Sleep medicine for the first year of life

1. Sleep medicine for the first year of life Oleg Kouskov, MD, MCR Director, Pediatric Sleep Services, St Luke’s Sleep Medicine Institute

2. Kids are not little adults

3. “Kids have their own special ability to see, to think and to feel, and there is nothing more stupid than try to substitute theirs with ours.” Jean-Jack Rousseau

5. Staging • Sensorimotor birth to age 2. Children experience the world through movement and senses. Extremely egocentric, cannot perceive the world from others' viewpoints. • Preoperational 2-7 • Concrete Operational 7-12 • Formal operational – 12+

6. There is only one step between me and a five year old. There is a horrendous distance between me and the newborn. Leo Tolstoi

7. What is normal?

8. Sleep- wake regulation • Newborns do not have an established circadian rhythm, sleep is distributed throughout the day and night with each period of sleep short because of feeding frequency (Davis, 2004) After birth,there is progressive maturation of the circadian system outputs, with pronounced rhythms in sleepwake and hormone secretion generally developing after 2 months of age (Rivkees,2007). • At around 10-12 weeks of age, the circadian rhythm begins to emerge, and infant sleep becomes increasingly nocturnal • Night wakings are common in infancy and early childhood

9. From Rivkees SA, Hofman PL, Fortman J. Newborn primate infants are entrained by low intensity lighting. Proc Natl Acad Sci USA 1997;94(1):292–7

10. Oskar G. Jenni, MDa,b,*, Mary A. Carskadon, PhDc, 2007

11. adapted from Challamel M.J., Thirion M. and Appleton & Lange, Kandel, Schwartz, Jessell, Principles of Neural Science

12. Sleep- wake regulation • Children’s ability to return to sleep unaided plays a major role in determining whether or not wakings will persist and become problematic (Touchette,2005) • The frequency of night wakings is one of the main factors by which parents judge the quality of their child’s sleep (Palmstierna,2008) • Sleep-wake patterns, driven by a complex interplay between biological processes, and environmental, behavioural and social factors, can vary widely (Galland,2011)

15. How to approach sleep complaints ?

16. In my opinion, best article in sleep medicine

17. 5-fingers approach • Circadian/environmental influences • Medication effects • General medical conditions • Psychosocial influences • Primary sleep diagnoses

18. Sleep environment • TV in the bedroom predicts sleep disturbance – like increase in SOL by 20 min average, increase in bedtime resistance, decrease in TST (National Sleep Foundation, 2004) • Bedsharing associated with increased nocturnal awakenings(Mc Kenna, 1994) Co sleeping increases from infancy, peaks at 4 yo, then decreases as child reaches 10 yo (Jenni, 2005) • Sharing room with siblings adversely affects sleep (NSF, 2004)

19. Parental mental problems and sleep • Most data on depression. Infant and childhood sleep problems correlated with maternal depression (Hiscock 2001, Zukerman 1987). Relationships between maternal depression and kid’s sleep is bidirectional. Depressed moms are less likely to implement sleep schedule, bedtime routine or be emotionally vailable(McLearn,2006). • Paternal psychiatric history is highly correlated with dyssomnias (Liu, 2000) • Marital conflict associated with sleep problems (Sheikh, 2007)

20. Parental problems and sleep • Family stress associated with lower SE and increased nightwakings. Suggested that distressed parents create disorganized environment and have less effective parental practices (Sadeh, 2001) • Parents who have difficulty setting or implementing limits consistently are more likely to have children with sleep disturbances (Owens-Stively, 1991) • Lower maternal education was associated with poor sleep (Rona, 1998). • Children of parents with higher education had highest sleep quality (Sadeh, 2000)

21. Mothers with poorer mental health reported that their infants had more night waking and bedtime distress and were more bothered by these sleep issues. • Individual differences in maternal well-being may color mothers’ interpretations of infants’ sleep behaviors. It may be prudent to intervene to support maternal mental health when infants are referred for sleep problems.

22. Effect of medical comorbidities • Acute problems like colds, otitis • Chronic medical conditions like asthma, epilepsy frequently disrupt sleep • Anticipatory anxiety for treatments • Frequent hospitalizations • Family stress related to diseases

23. Many of the sleep problems of infants are resolved by behavioral interventions and parental education

24. Behavioral insomnia of childhood: typical scenario • 9 m old, falls asleep while rocked in mom’s arms. Through the night wakes up multiple times, needs mom to come and rock back to sleep. • Key to treatment: teach to sleep independently

25. What is sleep study?

26. http://en.wikipedia.org/wiki/Polysomnography

27. http://en.wikipedia.org/wiki/Polysomnography

28. When should we order PSG in infants?

29. Common indications • Evaluation for potential breathing disorders • Sometimes for parasomnias • RLS/PLMD • Evaluation of cardiorespiratory function in kids with neuromuscular and chronic lung disease • PAP/vent titration • Tracheostomy decannulations

30. Limited data are available regarding the clinical utility of PSG (1) in infants less than 12 months of age with suspected SRBD; (2) for evaluation of children with chronic respiratory disorders such as chronic obstructive or restrictive lung disease, and suspected SRBD; and (3) for therapeutic purposes including PAP titration, repeat PSG following AT or other surgical procedures, consideration of changes in mechanical ventilator management, decannulation of tracheostomy, and other uses. A small but useful group of papers confirmed the usefulness of PSG for initiation and titration of PAP in children with OSAS. However, the data do not address the optimal timing for repeat studies in children on PAP.

31. The most relevant findings: • (1) recognition that the clinical history and physical examination are often poor predictors of respiratory PSG findings, • (2) preoperative PSG is helpful in predicting risk of perioperative complications, and • (3) preoperative PSG is often helpful in predicting persistence of OSA in a substantial minority of patients after AT. The latter issue is important because it may help identify children who require further treatment. However, the task force did not identify any prospective studies that specifically address whether clinical outcome following AT for treatment of OSA in children is improved in association with routine performance of PSG before surgery in otherwise healthy children

32. No studies/articles • It is likely that most infants with this entity are diagnosed based on the clinical history and observations in the nursery setting. • Clinically, these infants experience recurrent apneas with or without bradycardia and a variety of potential etiologies or comorbid conditions exist including prematurity, GER and other medical disorders, and neurological disorders.

33. A Level 2 study reported that in subjects with respiratory dysfunction, GER was present in 75%; conversely, in subjects with GER, respiratory dysfunction was present in 45%. • In other studies, findings were variable, and there were a variety of methodological limitations. • Further investigations are needed to understand the diagnostic yield and clinical utility of lower esophageal pH monitoring during overnight PSG in infants.

34. Two papers (1 Level 2 and 1 Level 4) provide limited data that addressed the potential clinical utility of PSG for evaluation of suspected CCHS. Further investigations may clarify the clinical utility and timing of PSG in suspected CCHS, the role of PSG in assessment of asymptomatic carriers of the PHOX2b mutation, and when periodic reevaluation may be necessary.

35. PSG may have clinical utility in evaluating SRBD before and after surgical intervention, particularly if there is clinical concern for moderate to severe respiratory disturbance. However, it is not possible to confirm the clinical utility of PSG in this population of infants based on only one Level 4 paper.

36. PSG does not provide sufficiently distinctive or predictive findings to support a routine clinical indication for PSG to determine risk of death due to SIDS. • This is an area of active investigation and future work with more sophisticated techniques that may lead to greater clinical utility of PSG.

37. 13 papers addressed the utility of PSG for ALTE • Two Level 3 and 1 Level 4 studies suggest that infants who experience an ALTE are at increased risk for SRBD because of facial dysmorphology, or other risk factors for SRBD. However, further evaluation is needed to assess the clinical utility of PSG in this population. • GER as well as nospecific or subtle abnormalities may be identified but it was not possible to estimate the diagnostic yield of PSG • In general the prognosis for recurrence of ALTE could not be predicted based on PSG findings, and a significant proportion of infants who experience an ALTE have a normal PSG • It is possible that PSG may be clinically useful in selected populations, particularly when there is clinical concern for upper airway obstruction or other forms of SRBD

38. Healthy premature infants at or near term and almost ready for hospital discharge experience frequent, unsuspected adverse cardiorespiratory events. • There may be role for daytime nap PSG or nocturnal PSG in infants born either preterm or at term, for differentiation between normal and abnormal breathing, and cardiorespiratory differences of heart rate and blood pressure, and sleep position. • In 1 paper with Level 3 evidence, investigators concluded that full PSG provides the physiological data for proper diagnosis in young infants and that limited cardio respiratory studies can be misleading in this population. Another article with Level 2 evidence evaluated 14 infants with cyanotic breath-holding spells, and all subjects were found to have PSG abnormalities consistent with SRBD. This is a small exploratory study, but findings suggest that infants who present with cyanotic breath holding spells may require PSG to evaluate for SRBD.

39. Sleep apnea in the first year of life

40. Definition, AASM 2012: apnea • a. There is a drop in the peak signal excursion by ≥90% of pre-event baseline using an oronasal thermal sensor (diagnostic study), PAP device flow (titration study), or an alternative apnea sensor (diagnostic study). • b. The duration of the ≥90% drop in sensor signal lasts at least the minimum duration as specified by obstructive, mixed, or central apnea duration criteria. • c. The event meets respiratory effort criteria for obstructive, central or mixed apnea.

42. Definition, AASM 2012: apnea • 2. Score an apnea as obstructive if it meets apnea criteria for at least the duration of 2 breaths during baseline breathing AND is associated with the presence of respiratory effort throughout the entire period of absent airflow.  

43. Tracing from : Timothy F. Hoban, MDa,*, Ronald D. Chervin, MD, MS, 2007

45. Definition, AASM 2012: apnea • 3. Score an apnea as central if it meets apnea criteria, is associated with absent inspiratory effort throughout the entire duration of the event AND at least one of the following is met:   • a. The event lasts ≥20 seconds. • b. The event lasts at least the duration of two breaths during baseline breathing and is associated with an arousal or a ≥3% arterial oxygen desaturation. • c. The event is associated with a decrease in heart rate to less than 50 beats per minute for at least 5 seconds or less than 60 beats per minute for 15 seconds (infants under 1 year of age only).

46. http://www-archive.thoracic.org/sections/education/sleep-fragments/quiz/arousal-triggered-respiratory-event.htmlhttp://www-archive.thoracic.org/sections/education/sleep-fragments/quiz/arousal-triggered-respiratory-event.html

47. Definition, AASM 2012: apnea • 4. Score an apnea as mixed if it meets apnea criteria for at least the duration of 2 breaths during baseline breathing AND is associated with absent respiratory effort during one portion of the event AND the presence of inspiratory effort in another portion, regardless of which portion comes first.

48. Definition, AASM 2012: hypopnea • 1. Score a respiratory event as a hypopnea if ALL of the following criteria are met:N1   a. The peak signal excursions drop by ≥30% of pre-event baseline using nasal pressure (diagnostic study), PAP device flow (titration study) or an alternative hypopnea sensor (diagnostic study). b. The duration of the ≥30% drop in signal excursion lasts for ≥2 breaths c. There is a ≥3% oxygen desaturation from pre-event baseline or the event is associated with an arousal

49. Central vs obstructive hypopnea • 2. If electing to score obstructive hypopneas, score a hypopnea as obstructive if ANY of the following criteria are met:   a. Snoring during the event b. Increased inspiratory flattening of the nasal pressure or PAP device flow signal compared to baseline breathing c. Associated thoracoabdominal paradox occurs during the event but not during pre-event breathing

50. Central vs obstructive hypopnea • 3. If electing to score central hypopneas, score a hypopnea as central if NONE of the following criteria are met:   a. Snoring during the event b. Increased inspiratory flattening of the nasal pressure or PAP device flow signal compared to baseline breathing c. Associated thoracoabdominal paradox occurs during the event but not during pre-event breathing