2. 2 Sleep in Infancy Development of sleep Cross cultural differences in sleep behavior Infant Apnea and Sudden Infant Death Syndrome (SIDS) Congenital Central Hypoventilation Syndrome

3. 3 How much do Infants Sleep? Iglowstein et al, Pediatrics, 2003

4. 4 Total Daytime Sleep (Napping) Iglowstein et al, Pediatrics, 2003 Naps per day 2 1 - 2 1 0 - 1

5. 5 Night Awakenings Goodlin-Jones et al, J Dev Behav Pediatr, 2001

6. 6 Determinants of Infant Sleep Behavior Biological Homeostasis Circadian factors Cultural Parental values Societal norms

7. 7 Variations in Sleep Behavior Sleeping arrangements Bedtime routines Transitional objects Naps Sleep problems

8. 8 Sleeping Arrangements: Co-sleeping Co-sleeping includes: Room sharing (sharing a room with a parent, another adult or sibling) and/or bed sharing Co-sleeping is prevalent in many cultures Tribal (e.g. Samoa, Mayan, Bali) Eastern (e.g. Korea, China, Japan, India) Southern Europe (e.g. Italy, Portugal) Scandinavia (e.g. Sweden)

9. 9 Co-sleeping in the United States Prevalence of co-sleeping varies with ethnicity, race and socioeconomic class. African Americans were reported to co-sleep more often than Caucasians (57% vs. 17%). Among Caucasian families only, co-sleeping was associated with lower socioeconomic class.

10. 10 Sleeping Arrangements Independent Sleeping Definition: infants and children sleep in their bed in their own rooms Rationale: promotes autonomy Independent sleeping is prevalent in western societies such as: Northern Europe: Germany, Holland, Switzerland, France United States

11. 11 Bed Sharing Bed sharing is prevalent in many cultures: It is more common with breast feeding It is more common among certain racial and ethnic groups

12. 12 Bed Sharing Most Western health care providers advocate against bed sharing in infancy Safety risks for SIDS No long term psychosocial consequences

13. 13 Prevalence of Bed Sharing (>1 times/week) Among Swiss Children Jenni et al, Pediatrics, 2005

14. 14 Infants should sleep in a crib or bassinet conforming with standards of Consumer Product Safety Commission. Infants may be brought to bed for nursing or comforting but should not bed share for sleep. The crib or bassinet should be placed in parents’ room close to their bed. American Academy of Pediatrics Task Force on Sudden Infant Death Syndrome

15. 15 Bedtime Many tribal societies have no formalized “bedtime.” Infants and children in Southern European countries often have unstructured bedtime routines and later bedtimes.

16. 16 Bedtime Routine (Northern European/American) In child’s own bedroom… Ritual: bath, dressing in pajamas, story/lullaby Child is placed in own bed with goodnight kisses and left alone for the night. Frequent use of nightlight and transitional objects

17. 17 Transitional Objects Industrialized societies - frequent use of sleep aids e.g. pacifier, teddy etc American Academy of Pediatrics Task Force (11/05) recommends pacifiers be used for infants when they are put down to sleep to reduce the incidence of SIDS. Non-industrialized cultures - low prevalence of transitional objects

18. 18 Naps Naps are common in Southern Europe, South America, Africa and Asia, but are disappearing with globalization and 24/7 societies. American children typically stop naps by age 4 - 5 yrs. African American children nap until older ages than Caucasian children.

19. 19 Racial Differences in Napping Crosby et al, Pediatrics, 2005

20. 20 International Pediatric Sleep Education Task Force Across cultures: Parenting practices, cultural values and lifestyles vary and influence sleep behavior. Sleep problems (e.g. bedtime resistance, nighttime wakings) are universally present. Prevalence of sleep problems is similar (20 - 25%) but differs for individual issues.

21. 21 Infant Apnea and Sudden Infant Death Syndrome (SIDS)

22. 22 Sudden Infant Death Syndrome (SIDS) The sudden death of any infant under one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history. Willinger et al. Pediatr Pathol 1991;11:677

23. 23 Apparent Life-threatening Event (ALTE) An episode that is frightening to the observer, and that is characterized by some combination of apnea (central or occasionally obstructive), color change, marked change in muscle tone, choking or gagging. In some cases, the observer fears that the infant has died.

24. 24 SIDS Most common cause of postneonatal infant death About 2,300 deaths/year SIDS rate: almost 0.6/1,000 live births Increased incidence in: Winter Males (60%) Lower socioeconomic groups Children whose parents smoke

25. 25 SIDS Antecedent Risk Factors NIH Consensus Committee, 1987

26. 26 Relative Risk for SIDS by Age at Death MMWR December 14, 1990;39 *first month as reference

27. 27 SIDS Postmortem Findings Right ventricular hypertrophy Periadrenal brown fat Extramedullary hematopoiesis Astroglial cell proliferation Intrathoracic petechiae Neurotransmitter deficits in brainstem

28. 28 Basis for the SIDS – Apnea Hypothesis Population Three infants with recurrent apnea and cyanosis Two siblings of SIDS victims Methods Serial PSG over three to six months Findings “frequent brief, self-limited” apneas during REM Two infants died of SIDS approximately three months of age Commentary small sample No control group Mother later convicted of murder Steinschneider A. Pediatrics 1972;50

29. 29 Collaborative Home Infant Monitoring Evaluation 1079 infants had PSG and home monitor (RIP, ECG, oximetry, position, expanded memory) Idiopathic ALTE 152 SIDS sibling 178 Preterm (<34 weeks) 443 Healthy term 306

30. 30 CHIME Cardiorespiratory Events Extreme EventsConventional Events Grouprisk ratiop p Preterm symptomatic18.0<.0014.3<.001 asymptomatic10.1<.0012.7<.001 ALTE7.6.0011.5.16 sibling5.6.0071.2.56 Term sibling2.6.111.4.07 ALTE2.5.181.1.75 healthy11 Only preterm infants had more events than healthy controls Ramanathan, et al. JAMA 2001

31. 31 CHIME Cardiorespiratory Events The likelihood of experiencing at least one ALTE decreased until about 43 weeks post conception, when all groups were similar. Ramanathan, et al. JAMA 2001

32. 32 Ventilatory Drive Respiratory control disorders in infants and children. Beckerman RC, Brouillette RT, Hunt CE (eds). Baltimore: Williams & Wilkins, 1992.

33. 33 Impaired Arousal Response McCulloch et al. J Pediatr 1982

34. 34 Heart Rate Variability Schechtman et al. Pediatr Res 1992

35. 35 Sleep Position and SIDS Relative Risk (prone vs. others) = 8.8 (p<.001) SIDSControl Prone 6276 Side 432 Supine 123 Unknown 03 Fleming et al. Br Med J 1990

36. 36 Change in SIDS Rate with Change in Sleep Position Baseline RateAfter Campaign England3.51.7 Netherlands1.00.4 Norway3.51.6 Tasmania7.64.1 Fleming et al. Br Med J 1990

37. 37 “Although prospective randomized clinical trials have not been performed, the weight of evidence implicates the prone position as a significant risk factor for SIDS.” Sleep Position and SIDS

38. 38 Sleep Position and SIDS “It should be stressed that, although the relative risk of the prone position may be several times that of the lateral or supine position, the actual risk of SIDS when placing an infant in a prone position is still extremely low.”

39. 39 Lateral Positioning SIDS risk similar to prone position Lateral position unstable High probability of rolling to prone Infants unaccustomed to prone position are at even greater risk when they are prone.

40. 40 U.S. SIDS Rate

41. 41 Sleep and Infant Position Prone positioning results in: increased sleep duration increased quiet (non-REM) sleep fewer, shorter arousals Prone positioning results in: upper airway occlusion CO 2 rebreathing hyperthermia –exacerbated by bundling, inappropriate bedding

42. 42 Sleep Position and SIDS Scandinavian Questionnaire Study 244 SIDS cases, 869 controls % of SIDS death that could be avoided if: All infants slept supine74% No maternal smoking during pregnancy47% Pre-term birth eliminated16% Low birth weight eliminated16%