Sleep medicine for
the first year of life
Oleg Kouskov, MD, MCR
Director, Pediatric Sleep Services,
St Luke’s Sleep Medicine Institute
Kids are not little
adults
“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
Staging
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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+
There is only one step between me and
a five year old. There is a horrendous
distance between me and the newborn.
Leo Tolstoi
What is normal?
Sleep- wake regulation
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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
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
adapted from Challamel M.J., Thirion M. and Appleton & Lange, Kandel, Schwartz, Jessell, Principles of Neural Science
Sleep- wake regulation
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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)
How to approach
sleep complaints ?
In my opinion, best article
in sleep medicine
5-fingers approach
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Circadian/environmental influences
Medication effects
General medical conditions
Psychosocial influences
Primary sleep diagnoses
Sleep environment
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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)
Parental mental problems and sleep
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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)
Parental problems and sleep
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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)
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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.
Effect of medical comorbidities
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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
Many of the sleep
problems of infants are
resolved by behavioral
interventions and
parental education
Behavioral insomnia of childhood:
typical scenario
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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
What is sleep study?
http://en.wikipedia.org/wiki/Polysomnography
http://en.wikipedia.org/wiki/Polysomnography
When should we
order PSG in
infants?
Common indications
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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
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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.
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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
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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.
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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.
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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.
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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.
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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.
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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
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Healthy premature infants at or near term and almost ready for hospital discharge
experience frequent, unsuspected adverse cardiorespiratory events.
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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.
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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.
Sleep apnea in the
first year of life
Definition, AASM 2012: apnea
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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.
Definition, AASM 2012: apnea
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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.
Tracing from : Timothy F. Hoban, MDa,*, Ronald D.
Definition, AASM 2012: apnea
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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).
http://www-archive.thoracic.org/sections/education/sleep-fragments/quiz/arousal-triggered-respiratory-event.html
Definition, AASM 2012: apnea
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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.
Definition, AASM 2012: hypopnea
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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
Central vs obstructive hypopnea
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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
Central vs obstructive hypopnea
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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
Definition, AASM 2012: RERA
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If electing to score respiratory effort-related arousals,
score a respiratory event as a RERA if there is a
sequence of breaths lasting ≥2 breaths (or the duration
of two breaths during baseline breathing) when the
breathing sequence is characterized by increasing
respiratory effort, flattening of the inspiratory portion of
the nasal pressure (diagnostic study) or PAP device flow
(titration study) waveform, snoring, or an elevation in the
end-tidal PCO2 leading to arousal from sleep when the
sequence of breaths does not meet criteria for an apnea
or hypopnea.
Periodic breathing
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Score a respiratory event as periodic
breathing if there are ≥3 episodes of
central apnea lasting >3 seconds
separated by ≤20 seconds of normal
breathing
Periodic breathing
Million dollar
question:
What is normal???
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For obstructive apnea, < 1.0 per hour,
Mixed apnea, < 1.0 per hour.
For central apnea defined as cessation of respiratory efforts for
more than 3 seconds,
- 45 per hour for 1-month-old infants,
- 30 per hour for 2-month-old infants,
- 22 per hour for 3-month-old infants,
- 10 - 20 for the older age groups.
For the desaturation episode defined as SpO2 less than 80% for
any length of time:
- up to 14.7 episodes per hour for day 1,
- up to 41 episodes for day 4,
- up to 15.1 episodes for day 39.
Treatment
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T+A
Supraglottoplasty
Positive Airway Pressure Therapy
Oxygen
Tracheostomy
Lip-tongue adhesion
Mandibular distraction osteogenesis
Midfacial advancement
Fronto facial distraction
Thank you!
Questions?