SLEEP STUDIES IN THE VERY, VERY YOUNG

Transcription

1 SLEEP STUDIES IN THE VERY, VERY YOUNG Julie DeWitte, RCP, RPSGT, RST Assistant Department Administrator Kaiser Permanente Fontana Sleep Center AAST Director-at-Large Board Member NEONATES THROUGH INFANCY Focus Fall 2018

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3 Objectives Development of sleep characteristics and rhythms Understand infants sleep requirements Appreciate the nuances of interpreting infant polysomnography Recognizing and treating infant sleep disorders

4 HISTORY 1971 Scoring Sleep in Infants < 2months old 1972 First Identification of Treating OSA 2002 Sleep Medicine Specialty 2007 Publication of Sleep Scoring Manual

5 Purpose of Sleep Only beginning to understand pediatric sleep effect on learning, memory, behavior, growth, and cognition Energy Conservation Evolutionary / Adaptive Learning / Unlearning Detoxification Newborn: 70% of 24 hours, Sleep is the work of a newborn Child: 35-60%, Work of a child is play Adult: 25-30% of 24 hours, Work is employment

6 Development of Sleep

7 Human Development: Preterm through Infancy Children are Different Visible Landmarks Mirror CNS development No Sleep-related Equivalent! Assessing Human Development During Waking Hours Fine Motor Gross Motor Personal/Social Language During Sleep No Equivalent Factors: Behavioral Structural Biological

8 Development of Sleep Behavioral Characteristics PRE-TERM Basic Rest / Activity Cycle Ultradian Minutes Free Run TERM INFANTS Ultradian minute cycles 3-4 hour feeding schedules Superimposed Circadian Background

9 Development of Sleep Behavioral Characteristics 1-3 MONTHS Tend to Free Run Circadian Background predominates at weeks 24 hour Sleep / Wake and Temperature Cycle 4 to 6 MONTHS Longest Sleep period at Night Longest Wake period during Day 2-3 Distinct Naps 6 to 12 MONTHS T wo discrete daytime naps 1-3 hours diurnal sleep hours nocturnal sleep Nocturnal awakenings common

10 Development of Sleep / Wake

11 Normal Sleep Hours Recommendations Age Maybe Best Maximum Newborn 0-3mo Infant 4-11mo Toddler 1-2 yr Preschool 3-5 yr School 6-13yr Teenager 14-17yr Young adult 18-25yr Adult 26-64yr Older adult 65+yr National Sleep Foundation American Academy of Sleep Medicine 2017

12 Initial Sleep Stages NREM REM Wake

13 Hypnogram of a infant nap study Immediate REM after sleep onset REM

14 Sleep Stages 3 months of age N1 5% N2 45% N3 25% Drowsiness, transition period to sleep, light sleep More stable sleep than N1 Deep Sleep Release of Growth Hormone Predominant in first half of night REM 25% Memory consolidation Immobilize Predominant in last half of the night

15 Sleep staging Polysomnography Awake Falling asleep Stage: N1 Light Sleep Stage: N2 Deep Sleep Slow wave sleep Stage: N3 REM Dreams (active sleep)

16 Assessment of Sleep Disorders in Pediatrics Detailed History and Physical Exam Overnight Polysomnography Identify type of sleep disorder in the patient

17 Infants Central Apnea\Periodic Breathing Chiari Malformation ALTE: Apparent Life Threatening Event Chronic Lung Disease of Infancy: Bronchopulmonary Dysplasia (BPD) Neonatal Apnea Chest Wall Abnormalities Neuromuscular Disorders Achondroplasia Down s Syndrome (Trisomy 21) Prader-Willi Normal Oxygen Baseline 95%

18 Late preterm: Between 34 weeks and less than 37 weeks Moderately preterm: Between 32 and 34 weeks Very preterm: Less than 32 weeks Extremely preterm: 25 weeks or less Preemies are more likely to have medical issues like heart, lung, or CNS immaturity

19 Importance of Polysomnography Majority of sleep studies performed: Embletta PH Probe Disadvantages: Unattended Study Poor signal quality Lack of capnography Lack of EEG

20 Embletta Example

21 SLEEP IN THE PREMATURE INFANT REM

22 SLEEP IN THE PREMATURE INFANT NREM Trace Alternant

23 Case #1 29 week premature infant who is now 5 weeks old Admitted to NICU (neonatal intensive care unit) with Apparent Life Threatening Event (ALTE) After feeding, infant appeared to stop breathing and turned blue.

24 Airflow SaO2 What s the diagnosis? How would you treat this patient?

25 Neonatal Apnea Pathophysiology: Central Apnea Airway Obstruction Bradycardia Hypoxemia

26 Management/treatment options Positioning Supplemental Oxygen Medications CPAP Mechanical Ventilation

27 THERAPY LPM O 2 Airflow SaO2 CO2

28 Follow-up Diagnosis: Apnea of Prematurity Therapy: LPM oxygen (initially around the clock) PSG nap study performed monthly with gradual improvement Resolved at 7 months

29 Newborn Sleep Studies Can conduct Nap Studies up to 9 months Need 4 hours of sleep for sleep study 3 to 9 months will validate duration of day sleep

30 SLEEP IN THE TERM INFANT REM

31 SLEEP IN THE TERM INFANT NREM

32 Cornelia de Lange Syndrome Short Stature Intellectual Disability Abnormal Facial Features Microcephaly

33 Case #2 6 month old female (39 week gestation) w/ Cornelia De Lange Syndrome 9 lb 12 oz currently Twin died from respiratory & GI complications ~1month Bronchopulmonary Dysplasia Congenital Diaphragmatic Hernia Congenital Pulmonary Hypoplasia Acute Respiratory Failure Soft Cleft Palate Surgeries: splenectomy, Nissan fundoplication, diaphragmatic hernia repair (left side)

34 Room Air Low 70 s 60 second epoch 0.25 LPM 90-92% 30 second epoch 0.5 LPM 90-93% 60 second epoch

35 Bronchopulmonary dysplasia More common in premature infants Inflammation and scarring of lungs Long-term breathing difficulty Results from mechanical ventilation and long-term oxygen use

36 Treatment 96-98% 0.75 LPM

37 Clinical course: Neonatal apnea vs Bronchopulmonary dysplasia (CLD) Abstract, Hwang et al. SLEEP 2015

38 Infant Sleep Sleep 9-12 hours during the night Will take 30-minute to 2 hour naps Nap: 1-4 times a day fewer as they reach the one-year mark. Recognizable signs of sleepiness Pacifiers aid in SIDS prevention

39 SLEEP IN THE 4 MONTH OLD INFANT NREM N2/N3

40 SLEEP IN THE 4 MONTH OLD INFANT N3

41 SLEEP IN THE 4 MONTH OLD INFANT REM

42 Case Study #3: Pierre Robin Characteristics: Micrognathia Glossoptosis Upper Airway Obstruction Cleft Palate Secondary to Mandibular Hypoplasia

43 NREM Sp02 TCOM 52-54% 73-77% REM TCOM Sp % 68-71%

44 Sp02 TCOM 1\4 LPM

45 Mandibular Distraction Increases the length of the jaw Pulls tongue forward Opens airway

46 Post-op NREM TCOM Sp02 REM TCOM Sp02

47 Summary Review of Objectives Development of sleep characteristics and rhythms Understand infants sleep requirements Appreciate the nuances of interpreting infant polysomnography Recognizing and treating infant sleep disorders Importance of polysomnography for infants & recognition of their unique medical conditions