Sleep disordered breathing (SDB) in neonates and implications for its long-term impact

What are the experiences of non-invasive ventilation for sleep-disordered breathing in children and young people and what outcomes matter? Perspectives of children and young people, their parents and the staff who care for them

BACKGROUND

Non-invasive ventilation (NIV) for sleep-disordered breathing (SDB) in children and young people (CYP) can result in multiple health outcomes; however, adherence to NIV can be challenging. Suboptimally treated SDB may increase the risk of adverse consequences. Placing children's and parents' goals at the core of their SDB treatment may support adherence to NIV. To identify these health outcomes, it is necessary to gain a greater understanding of CYP's experiences of using NIV, whether they perceive any benefits from NIV use, as well as the outcomes that their parents and NIV staff identify as important.

METHODS

Semi-structured qualitative interviews were conducted with nine CYP (aged 4-16 + years), 13 parents and nine healthcare professionals (HCPs); verbatim transcripts were analysed using Framework Analysis.

RESULTS

CYP predominantly reported an improvement in levels of energy, focus and ability to concentrate whereas parents also identified outcomes of mood and behaviour. The majority of children showed understanding of the reasons for being prescribed NIV. A subset of children did not notice their SDB. The health outcomes identified by HCPs and parents that could result from improved overnight gas exchange are subjective measures that rely on parent and child report. Measuring these health outcomes focussed on the impact of improved sleep rather than measuring improved sleep itself.

CONCLUSIONS

It is important for HCPs administering NIV to ascertain whether CYP have noticed any of their sleep-disordered breathing symptoms and any improvements from using NIV, including the relationship between benefits and side effects. Focussing on promoting understanding for CYP who are unable to link their wellbeing to their previous night's sleep may be futile and HCP strategies should concentrate on the process of tolerating the device. Parents, CYP and HCPs should collaborate to identify treatment goals specifically tailored for the child and monitor any progress against these goals.

The epidemiology of apnoea of prematurity

WHAT IS KNOWN AND OBJECTIVE

Many premature infants less than 37 weeks gestational age (GA), and almost all infants less than 28 weeks GA, will experience apnoea of prematurity (AOP)-a cessation of respiration for 20 or more seconds (or less than 20 s if accompanied by other signs). Because the treatment options for AOP are so limited, we explore its epidemiology, with the ultimate hope of learning how to decrease its incidence.

COMMENT

Although AOP usually resolves with maturation of the respiratory system, many short- and long-term negative effects are correlated statistically with AOP (although direct causality has not been established). The primary risk factor for AOP is preterm birth, but delivery technique, genetics, socioeconomic status, racial disparities and other influences are suspected to be involved. Anaemia, asthma and gastric reflux have also been associated with preterm birth, but the relationship with AOP is unclear. The postulated associations and the strength of the evidence are briefly reviewed and discussed.

WHAT IS NEW AND CONCLUSION

Attempts to elucidate the epidemiology of apnoea of prematurity have been challenging. Studies of AOP are hampered in part by challenges in monitoring the condition, the interplay of multiple comorbidities in preterm neonates and lack of expert consensus definitions. However, since the primary risk factor is preterm birth, efforts to decrease the prevalence of preterm birth would have a positive secondary effect on the prevalence of AOP. Until then, better pharmacotherapeutic options are needed.

Survey of the practices of neonatologists in managing neonates believed to be at high risk of sleep disordered breathing

OBJECTIVE

To determine the practices of neonatologists in managing high-risk neonates believed to be at risk of sleep disordered breathing (SDB).

DESIGN

An electronic web-based questionnaire assessing awareness of and current practices for managing neonates predisposed to SDB with conditions like craniofacial anomalies, neuromuscular disorders or airway problems was emailed to 232 neonatologists and neonatal fellows working in Australia and New Zealand (NZ). Additionally, neonatologists were approached directly during the annual Australia and NZ perinatal conference in 2019.

RESULTS

93 neonatologists (40%) responded to the survey. The majority (85%) of the respondents stated that there were no written protocols/criteria for sleep consultation in their unit. We found considerable variations in the threshold for performing tests including oximetry or referring for polysomnography. Most respondents would perform oximetry before referring for a sleep consultation. However, the duration of oximetry varied from 6 to 24 hours and there was no consensus about what is considered abnormal on an oximetry study.

CONCLUSION

Management of SDB is gaining importance in neonatal care because of prolonged length of hospital stay and possible long-term effects of SDB. Responses received suggest a lack of clarity regarding thresholds for referral for treatment of SDB. Likely contributory factors are concerns regarding a lack of long-term outcome data from treatment perceived to be onerous for the family, unsettling to some infants and delaying hospital discharge. To overcome inconsistencies in practice, standardised guidelines for assessing and managing SDB in neonates are needed.

Diagnosis and management of childhood sleep-disordered breathing. Clinical approach

Sleep-disordered breathing (SDB) includes disorders of breathing that affect airway patency, which impair children's sleep and lead to negative consequences. Obstructive sleep apnea, hypoventilation and upper airway resistance syndrome are common causes of morbidity and mortality in childhood. These clinical practice guidelines, intended for use by pediatricians and primary care clinicians, provide a clear recommendation for the diagnosis and management of sleep-disordered breathing, focusing on the most serious disorder, obstructive sleep apnea syndrome (OSAS). These clinical guidelines formulate clear recommendations to identify patients with suspected OSAS. Further, the manuscript will highlight the potential consequences of SBD in children, and how to overcome such difficulties, what could be the therapeutic options, a 12 recommendations and what are the future direction for pediatric sleep medicine.