routinely be ordered an MSLT paired with a prior-night
PSG since an MSLT is commonly known to most clinicians as indicated for the investigation
of hypersomnia disorders. However, if the somnolence symptoms far exceed the common
phenotypic presentation of sleepiness in a child, it may be worthwhile to exceptionally
consider inclusion of the MSLT in the initial testing. Third, for logistical and safety
reasons, the presence of devices such as vagal nerve stimulators,[9] need for overnight gastrostomy feeds, nursing support, ventilator management, nighttime
medication administration, or even the need for a hydraulic lift for physically challenged
patients should not come as a surprise for the nighttime technologist. For example,
while pre-tracheostomy tube decannulation sleep testing is often used to guide clinical
decisions in children with tracheostomies, such a child should not undergo tracheostomy
capping for the very first time in the sleep laboratory. Fourth, the patient and family
should be appropriately counseled by the ordering provider regarding the sleep test.
A routine overnight PSG may not work well for a teenager with a severely delayed sleep
schedule. Thus, sleep hygiene and circadian rhythms may need to be addressed first
unless the laboratory can synchronize the test to match the habitual sleep time. Finally,
the family should not only be clear about the purpose of the test and what answers
it can be expected to provide but they should also be made familiar with when, where,
and how the test will run.
Table 1
Abbreviated key examples of respiratory and non-respiratory indications for PSG and
MSLT testing in children
|
Standard indications
|
Generally accepted patient-care strategy with high degree of clinical certainty
|
|
• Clinically suspected OSA before or after adenotonsillectomy, especially in patients
at high risk for OSA (e.g. obese, craniofacial or Down syndrome, etc.)
|
|
• For positive airway pressure titration
|
|
• For the evaluation of narcolepsy (PSG followed by MSLT) or suspected periodic limb
movement disorder
|
|
Guideline indications
|
Generally based on a moderate degree of clinical certainty
|
|
• Clinically suspected hypoventilation in sleep
|
|
• To follow-up PAP therapy over time
|
|
• For the evaluation of hypersomnia and parasomnia under certain conditions
|
|
Optional indications
|
Implies uncertain clinical use
|
|
• To guide treatment of OSA with rapid maxillary expanders or other oral appliances
|
|
• For guiding non-invasive positive pressure ventilation titration, supplemental
oxygen, ventilator settings, or before tracheostomy decannulation
|
Abbreviations: EEG, electroencephalogram; MSLT, multiple sleep latency test; OSA,
obstructive sleep apnea; PAP, positive airway pressure; PSG, polysomnography.
Source: Modified from Aurora et al.[7]
[8].
A well-designed referral form can capture the common respiratory and nonrespiratory
conditions that merit a sleep study as described above. It can also provide the necessary
information to ascertain the complexity of the child's clinical and behavioral status.
This form should solicit pertinent demographic, medical (e.g., premature birth, muscular
dystrophy) and surgical history (e.g., previous adenotonsillectomy, cleft palate repair),
as well as current clinical status (e.g., witnessed apneas, sleep terrors). It should
also include a brief description of the pertinent physical examination findings (e.g.,
obesity, micrognathia) and current medications. A process also needs to be in place
to gather insurance information. Once the order is received, the sleep center should
have a procedure in which all such referrals are scrutinized or “triaged” by a sleep
specialist to ensure that the purpose of the test and the goal of any anticipated
therapy, such as oxygen or continuous positive airway pressure (CPAP) are clear. Any
omissions should be addressed by appropriate communication with the referring practitioner.
Based on the triage process, there may be a need to override existing laboratory protocols
based on clinical information specific to the case at hand. For example, it may be
prudent to not wait for demonstration of severe sleep apnea before starting CPAP in
a patient with a history of CPAP use who was simply being rechecked after a weight
loss intervention. In cases such as this, laboratory protocols may appropriately be
overridden to start CPAP at a lower apnea, and hypopnea index (AHI). The triage process
should also consider the staffing ratio based on the complexity of the test. For example,
if the child is very young or expected to be uncooperative or disruptive, the decision
may be to run the test with a 1:1 ratio (one patient for one technologist) instead
of the standard 2:1 ratio. There needs to be a mechanism in place whereby the order
and any clarifications or alerts made by the sleep specialist are available to the
night technologist in the form of a final plan for the test.
Most sleep laboratories that do pediatric studies allow only one parent to be with
the child during the sleep study. However, all too often families have not read the
instructions or simply do not have any other options, so other children or family
members come to the laboratory. A policy needs to be created to deal with this situation.
There are a dizzying number of laws and regulatory requirements that affect both medical
and general employment issues. Many of them are specific to children. All sleep laboratories
must have appropriate policies and procedures to avoid running into problems in this
area. The specific regulations that any specific laboratory will need to follow depends
on where the laboratory is located and whether it is part of a hospital or not.
As noted above, policies and procedures are important to ensure a seamless testing
experience. Educating the referring provider and patient is another mechanism to make
sure they are followed. In this regard, videos, brochures, or on-line descriptions
of the various tests and pretest preparation are very useful. Such resources may also
explain travel directions, arrival times, car parking, expected duration of various
tests, and give a list of things to bring to keep the child comfortable. They may
show videos or illustrations of the test environment and equipment which will serve
to reduce anxiety for the procedure. Phone numbers for the sleep service should be
readily available to answer questions. Toward this end, the authors routinely plan
speaking engagements with area practitioners to educate them about sleep disorders
and the appropriate indications for these tests. The practitioner's staff can also
be taught how to access needed information and to direct the patients to view the
sleep laboratory's on-line educational resources prior to the test.
Performing and Reporting the Pediatric Polysomnography
Performing and Reporting the Pediatric Polysomnography
Pediatric sleep laboratories perform PSG, positive airway pressure (PAP), and/or oxygen
titration studies most frequently. MSLT is next most frequently performed. The maintenance
of wakefulness test (MWT) and home testing are rarely performed in a pediatric laboratory.
The standard PSG study is attended continuously by a sleep technologist and standard
physiological parameters are measured. An abbreviated EEG is placed using landmarks
and nomenclature described by the standard International 10–20 system since the full
EEG array is not required to score sleep stages. Thus, scalp and face leads include
left (E1–M2) and right (E2–M1) electrooculogram, frontal (F3–M2 and F4–M1), central
(C3–M2 and C4–M1), and occipital (O1–M2 and O2–M1) EEG. Other channels include mental
and submental EMG, left and right anterior tibialis EMG, ECG, snore microphone, continuous
airflow with thermistor, and/or nasal pressure transducer, and/or PAP interface flow,
chest and abdominal breathing effort via respiratory inductance plethysmography (R.I.P.)
belts, pulse oximetry, end-tidal or transcutaneous capnography (ETCO2 and/or TcpCO2),
and audio–video monitoring to include body position analysis ([Figs. 3], [4]).
Fig. 3 A 60-second screenshot of a 2-year-old child with achondroplasia straddling the 590th
30-second epoch. On the left margin sequentially displayed channels include eyes (E1,
E2); chin EMG; frontal (F3, F4), central (C3, C4), and occipital (O1, O2) EEG; EKG;
pulse rate (PR); snore; nasal pressure transducer (NAP); thermistor (flow); thoraco-abdominal
effort belts (chest, ABD); pulse oximeter (OSat) and its associated plethysmogram
(Pleth); transcutaneous capnometer (TcCO2); leg EMG (R-LEG, L-LEG). The inset picture shows a video frame snapshot of the child
lying prone with a hyperextended neck to protect the patency of his airway. Nevertheless,
snoring (arrowheads), paradoxical breathing (solid arrows) and desaturations (broken
arrows) are present surrounding the episodes of apnea and hypopnea. The nonfunctioning
NAP channel was due to the patient's refusal to wear the nasal cannula. This prompted
the sleep technologist to substitute end-tidal CO2 monitoring with transcutaneous capnometry. EEG, electroencephalogram; EKG, electrocardiogram;
EMG, electromyogram.
Fig. 4 A teenage is being “hooked-up” for a polysomnogram. Note the EEG, EOG, chin EMG electrodes
are covered with tape or cotton. The respiratory inductance effort belts are snugly
but not tightly fitted. There is a pulse-oximeter probe on the left index finger (long
arrow). The close-up (inset) picture shows the nasal pressure cannula and thermistor
sensor stacked together in the oronasal area (broken arrow). An EKG lead is also in
position (short arrow). Also visible is a mark on the center of the forehead from
the skin-marking pencil used for the head measurements required for standard electrode
placement. EEG, electroencephalogram; EOG, electrooculogram; EKG, electrocardiogram;
EMG, electromyogram.
Depending on the clinical needs, the standard PSG setup may need to be altered. Variations
may include a full 10–20 EEG montage if complex motor phenomena have raised suspicion
of seizure disorder. The presence of a vagal nerve stimulator may call for extra leads
to capture the firing of the device and inform the reviewer of the influence of this
device on the cardiorespiratory signals.[9] TcpCO2 is preferred if PAP therapy is anticipated since ETCO2 is less accurate when ambient in-mask flow rates are high. Often, children with tracheostomy
will need to be studied to titrate supplemental oxygen settings or to test if the
child will tolerate a capped tracheostomy. Depending on the circumstances, oronasal
flow may need to be placed at a tracheal stoma or at the oronasal area based on the
expected direction of airflow. Sometimes studies may call for evaluating non-PAP interventions
for sleep-disordered breathing, such as body positioning devices or dental appliances.
A busy tertiary care center may do well to invest in mobile sleep study equipment
for the in-patient setting.
Many sleep centers have forms to elicit posttest feedback. Parental observations as
to whether the night was typical for the child (e.g., snored and gasped as usual)
or comments on test environment (e.g., awakened by a loud noise from an adjoining
room) are critical for the interpreting physician. The standard sleep test report
should take this feedback into account. Items to be addressed while reporting include
sleep architecture, respiratory, cardiac, and EEG findings, as well as movement events
and behavioral observations in accordance with the AASM requirements.[5]
Quality Improvement and Team Building
Quality Improvement and Team Building
As in any other center of excellence, quality improvement (QI) must be a day to day
aspect of the service. To this end, the posttest feedback form may also be designed
to gauge the overall testing experience to help with quality improvement efforts.
Of course, evaluating clinical parameters is an important part of the quality improvement
process. If the sleep team is unfamiliar with the QI process, training in this area
can be very helpful.
Regular meetings with the daytime and nighttime staff go a long way toward building
a cohesive team which can deliver an optimal patient experience and care. As the demand
for the sleep service grows, a fully staffed pediatric sleep center would do well
to include a clinical psychologist to help in the management of childhood behavioral
issues, such as behavioral insomnia, poor PAP compliance, and circadian rhythm disorders.
A dedicated sleep nurse and respiratory therapist are very useful components of a
comprehensive sleep team. A nurse practitioner or physician assistant can also be
a valuable member of the sleep team.
Sleep medicine crosses paths with many other specialties. Wherever possible, collaboration
should be built with colleagues in otolaryngology, neurology, pulmonology, dentistry,
endocrinology, genetics, as well as craniofacial and plastic surgery. Finally, continuous
education of local area physicians and the lay public at large by means of educational
talks and media appearances also goes a long way in establishing a well-respected
and popular service.
Conclusion
Children and adolescents constitute a substantial proportion of the number of PSGs
required by the population. However, in many areas of the country and the world, there
are not adequate numbers of beds to perform the required studies. This deficit can
be overcome by building more pediatric specific sleep laboratories or by adult sleep
laboratories adding the medical, technical, behavioral, and attitudinal skills to
perform studies in pediatric patients. To perform sleep studies for these young patients,
attention must be paid to many areas. It starts with the location and design of the
sleep laboratory. As noted above, safety and technical considerations have important
pediatric aspects that should be implemented. It is critical to have staff that enjoys
working with children but they must also be trained to take care of pediatric patients.
Good policies and procedures will go a long way toward making sure high-quality studies
are performed. Finally, engaging in regular QI processes will allow continual improvement
and can help keep make sure the sleep team is engaged and highly motivated. All these
efforts entail substantial demands and costs, but in the end, providing a highly needed
service to children is often enjoyable work and will be fraught with a deep sense
of professional satisfaction and fulfillment for the team.
