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Sleep Disordered Breathing at the Extremes of Age: Infancy

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Sleep Disordered Breathing at the Extremes of Age: Infancy Educational aims The reader will be able to: ●● Understand normal sleep patterns in infancy ●● Appreciate disorders of breathing in infancy ●● Appreciate disorders of respiratory control Breathe | March 2016 | Volume 12 | No 1 e1 Don S. Urquhart1,2, Hui-Leng Tan3 [email protected] 1Dept of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, UK. 2Dept of Child Life and Health, University of Edinburgh, Edinburgh, UK. 3Dept of Paediatric Respiratory and Sleep Medicine, Royal Brompton Hospital, London, UK. Sleep disordered breathing at the extremes of age: infancy Cite as: Urquhart DS, Tan H-L. Sleep disordered breathing at Normal sleep in infancy is a time of change with alterations in sleep architecture, sleep duration, the extremes of age: infancy. sleep patterns and respiratory control as an infant grows older. Interactions between sleep and res- Breathe 2016; 12: e1–e11. piration are key to the mechanisms by which infants are vulnerable to sleep disordered breathing. This review discusses normal sleep in infancy, as well as normal sleep breathing in infancy. Sleep disordered breathing (obstructive and central) as well as disorders of ventilatory control and infant causes of hypoventilation are all reviewed in detail. @ERSpublications This review covers sleep in infancy, a time of adaptation when infants are vulnerable to sleep disordered breathing http://ow.ly/YKzVO Introduction are used for scoring worldwide and divide sleep Sleep is a distinct physiological state with changes stages as R (REM), N1 (stage 1 NREM), N2 (stage 2 in brain activity, muscle tone and autonomic func- NREM), N3 (stage 3 and 4 NREM sleep combined, tion (cardiac and respiratory control) as compared also known as slow-wave sleep) and N (non-REM with wakefulness. Sleep architecture, total sleep indeterminate stage). The visual scoring rules for time and sleep staging differ considerably as one sleep staging in children are applicable from the transcends from fetal life to adulthood, with a age of 2 months post-corrected gestational age further set of changes to the way we sleep occur- onwards. Figure 1 demonstrates the appearances ring as one heads towards senescence. Sleep and of N3 and REM sleep in a child aged 8 years. In breathing are intrinsically related functions, and addition to the staging of sleep, the AASM guide- this relationship is critical to the understanding of lines are used for the scoring of respiratory events sleep disordered breathing in infancy. be they obstructive (apnoea or hypopnoea), central Sleep is characterised by a series of sleep stages. (apnoea or hypopnoea) or mixed, which occur with The scoring of sleep stages was first proposed for an associated arousal, awakening or desaturation. adults in 1968 by Rechtschaffen and Kales [1] Rules are available from infancy onwards to facili- who published a scoring manual. This manual tate scoring of respiratory events [2]. dichotomised sleep stages as rapid eye movement The scoring of infants sleep staging is more diffi- (REM) sleep or non-rapid eye movement (NREM) cult due to immaturity in the EEG pattern, such that sleep. NREM sleep was further divided into stages a dichotomy between active sleep and quiet sleep 1–4 based on electroencephalography (EEG) char- was proposed by Anders et al. [3] in 1971. An inde- acteristics. The Rechtschaffen and Kales scoring terminate sleep stage is used for epochs that display system has been superseded by the American Acad- characteristics of both active sleep and quiet sleep. emy of Sleep Medicine (AASM) guidelines [2], which In early infancy the distinction between active sleep e2 Breathe | March 2016 | Volume 12 | No 1 http://doi.org/10.1183/20734735.001016 Sleep disordered breathing in infancy a) EOG EEG EMG ECG b) EOG EEG EMG ECG Figure 1 30-s epochs of EOG, EEG, EMG and electrocardiography (ECG) illustrating a) N3 sleep and b) REM sleep in a child undergoing polysomnography. Images courtesy of the Dept of Cardiac, Respiratory and Sleep Physiology, Royal Hospital for Sick Children, Edinburgh, UK. and quiet sleep cannot be made on EEG criteria sleep). These guidelines recommend the use alone, and behavioural and respiratory correlates of a combination of behavioural characteristics will change with age. Indeed sleep stage scoring and characteristics of respiration as well as EEG, systems exist for infants that are independent of electro- oculography (EOG) and chin EMG patterns. [4] or complementary to [5] electrophysiological During stage R, the eyes are closed with REM measures. Active sleep shares some similarity with seen under closed eyelids along with grimacing, adult REM sleep (irregular heart rate and EEG, rapid squirming, sucking and small face and limb eye movements and reduced electromyography movements. Respiration is irregular during stage (EMG) activity/muscle tone). In addition, squirm- R sleep with some central pauses apparent. Stage ing, grimacing and small movements of face and N sleep is characterised by the eyes being closed limbs may be noted. Respiration is irregular. Quiet with few movements and a regular respiratory sleep appears similar to adult NREM sleep (high pattern. Stage T sleep is scored when both REM voltage EEG that may be continuous or discontin- and NREM characteristics are present within the uous: tracé alternant), with eyes closed, few move- same sleep epoch [2]. ments and a regular respiratory pattern. Figure 2 demonstrates the appearances of tracé alternant in an infant undergoing polysomnography. Infant scoring has been incorporated into Normal sleep and normal the most recent version of the AASM scoring sleep breathing in infancy guidelines [2] such that active sleep is named R (REM sleep), quiet sleep is named N (NREM sleep) Periods of cycling activity interspersed with periods and indeterminate sleep is named T (transitional of inactivity are identifiable in the human foetus Breathe | March 2016 | Volume 12 | No 1 e3 Sleep disordered breathing in infancy C3-A2 O2-A1 EEG RE-A1 LE-A2 RIB-RF Respiratory ABDO-RF eort bands FLOW-RF Airflow SaO2-RF SaO % 97 98 98 98 98 97 97 97 97 98 97 97 98 98 97 2 SpO HR bpm 147 148 148 147 147 145 144 145 146 149 151 152 151 149 147 2 Figure 2 Discontinuous slow wave EEG activity (tracé alternant) in infantile NREM sleep. Image courtesy of Dr Sadasivam Suresh, Dept of Paediatric Respiratory and Sleep Medicine, Lady Cilento Children’s Hospital, Brisbane, Australia. from 28–32 weeks of pregnancy that suggest In addition, both tidal volume and inspiratory human sleep is an entity by this gestational age time increase from preterm through infancy and [6]. However, in the post-natal setting active beyond. sleep emerges as a recognisable entity at around Periodic breathing is characterised by recur- 28–30 weeks gestational age, whilst quiet sleep rent central apnoea and intermittent respiratory begins to become apparent much later (around effort (figure 3). This is a normal phenomenon in 36 weeks) [6]. From this point onward quiet sleep both term and preterm infants, which is thought increases in proportion so that by 3 months cor- to reflect immaturity in breathing control [8]. rected gestational age it is the dominant sleep Periodic breathing is common in stage R sleep, state [7]. but may also occur rarely in N sleep. Periodic Over this first 3 months of life, many physio- breathing may be exaggerated or persist for longer logical functions become more organised. As in those who are born preterm, or in those with highlighted above, sleep architecture is one of coexisting pathology (i.e. low birth weight). There these, as are pattern and control of breathing. are some associations between periodic breath- Breathing patterns become more stable with ing and prolonged apnoea [9], as well as evidence increasing maturation with a reduction in vari- that hypoxia precipitates periodic breathing and ability of tidal volume as well as a fall in respira- increase apnoeas in infants close to term [10]. tory rate also occurring throughout infancy [8]. This may explain the demonstrable effects on C3-A2 EEG EMG Respiratory eort bands Airflow SpO2 96 96 96 94 94 94 95 96 96 94 91 91 90 93 96 95 92 92 92 96 96 95 93 90 93 94 96 95 92 90 SaO2 % HR bpm 112114 110 108 107 105 109 121 118115 110 109 108 109 108 108 109 109 109 119 123 122 119 117 117 120 119 119 116 117 Figure 3 Periodic breathing in an infant. Image courtesy of Dr Sadasivam Suresh, Dept of Paediatric Respiratory and Sleep Medicine, Lady Cilento Children’s Hospital, Brisbane, Australia. e4 Breathe | March 2016 | Volume 12 | No 1 Sleep disordered breathing in infancy ventilatory control and witnessed apnoeas that and obligate nasal breathing) and the predom- result in infants with intercurrent respiratory inant REM sleep state, which may exacerbate infections. Furthermore, oxygen appears to be obstruction due to loss of muscle tone. In infancy, a stabiliser of respiratory control with reduced causes of OSA are predominantly anatomical numbers of apnoeas and a reduced percentage of for example those with laryngomalacia [20, 21], periodic breathing noted in infants supplemented macroglossia [22] or craniofacial disorders [20, with oxygen [11]. 21] such as craniosynostoses (Crouzon’s disease, There is considerable variability in arterial oxy- Apert syndrome and Pfeiffer syndrome) [23], sub- gen saturation measured by pulse oximetry (SpO2) jects with cleft palate and Pierre–Robin sequence in infants. Cross-sectional work demonstrates the (PRS) [24], those with mid-face hypoplasia (e.g. wide variability in SpO2 measurements in preterm Treacher–Collins and Goldenhar syndromes) [23] infants with median (range) SpO2 values of 95% and those with choanal atresia/CHARGE associ- (92–99%) [12], while two longitudinal studies ation [25]. Muscle tone may also be a factor, for [13, 14] show how SpO2 variability reduces and example in infants with Down syndrome or neu- average SpO2 increases with age.
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