Helping High Risk Infants and Parents Sleep Better: ATS Guidelines for Outpatient Care of Premature Infants

Premature infants, particularly born before 30 weeks gestation who have been given a diagnosis of chronic lung disease, bronchopulmonary dysplasia, or post-prematurity respiratory disease face significant challenges in transition from the NICU environment to life at home.  The lack of guidelines to help focus care and quality medical literature differentiating outcomes is stark.  Parents and physicians need tools to care for these high risk infants. These new ATS guidelines nicely evaluate the role of inhaled medications, swallowing assessment, airway endoscopy, and especially sleep testing and provide timely recommendations.

Outpatient Respiratory Management of Infants, Children, and Adolescents with Post-Prematurity Respiratory Disease: An Official American Thoracic Society Clinical Practice Guideline

New recommendations are available to help guide physicians who must determine when and how to treat infants, children and adolescents with post-prematurity respiratory disease (PPRD). The American Thoracic Society has published an official clinical practice guideline in which a multidisciplinary panel of experts provide 13 conditional recommendations on the diagnostic testing and clinical management of these young people. The complete guideline detailing these recommendations was posted online ahead of print in the American Journal of Respiratory and Critical Care Medicine.

Worldwide, approximately 12 million infants—10 percent of live births—are born prematurely and are at risk for respiratory disease, the most common of which is bronchopulmonary dysplasia (BPD). However, all premature infants, even those who do not meet the criteria for having BPD, may develop poor respiratory health later in life with signs and symptoms including cough, recurrent wheezing, exercise intolerance, low blood oxygen (hypoxemia) and reduced pulmonary function. These individuals are classified as having PPRD.

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Sleeping for Better Cardiovascular Health in Children and Adolescents

There is a reason why personal sleep monitoring devices have proliferated in the wearable technology space.  Poor sleep health is linked to reduced cognitive function, quality of life, and cardiovascular outcomes.  Children are not immune to these complications, but they may present differently.  Obesity, hypertension, insulin resistance, and dyslipidemia have all been correlated in some form to obstructive sleep apnea or sleep disordered breathing.

Be on the lookout for the any of the following:

1) Chronic snoring, mouth breathing, pauses in breathing during sleep especially when associated with tonsillar enlargement

2) Signs of daytime sleepiness despite adequate sleep time.  Sleep needs in children vary by age, so it is important that sleep times reflect that.  Also, it is common for sleepiness to look completely different in children.  Problems with focus, attention and labile emotions and irritability in the second half of the day are quite common.

3) Special risk populations, including children that are obese, or those that have other medical disorders known to predispose to sleep apnea, such as Down Syndrome or other craniofacial abnormalities.

Any of the above warrants evaluation with a pediatric sleep specialist to discuss testing.

AHA Releases Scientific Statement on Obstructive Sleep Apnea and Cardiovascular Health in Children and Adolescents

 In a recent scientific statement, the American Heart Association (AHA) outlined evidence highlighting the effect of obstructive sleep apnea (OSA) on the cardiovascular health of children and adolescents. The full statement was published in Journal of the American Heart Association.

The AHA noted that this statement may be used to develop future guidelines in managing OSA with regard to cardiovascular disease (CVD) risk in the pediatric population.

Epidemiology and Risk Factors

Patients with OSA experience disruption during sleep caused by upper airway obstruction. In children and adolescents, the clinical presentation of the condition can vary by age, but it is generally characterized by habitual snoring, labored breathing, gasps/snorting noises, and daytime sleepiness. According to the AHA, 1% to 6% of children and adolescents have OSA. Current evidence suggests that the OSA prevalence in a pediatric population peaks between 2 and 8 years of age and corresponds to a peak in adenotonsillar hypertrophy prevalence.

Primary risk factors for OSA in the pediatric population include obesity, allergic rhinitis, upper and lower airway disease, enlarged tonsils and adenoids, low muscle tone, neuromuscular disorders, and craniofacial malformations. In addition, sickle cell disease (SCD) may be an independent risk factor for OSA. Premature birth, or birth that occurs prior to 37 weeks’ gestation, may also be associated with an increased risk for sleep-disordered breathing among children, partially because of delayed development of respiratory control.

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Good Sleep Hygiene in Adolescents With Asthma Linked to Improved Attention

A real world comparison of this study seems to fit what we know.  Child and adolescent sleep patterns are woefully bad.  It's no surprise then that attentiveness and other quality of life factors can improve immensely when we "clean up" our sleep habits. Dr. Susarla

Adolescents with asthma who practice good sleep hygiene may experience improvements in sleep and attention span, better quality of life in school, and lower rates of dysfunction during the daytime, according to a study published in the Journal of Asthma. 

This study included 41 participants with persistent asthma (mean age, 14.83±1.28 years; 51.2% male adolescents). Measures included demographic information (sex, age, race/ethnicity, education, caregiver marital status, and family income), information on asthma, sleep hygiene via the adolescent sleep hygiene scale (ASHS), quality of sleep via the Adolescent Sleep Wake Scale (ASWS), quality of life via the Pediatric Quality of Life Index (PedsQL), and attention span via the psychomotor vigilance task (PVT).

To investigate associations among variables related to asthma, as well as between demographic features and dependent variables, Pearson product-moment correlations were used. The predictive power of sleep hygiene on sleep quality, quality of life (school-related or otherwise), and attention span was calculated using linear regressions. Because the sample size was smaller than the recommended 73 participants, effect sizes were used to interpret results. Cohen's f² effect sizes were categorized as large (0.35), medium (0.15), or small (0.02).

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Digital Devices for Insomnia? Researchers say YES

Cognitive behavioral therapy is an intervention the incorporates coping strategies and behavioral modifications to treat a variety of conditions including insomnia.  When done properly it has been shown to be as effective as pharmacotherapy. Dr. Susarla

Digitally delivered cognitive-behavioral therapy not only improved insomnia, but also provided “around-the-clock” health, psychological, and quality-of-life improvements, according to investigators.

Compared with control subjects, patients who used a cognitive-behavioral therapy (CBT) program and associated iPhone app had small improvements in functional health and psychological well-being and large improvements in sleep-related quality of life, the investigators reported.

Those changes were mediated by a large improvement in insomnia, according to Colin A. Espie, PhD, professor of sleep medicine at the University of Oxford (England), and his colleagues.

“These findings indicate that digital CBT improves both daytime and nighttime aspects of insomnia, lending further weight to the clinical guideline recommendation of CBT as the treatment of choice for insomnia,” Dr. Espie and his colleagues reported in JAMA Psychiatry.

Their study included 1,711 adults with symptoms of insomnia that were self-reported and a score of 16 or less on the Sleep Condition Indicator (SCI), which has a range of 0-32. A total of 853 were randomized to receive digital CBT, of whom 413 completed six scheduled 20-minute sessions; an additional 276 adults completed at least one session. The control arm included 858 individuals randomized to sleep hygiene education, of whom 759 went on to receive that intervention.

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