Sleep of excessively crying infants: a 24-Hour Ambulatory Sleep Polygraphy study

Clinical application of home sleep apnea testing in children: a prospective pilot study

STUDY OBJECTIVES

(1) To determine the sensitivity and specificity of the home sleep apnea test (HSAT) performed in typically developing children who were diagnosed with moderate to severe obstructive sleep apnea during overnight attended laboratory polysomnography (LPSG). (2) To determine the utility of a screening questionnaire to identify children at increased risk for obstructive sleep apnea.

METHODS

Participants completed 2 consecutive study nights, the first night with the HSAT followed by LPSG on the second night. The SHOOTS questionnaire, composed of 6 questions (snoring, hyperactivity, obesity, observed apnea, tonsillar hypertrophy, and sleepiness) concerning sleep-disordered breathing, was administered by the clinician before the first study night.

RESULTS

Thirty-eight participants completed both studies. The mean age was 13.8 ± 3.0 years. Twenty (53%) were male. Most participants were obese. The mean LPSG total sleep time was 7.34 ± 1.19 hours; the mean HSAT total recording time was 8.86 ± 1.73 hours (P < .001). The median obstructive apnea-hypopnea index for LPSG and HSAT was 6.6 and 0.8 events/h, respectively. For an obstructive apnea-hypopnea index ≥ 3.1 events/h by HSAT, the sensitivity was 71.43% (95% confidence interval, 41.9-91.6) and the specificity was 95.83% (95% confidence interval, 78.9-99.9) for identifying those with an LPSG obstructive apnea-hypopnea index of ≥ 10 events/h. For a SHOOTS score with ≥ 4 "yes" responses, the sensitivity and specificity were 85.7% (95% confidence interval, 57.2-98.2) and 54.2% (95% confidence interval, 32.8-74.4), respectively, for identifying those with an LPSG obstructive apnea-hypopnea index ≥ 10 events/h.

CONCLUSIONS

Using HSAT, we clinically applied cutoff values to identify moderate to severe obstructive sleep apnea in typically developing children. The SHOOTS questionnaire may aid in identifying children at risk for obstructive sleep apnea and who are candidates for HSAT.

CITATION

Revana A, Vecchio J, Guffey D, Minard CG, Glaze DG. Clinical application of home sleep apnea testing in children: a prospective pilot study. J Clin Sleep Med. 2022;18(2):533-540.

Tools assessment and diagnosis to infant colic: a systematic review

BACKGROUND

Infant colic occurs between 10% and 40% of healthy born children in their first year of life. Its assessment is complex, and there are only a few instruments of appraisement and diagnosis.

METHODS

Scientific articles located through a systematic review using the Pubmed, Scopus, Cochrane, PEDro, Dialnet, IME and Dialnet databases. Two researchers obtained data independently from relevant studies previously identified. Risk of bias was assessed according to the methods recommended by the Cochrane Collaboration, with reporting following the preferred reported items for systematic reviews and meta-analyses guidelines and evaluating their methodological quality based on the EMPRO scale.

RESULTS

Four tools were obtained for valuation of infant colic. Parental diary of infant cry and fuss behaviour, Crying Pattern Questionnaire, Infant Colic Scale and, lastly, a validity of the Turkish version of the Infant Colic Scale.

CONCLUSIONS

Analysis of the existing tools involves the need to design and validate new assessment scales for this clinical frame.

The adapted American Academy of Sleep Medicine sleep scoring criteria in one month old infants: A means to improve comparability?

OBJECTIVE

The lack of standards induces variability in the sleep staging of infants less than two months of age. We evaluated the feasibility of the 2012 AASM sleep scoring rules for healthy one month old infants.

METHODS

84 polysomnographies were scored into sleep stages with the adapted AASM criteria. The acquired sleep parameters were compared with the parameters in the literature. In addition the effect of age on sleep was studied.

RESULTS

The two independent scorers achieved substantial agreement by using the adapted AASM criteria. The infants' sleep parameters showed marked variability. The amount of active sleep was 36.7% (mean, range 21.3-54.1%), quiet sleep 41.5% (30.3-57.7%) and indeterminate sleep 21.6% (9.7-36.0%). With age sleep became more continuous, but the sleep stage percentages did not change. Our sleep parameters differed clearly from the parameters presented in the literature.

CONCLUSIONS

The adapted scoring rules were reproducible. This encourages their use in clinical practice, as no uniform recommendations exist.

SIGNIFICANCE

Normal values are essential in pediatric sleep medicine and the individual variability in the sleep parameters of healthy infants advocates the standardisation of scoring methods. Here we present sleep stage normative values for one month old infants based on the AASM scoring criteria.

Assessment of nocturnal sleep architecture by actigraphy and one-channel electroencephalography in early infancy

OBJECTIVE

To elucidate characteristic sleep architecture of different nocturnal sleep patterns in early infancy.

METHODS

Participants were 27 infants at the same conceptional age of 3-4months. Nocturnal sleep of these infants was monitored at home by simultaneously using actigraphy and a one-channel portable EEG device. According to the infants' activity for 6h from sleep onset, each night's sleep pattern was classified into three categories: sleeping through the night (STN), sleeping with weak signals (crying/fuss episodes <10min or fed), and sleeping with strong signals (crying/fuss episodes≧10min). Associations of sleep patterns with sleep variables (percentage of time in sleep stages, pattern of slow-wave sleep (SWS) recurrence, etc.) were investigated.

RESULTS

Analysis was conducted in 95 nights. STN pattern (n=36) was characterized by suppressed body movements while EEG represented a state of wakefulness. Weak signal pattern (n=27) tended to indicate rich and regular distributions of SWS across the night. Strong signal pattern (n=32) was characterized by reduced sleep time, although the amount of SWS was not reduced to that degree. Exclusively breastfed infants accounted for 78% of weak signal patterns, whereas formula-feeding infants, 67% of STN patterns. In several nights with STN or strong signal pattern, SWS did not occur in >50% of the sleep cycles. Multiple regression analysis showed that exclusive breastfeeding may increase the proportion of SWS in non-REM sleep.

CONCLUSIONS

Each nocturnal sleep pattern was associated with some sleep architecture, part of which would be attributed to infant's feeding methods.

Associations between infants' crying, sleep and cortisol secretion and mother's sleep and well-being

BACKGROUND

Infants' continuous crying is a challenge both for the child and the principal caregiver. However, the links between infants' sleep, crying and cortisol secretion and mothers' well-being and sleep have been scarcely investigated. The aim of the present study was therefore to examine the link between cortisol secretion, crying and sleep of infants characterized by infantile colic (IC) and mothers' psychological well-being and own sleep.

METHODS

Mothers of 24 infants characterized by IC (mean age = 8 weeks, SD = 1.5 weeks) completed a series of questionnaires regarding the infant's crying and sleeping patterns. Infants' sleep was objectively assessed with actigraphs. Cortisol secretion was measured by means of saliva samples in the mornings after waking. After 4 weeks, infants were assessed once again. Mothers completed questionnaires assessing their psychological well-being (depressive symptoms, family strain) and sleep.

RESULTS

Mothers' psychological well-being and sleep was greatly predicted by infants' morning saliva cortisol levels, sleep disruptions and crying intensity, whereas infants' crying duration and volume had low predictive value.

CONCLUSIONS

Mothers with infants characterized by IC are at increased risk for reporting impaired sleep, developing depressive symptoms and reporting higher family strain. Most importantly, this risk seems to be greater if their infants' sleep is fragmented.

Review of sn-2 palmitate oil implications for infant health

Human milk provides the optimal balanced nutrition for the growing infant in the first months after birth. The human mammary gland has evolved with unusual pathways, resulting in a specific positioning of fatty acids at the outer sn-1 and sn-3, and center sn-2 of the triacylglyceride, which is different from the triglycerides in other human tissues and plasma. The development of structured triglycerides enables mimicking the composition as well as structure of human milk fat in infant formulas. Studies conducted two decades ago, together with very recent studies, have provided increasing evidence that this unusual positioning of 16:0 in human milk triglycerides has a significant role for infant health in different directions, such as fat and calcium absorption, bone health, intestinal flora and infant comfort. This review aims to unravel the relevance of human milk triglyceride sn-2 16:0 for intestinal health and inflammatory pathways and for other post-absorption effects.

Relationship between duration of crying/fussy behavior and actigraphic sleep measures in early infancy

OBJECTIVE

The objective of the study is to understand the relationship between sleep development and crying episodes during early infancy more accurately by longitudinal and objective sleep evaluations.

DESIGN

The study is designed as a prospective longitudinal study of infants in the first 4 months of life.

METHODS

This study included 31 healthy term infants. At approximately 4- to 6-week intervals, when the infants were aged 4-6 weeks, 8-10 weeks, and 14-16 weeks, their mothers recorded the duration of crying/fussy behavior of infants in a timetable and attached an actigraph to the infants for 3 days. The relationship between 24-h crying/fussy behavior duration and actigraphic sleep measures was examined from both a cross-sectional (age group) and longitudinal (within-infants) perspective. Interactions with diverse covariates were studied by multiple regression analysis.

RESULTS

A significant correlation was found between 24-h crying/fussy behavior duration and proportion of active sleep in infants at 14-16 weeks and in within-infant relationships. Among potential covariates, gestational age and co-sleeping had a significant impact on proportion of active sleep. Results of multiple regression analysis showed that gestational age and co-sleeping were positively associated with proportion of active sleep, whereas 24-h crying/behavior duration was not associated with proportion of active sleep.

CONCLUSIONS

Subsiding of early crying and decreasing of proportion of active sleep are parallel phenomena in some infants. However, this association was thought to be attributable to the influence of covariates, including co-sleeping or gestational age. The underlying mechanisms regulating these developmental processes might overlap with one another, as covariates that affect one process could affect the other.

A randomized control trial of integrated care for families managing infant colic

This article presents a randomized clinical trial examining the effectiveness of a unique model of integrated care for the treatment of infant colic. Families seeking help for infant colic were randomized to either the family-centered treatment (TX; n = 31) or standard pediatric care (SC; n = 31). All parents completed 3 days of Infant Behavior Diaries (Barr et al., 1998) and the Colic Symptom Checklist (Lester, 1997), Beck Depression Inventory (Beck & Steer, 1984), and Parenting Stress Index 3rd ed.-SF (Abidin, 1995). TX families were seen three times by a pediatrician and a mental health clinician within 1, 2, and 6 weeks of baseline data. TX families received individualized treatment plans addressing problem areas of sleep, feeding, routine, and family mental health. SC families were seen only by their own healthcare provider. All families were visited at home by a research assistant to retrieve data at 2, 6, and 10 weeks after baseline. Family-based treatment accelerated the rate of reduction of infant crying faster than did standard pediatric care. Infants in the TX group had more hours of sleep at 2 weeks posttreatment and spent less time feeding at 2, 6, and 10 weeks posttreatment than did SC infants. Results indicate that individualized family-based treatment reduces infant colic more rapidly than does standard pediatric care.

'Oh, baby, please don't cry!': in infants suffering from infantile colic hypothalamic-pituitary-adrenocortical axis activity is related to poor sleep and increased crying intensity

BACKGROUND/AIM

Infantile colic (IC) is considered to represent the upper end of the spectrum of early developmental crying behavior. Little is known about hypothalamic-pituitary-adrenocortical axis activity and sleep in relation to infants' crying. The aim of the present study was to assess cortisol secretion in infants in relation to their sleep and crying patterns.

METHOD

Sixteen infants (mean age: 8 weeks; SD = 1.5 weeks) were enrolled. Their mothers completed a series of questionnaires regarding the infants' crying and sleeping patterns. The infants' sleep was objectively assessed with actigraphs. After 4 weeks, the infants were assessed once again. Cortisol secretion was measured by means of saliva samples in the mornings after awakening.

RESULTS

Morning saliva cortisol levels were related to more frequent awakening and to increased crying intensity, but not to sleep or crying duration. Over 4 weeks, both crying behavior and sleep duration decreased, but there was no association between them. Cortisol secretion did not significantly change.

CONCLUSIONS

In infants suffering from IC, fragmented sleep patterns and increased saliva cortisol levels were related. Cortisol secretion seems to be related to crying intensity, but not to crying duration. Crying intensity may reflect greater physiological or psychological stress rather than mere duration of crying.

Maternal vitamin B-12 and folate status during pregnancy and excessive infant crying

BACKGROUND

The etiology of excessive infant crying is largely unknown. We hypothesize that excessive infant crying may have an early nutritional origin during fetal development.

AIMS

This study is the first to explore whether (1) maternal vitamin B-12 and folate status during pregnancy are associated with excessive infant crying, and (2) whether and how maternal psychological well-being during pregnancy affects these associations.

STUDY DESIGN

Women were approached around the 12th pregnancy week to complete a questionnaire (n=8266) and to donate a blood sample (n=4389); vitamin B-12 and folate concentrations were determined in serum. Infant crying behavior was measured through a postpartum questionnaire (±3 months; n=5218).

SUBJECTS

Pregnant women living in Amsterdam and their newborn child.

OUTCOME MEASURES

Excessive infant crying, defined as crying ≥3 h/day on average in the past week.

RESULTS

Multiple logistic regression analysis was performed for 2921 (vitamin B-12) and 2622 (folate) women.Vitamin B-12 concentration (categorized into quintiles) was associated with excessive infant crying after adjustment for maternal age, parity, ethnicity, education, maternal smoking and psychological problems (OR[95%CI]: Q1=3.31[1.48-7.41]; Q2=2.50[1.08-5.77]; Q3=2.59[1.12-6.00]; Q4=2.77[1.20-6.40]; Q5=reference). Stratified analysis suggested a stronger association among women with high levels of psychological problems during pregnancy. Folate concentration was not associated with excessive infant crying.

CONCLUSIONS

First evidence is provided for an early nutritional origin in excessive infant crying. A low maternal vitamin B-12 status during pregnancy could, in theory, affect infant crying behavior through two potential mechanisms: the methionine-homocysteine metabolism and/or the maturation of the sleep-wake rhythm.

Clinical practice: sleep problems during infancy

Sleep problems are very prevalent during infancy. The most common problems are those related to night wakings and sleep-disordered breathing (SDB). Most common night waking problems do not have identified physiologic etiology. Their causes appear to be behavioral or developmental by nature, and they usually respond well to behavioral interventions. SDB may result from a variety of anatomic and neurologic factors and is associated with a variety of medical and developmental disorders. Because of the high prevalence of sleep problems during infancy, their persistence, their potential adverse developmental effects, and the positive treatment outcomes, pediatricians should serve as the primary address for screening and referral to proper assessment and treatment.

Crying behaviour in early infancy is associated with developmental outcome at two years of age in very low birth weight infants

AIM

To evaluate the association between infant fussing and crying and developmental outcome in very low birth weight (VLBW) infants.

METHODS

Hundred and seventeen VLBW infants were followed up to 24 months of corrected age. The duration of fussing and crying and frequency of fuss/cry bouts were measured at term 6 weeks and 5 months of corrected age. Cognitive and motor development was assessed at 24 months of corrected age.

RESULTS

The increased duration of combined fuss/cry at term associated with lower psychomotor developmental index (PDI), [regression coefficient (b)=-0.83, p=0.025]. Crying at term associated negatively with mental developmental index (MDI) (b=-0.91, p=0.040) and PDI (b=-1.10, p=0.015). The associations between fuss/cry and PDI, and crying and PDI persisted in multiple regression analysis (b=-0.89, p=0.030 and b=-1.23, p=0.018, respectively). Excessive fuss/cry (>or=180 min/day) at term associated with lower PDI (p=0.005) and at 6 weeks with lower MDI (p=0.024) and PDI (p=0.012). Increase in the frequency of fuss/cry bouts at 5 months associated with higher PDI in both simple (b=2.90, p=0.045) and in multiple regression analysis (b=3.60, p=0.019).

CONCLUSIONS

In VLBW infants, longer duration of fussing and crying in very early infancy, but not at 5 months, is associated with less optimal development at 24 months of age.

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.

Using diaries to collect data in resource-poor settings: questions on design and implementation

Diaries, as a tool for data collection, have been around for some time. Lessons shared to date come from disparate settings and there remains a degree of ambiguity regarding the value of diaries, particularly in resource-poor settings where populations are often illiterate and highly mobile. We recently designed a pictorial diary for the collection of data on household consumption and expenditure in Tanzania and The Gambia. A random sample of 361 diary keepers in The Gambia and 308 in Tanzania maintained diaries for a period of 12 months. The aim of this paper is to share some of the lessons learnt in developing and applying this instrument. It is structured around a series of questions about diaries that we found relatively few answers to when we first embarked on this study. These questions include: how should a diary be designed? How long should a diary be maintained? When should entries be recorded? Who should keep the diary? The motive behind this paper is simple: to provide future researchers who are contemplating using diaries in resource-poor settings with some practical information that may guide them through this process.