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

4. It is impossible to talk about the sleep disorders in kids without knowing about the normal and abnormal development, so we will talk about the normal child development and briefly review the stages of development as by Dr Piaget

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+
The four development stages are described in Piaget's theory as:
Simple reflexes is from birth to 1 month old. At this time infants use reflexes such as rooting and sucking.
First habits and primary circular reactions is from 1 month to 4 months old. During this time infants learn to coordinate sensation and two types of scheme (habit and circular reactions). A primary circular reaction is when the infant tries to reproduce an event that happened by accident (ex: sucking thumb).
The third stage, secondary circular reactions, occurs when the infant is 4 to 8 months old. At this time they become aware of things beyond their own body; they are more object oriented. At this time they might accidentally shake a rattle and continue to do it for sake of satisfaction.
Coordination of secondary circular reactions is from 8 months to 12 months old. During this stage they can do things intentionally. They can now combine and recombine schemes and try to reach a goal (ex: use a stick to reach something). They also understand object permanence during this stage. That is, they understand that objects continue to exist even when they can't see them.
The fifth stage occurs from 12 months old to 18 months old. During this stage infants explore new possibilities of objects; they try different things to get different results.
During the last stage they are 18 to 24 months old. During this stage they shift to symbolic thinking. [13] Some followers of Piaget's studies of infancy, such as Kenneth Kaye[14] argue that his contribution was as an observer of countless phenomena not previously described, but that he didn't offer explanation of the processes in real time that cause those developments, beyond analogizing them to broad concepts about biological adaptation generally.
[edit] The developmental process
Piaget provided no concise description of the development process as a whole. Broadly speaking it consisted of a cycle:
This process is not wholly gradual, however. Once a new level of organization, knowledge and insight proves to be effective, it will quickly be generalized to other areas. As a result, transitions between stages tend to be rapid and radical, and the bulk of the time spent in a new stage consists of refining this new cognitive level. When the knowledge that has been gained at one stage of study and experience leads rapidly and radically to a new higher stage of insight, a gestalt [disambiguation needed] is said to have occurred.
It is because this process takes this dialectical form, in which each new stage is created through the further differentiation, integration, and synthesis of new structures out of the old, that the sequence of cognitive stages are logically necessary rather than simply empirically correct. Each new stage emerges only because the child can take for granted the achievements of its predecessors, and yet there are still more sophisticated forms of knowledge and action that are capable of being developed.
Because it covers both how we gain knowledge about objects and our reflections on our own actions, Piaget's model of development explains a number of features of human knowledge that had never previously been accounted for. For example, by showing how children progressively enrich their understanding of things by acting on and reflecting on the effects of their own previous knowledge, they are able to organize their knowledge in increasingly complex structures. Thus, once a young child can consistently and accurately recognize different kinds of animals, he or she then acquires the ability to organize the different kinds into higher groupings such as "birds", "fish", and so on. This is significant because they are now able to know things about a new animal simply on the basis of the fact that it is a bird – for example, that it will lay eggs.
At the same time, by reflecting on their own actions, the child develops an increasingly sophisticated awareness of the "rules" that govern in various ways. For example, it is by this route that Piaget explains this child's growing awareness of notions such as "right", "valid", "necessary", "proper", and so on. In other words, it is through the process of objectification, reflection and abstraction that the child constructs the principles on which action is not only effective or correct but also justified.
One of Piaget's most famous studies focused purely on the discriminative abilities of children between the ages of two and a half years old, and four and a half years old. He began the study by taking children of different ages and placing two lines of sweets, one with the sweets in a line spread further apart, and one with the same number of sweets in a line placed more closely together. He found that, “Children between 2 years, 6 months old and 3 years, 2 months old correctly discriminate the relative number of objects in two rows; between 3 years, 2 months and 4 years, 6 months they indicate a longer row with fewer objects to have "more"; after 4 years, 6 months they again discriminate correctly” (Cognitive Capacity of Very Young Children, p. 141). Initially younger children were not studied, because if at four years old a child could not , then a younger child presumably could not either. The results show however that children that are younger than three years and two months have quantity conservation, but as they get older they lose this quality, and do not recover it until four and a half years old. This attribute may be lost due to a temporary inability to solve because of an overdependence on perceptual strategies, which correlates more candy with a longer line of candy, or due to the inability for a four year old to reverse situations.
By the end of this experiment several results were found. First, younger children have a discriminative ability that shows the logical capacity for cognitive operations exists earlier than acknowledged. This study also reveals that young children can be equipped with certain qualities for cognitive operations, depending on how logical the structure of the task is. Research also shows that children develop explicit understanding at age 5 and as a result, the child will count the sweets to decide which has more. Finally the study found that overall quantity conservation is not a basic characteristic of humans' native inheritance.

6. There is only one step between me and a five year old
There is only one step between me and a five year old. There is a horrendous distance between me and the newborn.
Leo Tolstoi
Per some researches, night wakings at the end of the first year are a common developmental phenomenon rather than an indicator of separation/quality of attachment (Scher, 2001)

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 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
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
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?

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
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

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

52. Definition, AASM 2012: RERA
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.

53. Periodic breathing
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

54. Periodic breathing
This pt with arnold chiari

55. Million dollar question:
What is normal???

59. 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,
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.

61. Treatment T+A Supraglottoplasty Positive Airway Pressure Therapy
Oxygen
Tracheostomy
Lip-tongue adhesion
Mandibular distraction osteogenesis
Midfacial advancement
Fronto facial distraction

63. Thank you!

64. Questions?