Preemies' Risk for SIDS Jumps with Prone Sleep

A well designed research study reinforces the importance of "back to sleep", showing that oxygen saturations in newborn infants tend to be lower in the prone position.  Dr. Susarla

Preemies' Risk for SIDS Jumps with Prone Sleep

BALTIMORE -- Preterm infants who sleep in the prone position may be at additional risk for sudden infant death syndrome (SIDS) due to decreased cerebral oxygenation, researchers reported here.

Measures of cerebral tissue oxygenation in preterm infants showed prone position sleeping was associated with significantly 7% reduced tissue oxygenation during quiet sleep at weeks 2 to 4, and months 2 to 3 (P<0.05), according to Karinna Fyfe, PhD, of the Ritchie Center of Monash University in Melbourne, Australia, and colleagues.

The preterm infants also had 3% significantly lower cerebral oxygenation during quiet (P<0.01) and active sleep (P<0.05) when sleeping in the prone position at 5 to 6 months, Fyfe said during an oral presentation at the Associated Professional Sleep Societies meeting.

The authors noted that preterm infants are at 9.6% increased risk for SIDS, which may be associated with cardiovascular instability and failure of arousal from sleep. Preterm births are also associated with lower blood pressure, abnormal blood pressure control, higher heart rate, and reduced heart rate control in infants.

The prone sleeping position has been associated with reduced blood pressure and cerebral oxygenation in full-term infants, which increases risk for SIDS.

The authors studied cerebral oxygenation and continuous blood pressure in a population of 25 otherwise healthy preterm infants who had 27 to 36 weeks gestation. Special attention was paid to months 2 and 3, as they are considered the highest risk period for SIDS, Fyfe noted.

Participants received daytime polysomnography at ages 2 to 4 weeks, 2 to 3 months, and 5 to 6 months at corrected developmental age, during which the researchers measured continuous blood pressure, heart rate, oxygen saturation, body temperature, and cerebral tissue oxygenation index.

Vital signs were measured in 2-minute intervals and were validated through continuous, noninvasive, measures.

The authors collected data on infants while in the prone and supine sleeping positions, as well as during active and quiet sleep, and all comparisons were done between prone and supine sleeping positions.

Prone sleep was significantly associated with lower oxygenation during active and quiet sleep in preterm infants at ages 2 to 4 weeks and 2 to 3 months. Oxygenation was lower, but not significantly so, at months 5 and 6 in the prone position while sleeping.

Blood pressure and peripheral oxygen saturation did not differ significantly between sleep positions.

Heart rate was significantly elevated in prone versus supine sleeping position at weeks 2 to 4 during quiet sleep (P<0.05), although this association was not seen at months 2 to 3, 5 to 6, or during active sleep.

Preemies also had a significantly higher skin temperature across all ages in the prone position versus supine position (P<0.05 for all).

Fyfe suggested the effects on oxygenation and body temperature were associated with neck blood vessels while in the prone position, as well as immature cerebral autoregulation, based on post-mortem and Doppler flow studies.

"Reduced cerebral oxygenation in the prone position may leave preterm infants vulnerable to critically low cerebral oxygenation during a cardiorespiratory event during sleep," Fyfe said, adding that these changes based on sleep position "may underpin the risks of SIDS amongst preterm infants."

She also noted that oxygenation outcomes were worse in preterm infants than full-term infants in a comparison of data from a separate study.

Session moderator Ann Halbower, MD, of Children's Hospital Colorado in Aurora noted that follow-up research should look at carbon dioxide levels of infants in a prone sleeping position.Read article here.

Sleep deficit may underlie kids' ADHD, migraines

Sleep deficit may underlie
kids' ADHD, migraines

Congratulations on raising awareness  Dr Joseph!

The child displays hallmark behaviors – fidgety, impulsive, irritable, inattentive – and has been diagnosed with ADHD. Dr. Kevin Joseph isn’t stepping through a DSM-IV screening, though. His questions tack in another direction.
“How well does your child sleep?”
Joseph, a board-certified pediatric neurologist and sleep specialist at Valley Medical Center, regularly witnesses the revelations of an overnight polysomnography.

“I saw a boy, 9 years old, who couldn’t sit still in class, couldn’t remember to brush his teeth. Turns out he had severe sleep apnea, like 101 events per hour, and for a child, normal is 1.5 events,” Joseph said. “His oxygen saturations were down in the 70-80 percent level when they should’ve been 95-100 percent. We sent him for a tonsillectomy and at follow-up his parents reported he was sitting in class, not fighting, even losing some weight.

“He was like a new kid, and they were thrilled. And I never put him on medication.”

When sleep disturbances such as apnea are brought to light, cases of childhood migraines and attention deficit hyperactivity disorder – even epilepsy – often can be ameliorated or resolved.

Joseph studied at Walter Reed Army Medical Center and added training in pediatric neurology at Children’s National Medical Center. In the last four of his nine years of active duty, he treated soldiers for brain injuries in Iraq and was chief of child neurology at Madigan Army Medical Center in Tacoma.

There he saw how a parent’s deployment can subvert a child’s evening routines, spurring migraines and nightmares. More recently, he has witnessed how economic hardship deprives the whole household, not just the breadwinners, of sleep.

“The key difference between pediatrics and adult medicine is that, with pediatrics, you have to attend to the family, not just the child,” Joseph said. “I always ask about stressors at home. If parents are out of work or have financial issues, even if they only talk about those issues behind closed doors, it tends to seep through. It’s easy for me to give guidance about structure a child should have around bedtime. It’s harder for a family to implement, especially in single-parent households.”

The American Academy of Pediatrics in August revised its clinical-practice guideline, recommending that all children and adolescents who snore regularly be screened in a lab setting for obstructive sleep apnea. But snoring isn’t the only red flag: “Daytime learning problems,” the guideline notes, should compel attention, too.
Despite well-documented negatives associated with adult sleep disorders, parents are often surprised to learn about sleeplessness’ impact on a child, Joseph said. Sleep is when growth hormone is secreted, fueling body and brain development.

Joseph’s patients at the Pediatric Sleep Center include NICU preemies and 18-year-olds. They are restless or listless or developmentally delayed. They (or their parents) present with concerns about snoring, night terrors, sleepwalking, headaches and seizures, poor report cards and other events.

For people with epilepsy, disrupted sleep can re-awaken symptoms that medication had largely controlled. Joseph mentioned cases of college freshmen whose newfound freedom led them to join a late-night study session, and then seizures struck anew.

It’s important to get a formal diagnosis of obstructive apnea before a tonsillectomy is weighed, because a child with the condition is at greater risk of postoperative problems with the airway and with bleeding, Joseph said. The usefulness of a CPAP device should be considered, as well, because tonsillectomy doesn’t always bring relief.
“I saw a girl who had migraines that we couldn’t control with medication. She had obstructive apnea. She had a tonsillectomy, which didn’t affect the apnea, but then we put the CPAP on her and her headaches went away,” he said. “It was a huge success for the family. She wears this thing religiously.”

It's been said before, but it warrants reminding that when it comes to sleep disorders, children are not little adults.  Pediatric sleep medicine is a highly specialized field where the specialties of pediatric pulmonology and neurology intersect to help address problems unique to children.  Although polysomnnography, or "sleep studies" are very similar to adults.  The techniques, equipment, scoring methods , and even personnel are highly specialized.

 A long overdue update to the American Academy of Pediatrics Recommendations was recently published specifically addressing the problem of childhood obstructive sleep apnea.  This guideline discusses important symptoms for parents and physicians such as chronic snoring, mouth breathing, and pauses in breathing during sleep.  But it also discusses less recognized features of sleep disorders such as inattentiveness and hyperactivity which can also result from disrupted sleep.  Talk to your pediatrician if you suspect a sleep problem in your child.  Dr. Susarla

AAP Recommendations for Childhood Sleep Disorders

Sleep disturbances, including obstructive sleep apneasyndrome (OSAS), are common in children and can result in significant health problems if left untreated.

In a revised clinical practice guideline, “Diagnosis and Management of Childhood Obstructive Sleep Apnea Syndrome,” published in the September 2012 Pediatrics (published online August 27), the American Academy of Pediatrics (AAP) recommends that all children or adolescents who snore regularly be screened for OSAS.

Additional symptoms can include labored breathing during sleep, disturbed sleep with frequent gasps, snorts or pauses, and daytime learning problems. It is important for children exhibiting signs of OSAS to get a comprehensive diagnosis by having an overnight, in-laboratory sleep study done.

If left untreated, OSAS can result in problems such as behavioral issues, cardiovascular problems, poor growth and developmental delays. Treatments are available that can result in significant improvements in these complications. Adenotonsillectomy is effective in treating OSAS and is recommended as the first line of therapy. Obesity can be a risk factor, so physicians may recommend weight loss in addition to other therapies in overweight or obese children. Post-operatively, physicians should be aware of the criteria suggesting which patients should be admitted and when other treatment should be considered, such as CPAP.

Read article here.