Post-natal development of sleep organization in man: speculations on the emergence of the 'S process'

Precision caffeine therapy for apnea of prematurity and circadian rhythms: New possibilities open up

Caffeine is the globally consumed psychoactive substance and the drug of choice for the treatment of apnea of prematurity (AOP), but its therapeutic effects are highly variable among preterm infants. Many of the molecular underpinnings of the marked individual response have remained elusive yet. Interestingly, the significant association between Clock gene polymorphisms and the response to caffeine therapy offers an opportunity to advance our understanding of potential mechanistic pathways. In this review, we delineate the functions and mechanisms of human circadian rhythms. An up-to-date advance of the formation and ontogeny of human circadian rhythms during the perinatal period are concisely discussed. Specially, we summarize and discuss the characteristics of circadian rhythms in preterm infants. Second, we discuss the role of caffeine consumption on the circadian rhythms in animal models and human, especially in neonates and preterm infants. Finally, we postulate how circadian-based therapeutic initiatives could open new possibilities to promote precision caffeine therapy for the AOP management in preterm infants.

Very preterm infants show earlier emergence of 24-hour sleep-wake rhythms compared to term infants

BACKGROUND

Previous studies show contradictory results about the emergence of 24-h rhythms and the influence of external time cues on sleep-wake behavior in preterm compared to term infants.

AIMS

To examine whether very preterm infants (<32 weeks of gestational age) differ in their emergence of the 24-h sleep-wake rhythm at 5, 11 and 25 weeks corrected age compared to term infants and whether cycled light conditions during neonatal intermediate care affects postnatal 24-h sleep-wake rhythms in preterm infants.

STUDY DESIGN

Prospective cohort study with nested interventional trial.

SUBJECTS

34 preterm and 14 control term infants were studied. During neonatal hospitalization, preterm infants were randomly assigned to cycled light [7 am-7 pm lights on, 7 pm-7 am lights off, n=17] or dim light condition [lights off whenever the child is asleep, n=17].

OUTCOME MEASURES

Sleep and activity behavior recorded by parental diary and actigraphy at 5, 11 and 25 weeks corrected age.

RESULTS

Sleep at nighttime and the longest consolidated sleep period between 12 pm-6 am was longer (mixed model analysis, factor group: p=0.02, resp. p=0.01) and activity at nighttime was lower (p=0.005) at all ages in preterm compared to term infants. Cycled light exposed preterm infants showed the longest nighttime sleep duration. Dim light exposed preterm infants were the least active.

CONCLUSIONS

Preterm infants show an earlier emergence of the 24-h sleep-wake rhythm compared to term infants. Thus, the length of exposure to external time cues such as light may be important for the maturation of infant sleep-wake rhythms. Trial registry number: This trial has been registered at www.clinicaltrials.gov (identifier NCT01513226).

Overnight changes in the slope of sleep slow waves during infancy

STUDY OBJECTIVES

Slow wave activity (SWA, 0.5-4.5 Hz) is a well-established marker for sleep pressure in adults. Recent studies have shown that increasing sleep pressure is reflected by an increased synchronized firing pattern of cortical neurons, which can be measured by the slope of sleep slow waves. Thus we aimed at investigating whether the slope of sleep slow waves might provide an alternative marker to study the homeostatic regulation of sleep during early human development.

DESIGN

All-night sleep electroencephalography (EEG) was recorded longitudinally at 2, 4, 6, and 9 months after birth.

SETTING

Home recording.

PATIENTS OR PARTICIPANTS

11 healthy full-term infants (5 male, 6 female).

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

The slope of sleep slow waves increased with age. At all ages the slope decreased from the first to the last hour of non rapid-eye-movement (NREM) sleep, even when controlling for amplitude differences (P < 0.002). The decrease of the slope was also present in the cycle-by-cycle time course across the night (P < 0.001) at the age of 6 months when the alternating pattern of low-delta activity (0.75-1.75 Hz) is most prominent. Moreover, we found distinct topographical differences exhibiting the steepest slope over the occipital cortex.

CONCLUSIONS

The results suggest an age-dependent increase in synchronization of cortical activity during infancy, which might be due to increasing synaptogenesis. Previous studies have shown that during early postnatal development synaptogenesis is most pronounced over the occipital cortex, which could explain why the steepest slope was found in the occipital derivation. Our results provide evidence that the homeostatic regulation of sleep develops early in human infants.

Infant growth in length follows prolonged sleep and increased naps

STUDY OBJECTIVES

The mechanisms underlying infant sleep irregularity are unknown. This study tests the hypothesis that sleep and episodic (saltatory) growth in infant length are temporally coupled processes.

STUDY DESIGN

Daily parental diaries continuously recorded sleep onset and awakening for 23 infants (14 females) over 4-17 months (n = 5798 daily records). Multiple model-independent methods compared day-to-day sleep patterns and saltatory length growth.

MEASUREMENTS AND RESULTS

Approximate entropy (ApEn) quantified temporal irregularity in infant sleep patterns; breastfeeding and infant sex explained 44% of inter-individual variance (P = 0.001). Random effects mixed-model regression identified that saltatory length growth was associated with increased total daily sleep hours (P < 0.001) and number of sleep bouts (P = 0.001), with breastfeeding, infant sex, and age as covariates. Infant size and illness onset were non-contributory. CLUSTER analysis identified peaks in individual sleep of 4.5 more h and/or 3 more naps per day, compared to intervening intervals, that were non-randomly concordant with saltatory length growth for all individuals (P < 0.05), with a time lag of 0-4 days. Subject-specific probabilities of a growth saltation associated with sleep included a median odds ratio of 1.20 for each additional hour (n = 8, 95% CI 1.15 to 1.29) and 1.43 for each additional sleep bout (n = 12, 95% CI 1.21-2.03). Increased sleep bout duration predicted weight (P < 0.001) and abdominal skinfold accrual (P = 0.05) contingent on length growth, and truncal adiposity independent of growth (P < 0.001).

CONCLUSIONS

Sleeping and length growth are temporally related biological processes, suggesting an integrated anabolic system. Infant behavioral state changes may reflect biological mechanisms underlying the timing and control of human growth.

Risk factors and consequences of early childhood dyssomnias: New perspectives

Dyssomnias are largely under-diagnosed in infants and toddlers. This literature review proposes an integrative model based on empirical data on determinants and consequences of sleep disturbances occurring in early life. This model proposes that parental behaviors that impede the child's autonomy toward sleep periods are primary grounds for the development of dyssomnias, e.g., parental presence until the child falls asleep, and putting an already sleeping child to bed. The model also indicates the serious potential consequences of a modest but chronic loss of sleep in childhood. At least three developmental domains could be directly affected: behavioral/social competence, cognitive performance, and physical condition. Thus, children with short nocturnal sleep duration before age 3.5 years show increased risk of high hyperactivity-impulsivity scores and low cognitive performance at 6 years compared to children who sleep 11 h per night, after controlling for potentially confounding variables. Moreover, persistent short sleep duration in early infancy increased the risk of suffering of obesity at 6 years of age, after controlling for potentially confounding variables. Finally, the importance of allowing the child to sleep at least 10 h per night in early childhood is stressed, as the National Sleep Foundation Poll suggests, for optimal child development.

Understanding sleep-wake behavior and sleep disorders in children: the value of a model

PURPOSE OF REVIEW

Sleep-wake problems such as night wakings, excessive crying, or difficulties in falling asleep are frequent behavioral issues during childhood. Maturational changes in sleep and circadian regulation likely contribute to the development and maintenance of such problems. This review highlights the recent research examining bioregulatory sleep mechanisms during development and provides a model for predicting sleep-wake behavior in young humans.

RECENT FINDINGS

Findings demonstrate that circadian and sleep homeostatic processes exhibit maturational changes during the first two decades of life. The developing interaction of both processes may be a key determinant of sleep-wake and crying behavior in infancy. Evidence shows that the dynamics of sleep homeostatic processes slow down in the course of childhood (i.e., sleep pressure accumulates more slowly with increasing age) enabling children to be awake for consolidated periods during the day. Another current topic is the adolescent sleep phase delay, which appears to be driven primarily by maturational changes in sleep homeostatic and circadian processes.

SUMMARY

The two-process model of sleep regulation is a valuable framework for understanding and predicting sleep-wake behavior in young humans. Such knowledge is important for improving anticipatory guidance, parental education, and patient care, as well as for developing appropriate social policies.

Development of the nocturnal sleep electroencephalogram in human infants

The development of nocturnal sleep and the sleep electroencephalogram (EEG) was investigated in a longitudinal study during infancy. All-night polysomnographic recordings were obtained at home at 2 wk and at 2, 4, 6, and 9 mo after birth (analysis of 7 infants). Total sleep time and the percentage of quiet sleep or non-rapid eye movement sleep (QS/NREMS) increased with age, whereas the percentage of active sleep or rapid eye movement sleep (AS/REMS) decreased. Spectral power of the sleep EEG was higher in QS/NREMS than in AS/REMS over a large part of the 0.75- to 25-Hz frequency range. In both QS/NREMS and AS/REMS, EEG power increased with age in the frequency range <10 Hz and >17 Hz. The largest rise occurred between 2 and 6 mo. A salient feature of the QS/NREMS spectrum was the emergence of a peak in the sigma band (12-14 Hz) at 2 mo that corresponded to the appearance of sleep spindles. Between 2 and 9 mo, low-frequency delta activity (0.75-1.75 Hz) showed an alternating pattern with a high level occurring in every other QS/NREMS episode. At 6 mo, sigma activity showed a similar pattern. In contrast, theta activity (6.5-9 Hz) exhibited a monotonic decline over consecutive QS/NREMS episodes, a trend that at 9 mo could be closely approximated by an exponential function. The results suggest that 1) EEG markers of sleep homeostasis appear in the first postnatal months, and 2) sleep homeostasis goes through a period of maturation. Theta activity and not delta activity seems to reflect the dissipation of sleep propensity during infancy.

Development of fetal and neonatal sleep and circadian rhythms

The origin of sleep and circadian rhythms development is found during the fetal period. Both quiet (NREM) and active (REM) sleep are distinguishable during the last 10 weeks of gestation. Comparable to fetuses, low risk preterm infants recorded at 30-40 weeks postconceptional age, had a similar development of sleep i.e. an increase in quiet sleep and a decrease in indeterminate sleep. A further development in sleep organization characterized by increased slow wave and spindle activity during quiet sleep and coupling with circadian rhythm takes place during the first 6 months of life in both term and preterm infants.Circadian rhythm of fetal heart rate synchronized with maternal rest-activity, heart rate, cortisol, melatonin, and body temperature rhythms is present during the last 10 weeks of gestation. Although maternally influenced, circadian rhythm antenatally becomes ultradian at birth. Both preterm and term infants show a significant increase in circadian body temperature rhythm amplitude during the first 3 months of life.

Spontaneous awakenings from sleep in the first year of life

Spontaneous awakenings from nocturnal sleep were studied in a sample of 48 healthy infants (M = 26, F = 22), in four age groups (1 to 7 weeks, 8 to 15 weeks, 17 to 22 weeks, 25 to 54 weeks). Consistent with previous data, the number of awakenings is reported less frequently at later ages, owing to a lower frequency of awakenings out of REM sleep. Like young adults, infants in all age groups awake more often from REM than from quiet sleep (QS); this is particularly evident in the first 6 months of life, less so in the second. The duration of the bouts of wakefulness following awakenings remains stable with age. Awakenings out of QS are followed by longer periods of wakefulness than those out of REM sleep, although in older infants the duration is considerably reduced. Night sleep first shows a decrease in the number of awakenings out of REM sleep and then continues after the sixth month of life with the shortening of the wakefulness after awakenings out of QS. In the two younger groups, the distribution of the awakenings shows two main peaks and one main peak differently located during the night; a polymodal pattern appears in group 3, and is even more evident in group 4. It should be stressed that several changes as a function of age occur in the second 6 months of life, indicating this as a period of intense developmental change in sleep-wake rhythms.

[Sleep maturation in the first two years of life: quantitative aspects, structural and circadian]

This study presents results on sleep maturation during the first two years of life, based on a longitudinal study of 15 normal children recorded at home over 24 hours at the ages of 3, 6, 9, 12, 18 and 24 months. The development of the different stages and parameters of sleep was studied in quantitative, structural and circadian terms. To do so, various analyses were performed on the polygraphic recording data interpreted using the "adult" criteria suggested by Rechtschaffen et Kales in 1968. Results show the very early presence of some adult sleep parameters, such as the stable mean duration of episodes of paradoxical sleep (PS), the rapid decrease in the amount of this sleep stage, which reaches adult levels by the age of 9 months, the large amount of slow wave sleep in the first sleep cycle from the age of 3 months and the stability of the acrophase of the PS circadian rhythm. The position of the acrophase corresponds to the period of high PS density at the end of the night in adults. Other parameters, such as the increase in stages 1 and 2 of slow wave sleep, the increase in the latency of PS with disappearance at 9 months of PS onset, and the increase in stability of sleep with a decrease in nocturnal waking and body movements, are related to the maturation of the central nervous system structures implicated in the mechanisms of sleep (maturation of the thalamo-cortical pathways and the rostro-caudal pons-thalamus connections). These maturation processes may be markedly influenced by the environment. Finally, the increase with age in the amplitude of the sleep circadian rhythm may lead to both lengthening of the sleep cycle at the age of 12 months and development of the homeostatic process of sleep analysed by temporal changes in slow wave sleep.

Slow wave sleep (SWS) distribution across night sleep episode in the elderly

Slow wave sleep (SWS) distribution across night sleep was shown to be different between infants and young adults. The present research aimed at studying the SWS distribution across night sleep in elderly subjects. Nine healthy elderly subjects, 61-71 years old, were submitted to nocturnal polygraphic sleep recording. Eleven young subjects, 21-23 years old, were the control group. Recordings were visually analyzed according to Rechtschaffen and Kales rules; the method proposed by Webb and Dreblow was used for scoring SWS. An NREM-REM cycle was defined as a sequence of NREM and REM sleep not interrupted by a waking period longer than 15 minutes. SWS percentage was calculated for each successive NREM episode. No significant association between SWS percentage and cycle rank was shown in elderly subjects, whereas a significant association was observed in the young ones. This kind of SWS distribution could be interpreted as reflecting the restructuring of internal organization of sleep in the elderly.

Prior spontaneous nocturnal waking duration and EEG during quiet sleep in infants: an automatic analysis approach

To ascertain the role of spontaneous nocturnal waking duration on the EEG dynamics during quiet sleep (QS) periods, we analysed the nocturnal polygraphic recordings of 12 infants aged 9 47 weeks old. Their sleep was characterised by two sleep episodes, separated by spontaneous waking and containing at least two QS-paradoxical sleep (PS) cycles each. Automatic analysis of the EEG activity recorded by the centro-occipital lead and reflecting the degree of synchronisation allowed us to compute a parameter whose values ranged from 0 (maximum of EEG synchronisation) to 10 (maximum of EEG de-synchronisation). Three indicators of the time course of the parameter value were computed during the first QS period of the sleep episode subsequent to nocturnal waking: (i) the parameter range (difference between the EEG parameter value at the QS onset and that at the trough-maximum of EEG synchronisation); (ii) the trough latency (time interval between QS onset and trough); and (iii) rate of synchronisation (range/trough latency). These three indicators were the dependent variables in a multiple regression model, where the independent variables were age and the logarithm of the duration of prior waking. The parameter range was correlated with the duration of prior waking. Both the trough latency and the rate of synchronisation were correlated with age only, respectively, positively and negatively. The marked decline in the rate of synchronisation throughout the first year of life could account for the failure to find a significant correlation between prior waking and the above indicator of the EEG dynamics. The relationship between the duration of prior waking and the parameter range in following sleep in infants supports the hypothesis of the early emergence of the homeostatic regulation of sleep.

Dynamics of EEG background activity level during quiet sleep in multiple nocturnal sleep episodes in infants

The study reported in this paper investigated the dynamics of EEG background activity during quiet sleep (QS) in the first year of life. These dynamics have been previously shown to follow an intra-sleep trend within a single sleep episode, and the aim of this study was to show whether they were similar in two successive nocturnal sleep episodes interrupted by a waking episode, or whether they exhibited a progressive trend across the two episodes. The polygraphic recordings of two groups of 6 infants aged from 9 to 15 weeks old and from 25 to 47 weeks old, whose nocturnal sleep organisation was spontaneously interrupted, were selected. Three indicators of the time course of the parameter value, obtained from automatic analysis and reflecting the degree of synchronisation of the EEG activity recorded by the centro-occipital lead, were computed for the first two QS periods of two successive sleep episodes: the parameter range (difference between the EEG parameter value at the QS onset and that at the trough); the trough latency (time interval between QS onset and trough); and rate of synchronisation (range/trough latency). All 3 indicators differed between the first and the second QS period of both sleep episodes independently of age. The rate of synchronisation (but not the parameter range and the trough latency) was higher in the first sleep episode than in the second one, showing an over-night decreasing trend. Those results show that, when nocturnal sleep in infants is split into two episodes separated by an intervening waking, also the second sleep episode displays an internal organisation of its EEG dynamics. Moreover, an across-night trend in the rate of synchronisation can be observed from an early age, a finding which suggests, again, the early emergence of homeostatic regulation of sleep.

Heart rate changes during sleep in normal two-month-old infants

Thirty-five normal two-month-old infants had nighttime followed by daytime polygraphic recordings. Heart rates were calculated every minute in active and quiet sleep states. A difference in mean heart rates was found between the two states and between the two recordings. Rates were lower at night than during the day (P < 0.0001), regardless of the sleep state. During nighttime or daytime recordings as a function of sleep cycles or during sustained sleep episodes, heart rates were minimal in the middle of recordings, but differences were statistically significant for only a few results (mainly in QS). Intrasleep awakening led to a marked increase in heart rate after sleep was resumed, although differences were only statistically significant when the awakened infant was fed. Infants with episodes of periodic breathing had lower mean heart rates throughout the recordings, but differences were not statistically significant. Respiratory and heart rates showed similar changes during the recordings, and a statistically significant correlation was found between the two measurements.

Sleep for development or development for waking?--some speculations from a human perspective

The issue of the relationship between sleep and development could be posed in the following terms: (1) does sleep have a function for development? and (2) which is the specificity of sleep function during development? Is it possible to assess critical ages of emergence and decline of specific sleep functions? The results of recent investigations related to the so-called ontogenetic hypothesis for the function of rapid eye movement (REM) sleep will be reviewed; suggestions are put forward concerning the possible role of non-rapid eye movement (NREM) sleep. Because of the difficulties to provoke long-lasting sleep deprivation in humans during development, two different approaches were used. The results of one set of analyses concerned the secretion of growth hormone during sleep under normal and pathological conditions and the relationship between sleep organization and nutritional supply utilisation in infants and children. The second approach aimed at investigating the long-term development of children suffering from sleep abnormalities at earlier ages. Furthermore, the role of dreaming during development will be discussed. The data summarized here only partly support the function of sleep during development; we would like to underscore the difficulty to dissociate the function of sleep from that of waking.

Dynamics of EEG background activity level within quiet sleep in successive cycles in infants

We investigated in infants the emergence of the trends of the EEG synchronization throughout quiet sleep (QS) as a function of the QS rank. The night sleep of 3 groups with 6 subjects each (aged respectively 9-18 weeks, 21-47 weeks, and 16-45 years) was recorded. A parameter value reflecting the degree of synchronization of the EEG background activity for successive epochs was computed by automatic analysis. For each QS phase 3 indicators of the dynamics of the time course of the EEG parameter activity were determined: the range (difference between the EEG parameter value at the beginning of the QS episode and that at the trough), the trough latency (after QS onset), and the rate of synchronization (range/trough latency). The range and the trough latency increased with age, whereas the rate of synchronization decreased. The range and the rate of synchronization decreased in the successive cycles, whereas the trough latency increased. These results provide further support for the hypothesis of the early emergence of the process S mechanisms and suggest that the framework of the 2-process model could account also for the development of both the EEG background activity dynamics and the sleep-wake organization.

Heart rate and sleep states in infants

Heart Rate (HR) was analyzed during the first six Quiet Sleep (QS)--Paradoxical Sleep (PS) cycles of the polygraphically-recorded nocturnal sleep in three groups of six infants each, aged respectively 1 to 2 weeks, 15 to 19 weeks, and 25 to 47 weeks. HR decreased with age, and was higher during PS than during QS, without difference between odd QS phases (1st, 3rd and 5th, which contain always, but only in oldest infant's group, Slow wave sleep (SWS) stage 3 and 4 episodes), and even QS phases (2nd, 4th and 6th, never containing SWS episodes). In the oldest infant's group, in odd QS phase only, HR was higher in the first half with respect to the second half. The HR modulation according to the QS-PS alternance was obvious in all infant groups. In the oldest infant's group the QS phases without SWS episodes were characterized by a dissociation between EEG activity level (close to that of PS) and HR (similar to that of QS phases with SWS); in QS phases with SWS, however, the HR was modulated according to the type of EEG activity (stage 2 vs SWS).

The role of slow-wave sleep on the duration of quiet sleep in infants

The duration of quiet sleep (QS) phases has been shown to increase during the first year of life. Slow-wave sleep (SWS) appears in about half of the QS phases beyond 20 weeks. In order to evaluate the role of SWS in the lengthening of QS phase duration during the first year of life, we looked at 48 normal full-term infants (aged between 1 and 54 weeks), recorded for a whole-night period. Records included electro-encephalogram (EEG) and other polygraphic parameters. Infants were separated into two groups: (1) those who did not show SWS episodes at all, and (2) those who show both QS phases with (QS SWS+) and without (QS SWS-) SWS episodes. In group 2 the duration of QS SWS+ was longer than that of QS SWS, as well as longer than that of QS of group 1. Group 1 had a duration of QS phases similar to that of QS SWS-. The duration of QS SWS+ depended both on the SWS latency and SWS duration. The lengthening of QS phases with age is accounted for by those phases containing SWS episodes, reflecting a maturational restructuring of QS.