Sudden infant death syndrome: an update on epidemiology and cardiorespiratory mechanisms.
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Airway Obstruction↗
Biomedical subjects
E Rebuffat
Publications and source records attributed to E Rebuffat.
Prospective study on the prevalence of sudden infant death and possible risk factors in Brussels: preliminary results (1987-1988).
A prospective study was carried out to assess the frequency of sudden infant death (SID) in the Brussels area. The study was conducted between January and December 1987 on infants presented to the health clinics of the Brussels "Office de la Naissance et de l'Enfance" (ONE). The infants entered the study if: (a) they were born between January 1 and December 31, 1987; (b) they attended an ONE consultation in the Brussels area between January 1987 and December 1988; (c) visits were repeated monthly during the first 12 months of life, or until death occurred; and (d) standard questionnaires were completed for each visit. For 4,064 infants these four criteria were fulfilled. During the study period 7 infants died of SID. Their deaths were unexpected and remained unexplained despite post-mortem investigations. For each SID case, 10 control infants were selected from the same health clinics. Controls matched the SID cases in the following respects: (a) dates of visits; (b) sex; (c) gestational age; (d) legal age; and (e) the profession of both parents. For most of the 65 items studied no significant difference was seen between the 7 SID infants and their 70 matched controls. Only two variables significantly differentiated the two groups. Repeated fatigue during feeding was seen in 4 of the 7 SID cases, but only in 10 of the 70 control infants (Fisher P = 0.017). Profuse sweating during sleep was reported in 2 of the 7 SID infants, and in none of the 70 controls (Fischer P = 0.007). These two infants' bedclothes were repeatedly wet with sweat.(ABSTRACT TRUNCATED AT 250 WORDS)
Belgium↗
Home monitors for infants: use, misuse, and "over-the-counter" use.
The prevalence of "over-the-counter" monitors, was surveyed in infants referred to five Belgian paediatric centres between September 1987 and March 1988 for evaluation of their risk for sudden infant death (SID). Questionnaires were collected from 1625 families. Of the infants, 8.9% were already being monitored at home. For 78.1% of the infants no medical advice had been solicited, and for 21.9%, a paediatrician or a general practitioner had advised home monitoring without previous evaluation. Forty of 824 infants referred with no history of SID, and no history of apparent life-threatening event (ALTE), were monitored (4.8%). Monitoring was started for 3.8% (5 out of 130) of the infants who had lost a cousin or an uncle to SID, and for 22.2% (69 of 310) of the younger siblings of a SID victim. Of the 341 infants who had presented with an ALTE, monitoring was started in 32 (9.4%). The infants were monitored with respiratory monitors only, and in 86% of the monitors, the alarm delay had been regulated unnecessarily low.
Belgium↗
Recent advances in sudden infant death syndrome: possible autonomic dysfunction of the airways in infants at risk.
Epidemiological studies of sudden infant death syndrome (SIDS) reveal a progressive increase in the incidence of cases, suggesting that the in utero environment and postneonatal care were less than optimal. Subtle differences in symptoms could indicate that, since birth, the SIDS infants are different from control infants, some having an autonomic dysfunction of the airway controls. These observations could contribute to a better understanding of some of the causes of sudden death in infants and could eventually lead to new therapeutic approaches.
Autonomic Nervous System↗
Brief airway obstructions during sleep in infants with breath-holding spells.
We investigated the possibility that infants with breath-holding spells have breathing disorders during sleep. Seventy-one breath holders with a median age of 14 weeks were selected from a well babies clinic because of their histories: 34 infants without loss of consciousness, and 37 with loss of consciousness (21 of the latter had had cyanotic spells, 14 pallid spells, and 2 combined cyanotic and pallid spells). For each breath holder, one control infant without a history of breath holding was chosen from the same clinic. All infants were healthy and had no known cause of disrupted breathing during sleep. Their histories indicated that the breath holders were covered with sweat during sleep (p = 0.005) or wakefulness (p = 0.006) significantly more often than were the control infants. The infants were studied during a one-night monitoring session, and the 142 sleep recordings were analyzed without knowledge of the history. The breath holders had significantly less nonrapid eye movement (stage III) sleep, more indeterminate sleep, more arousals, and more sleep-stage changes than the control infants had. Central apneas were evenly distributed in the two groups. Airway obstructions were found in 41 breath holders and six control infants; the obstruction lasted longer in the breath holders. The infants with airway obstruction during sleep snored more often (p = 0.023) and sweated more (p = 0.035) during sleep. The water evaporation rate, measured on the forehead with an evaporation meter, was significantly greater in the breath holders (p = 0.001). Ocular compression induced longer asystoles in the infants with pallid syncopes than in either those with cyanotic syncopes (p = 0.036) or those without loss of consciousness (p = 0.031). We conclude that the obstructed breathing during both wakefulness and sleep could be related to a common immature breathing control.
Female↗
Sleep apneas and acid esophageal reflux in control infants and in infants with an apparent life-threatening event.
Clinical experience shows that episodes of apnea can occur during regurgitations or vomiting. We questioned whether sleep apneas could be related temporally to documented falls in esophageal pH, when no clinical symptoms of emesis are witnessed. Twenty infants admitted after an apparently life-threatening event ('ALTE') during sleep, but with no clinical symptoms of vomiting or regurgitations at the time of the event, and ten control infants were studied. All infants had occasional episodes of regurgitations. Polygraphic monitoring of state of alertness, cardiorespiratory activity and low esophageal pH was performed continuously during 1 night. The data were analyzed blindly. A total of 334 central and 36 obstructive apneas were monitored, mainly in the ALTE group, during NREM sleep. A total of 116 falls in esophageal pH below 4 units were seen in 18 infants; 50% occurred during wakefulness, and 31% in REM sleep. Arousals or body movements preceded the pH fall in 50% of the cases. Within 5 min following the reflux onset, 18 central apneas (7.2% of the apneas) were seen. There was no correlation between the duration, or the lowest values of esophageal pH measured, and the number or duration of apneas. No obstructive apnea, bradycardia or arousal followed the falls in esophageal pH. Acid esophageal reflux did not play a significant role in the development of apnea in our population.
Esophagus↗
Sleep pattern alterations and brief airway obstructions in overweight infants.
The sleep characteristics of 10 overweight infants were monitored polysomnographically and compared with those of 10 age- and sex-matched control infants with no weight excess. The infants were selected from a well-babies clinic. Infants were assigned to the weight excess group if their weight was greater than 120% of ideal weight/height for age. There were six boys and four girls in both groups, with a median age of 23.5 weeks in the weight excess group and 22.0 weeks in the control group. The infants with weight excess spent significantly less time sleeping in non-rapid-eye-movement (NREM) sleep stage 3-4 and more time in indeterminate sleep than their matched controls. The infants with weight excess had also significantly more gross body movements and more sleep stage shifts than the control infants. Brief airway obstructions were found significantly more frequently in the weight excess group than in the control group. Seven overweight infants showed a total of 74 brief airway obstructions; 41 occurred in NREM sleep stage 1 or 2 and 14 in rapid-eye-movement (REM) sleep. The median duration of the obstructive episodes was 8 s (range 3-13 s). Of the 10 control subjects, only 2 had one obstructive episode each, lasting 3 and 4 s and occurring during REM sleep. Only one mixed apnea of 6.5 s was recorded in a 39-week-old overweight boy. The obstructive episodes were accompanied by a median fall in heart rate of 9% (range 0-51%) and by a median fall in oxygen saturation of 0.9% (range 0-10%).(ABSTRACT TRUNCATED AT 250 WORDS)
Airway Obstruction↗
Long-term development of children monitored as infants for an apparent life-threatening event during sleep: a 10-year follow-up study.
The outcomes of 26 children who had an apparent life-threatening event during sleep and who were monitored at home were evaluated. In a preliminary study that was first reported when the children had a mean age of 2.7 years, only minor behavioral difficulties were seen. The children of this earlier study were characterized by more aggressive behavior, which was tentatively related to parental anxiety. The same children were retested at a mean age of 7 years (range 6 to 10 years), together with sex-, age-, and social class-matched control children. No significant differences were found in their clinical daytime and nighttime behavior or in IQ tests, although in some of the psychodevelopmental tests minor signs of anxiety were revealed. In conclusion, infants with an apparent life-threatening event who underwent continued cardiopulmonary home monitoring develop normally during preadolescence. A prolonged follow-up of the children during adolescence is needed to evaluate later school performance.
Anxiety↗
Milk intolerance in children with persistent sleeplessness: a prospective double-blind crossover evaluation.
From July 1986 to July 1988, 146 children less than 5 years of age were referred by their physicians to our university sleep clinic for continual waking and crying during sleep hours. For 85 children (58.2%), the sleeplessness was attributed to inappropriate sleep habits. For 17 children (11.6%), no explanation was found for the sleep difficulties in spite of an extensive workup. Their median age at referral was 13.5 months (range 2.5 to 29 months). Their persistent sleeplessness was tentatively attributed to an undiagnosed intolerance to cow's milk. Cow's milk was excluded from their diet. In 15 children sleep normalized after 5 weeks (range 4 to 6 weeks). As seen from the parents' logs, the median time needed by the children to fall asleep decreased from 15 minutes (range 15 to 60 minutes) to 10 minutes (range 10 to 15 minutes, P = .001). The number of complete arousals decreased from 5 (range 1 to 12) to less than 1 per night (range 0 to 2) (P = .001). Total sleep time per 24 hours increased from 5.5 hours (range 3 to 8.5 hours) to 13.0 hours (range 10 to 14.5 hours, P = .001). Sleep normalized in one child who continued to receive no cow's milk only after the hydrolyzed hypoallergenic diet was discontinued. In every child, a double-blind crossover challenge was conducted involving a control diet containing no cow's milk and a diet containing cow's milk. The challenge induced the reappearance of insomnia and agitated behavior in all except one child. The child's initial sleep difficulties were retrospectively attributed to inappropriate sleep habits.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Sleep problems in healthy preadolescents.
Few data currently exist concerning the sleep problems of preadolescents. A parent report questionnaire concerning sleep habits and problems was developed. The questionnaires were completed by the parents of 1000 unscreened elementary school children attending the third, fourth, and fifth grades. The schools were randomly selected from an urban area. Of the 1000 questionnaires, 972 were completed and could be used for statistical analysis. Among the parents, 24% reported sleeping poorly and 12% regularly relied on sedatives to induce sleep. Sleep difficulties lasting more than 6 months were present in 43% of the children. In 14% (132 of 972), sleep latency was longer than 30 minutes, and more than one complete arousal occurred during the night at least two nights per week. The following variables were seen among the poor sleepers: lower parental educational and professional status, parents who were more likely to be divorced or separated, and more noise or light in the rooms were they slept. They also presented a higher incidence of somnambulism, somniloquia, and night fears (nightmares and night terrors) than the children who slept well. Boys who slept poorly were significantly more likely to have insomniac fathers (P less than .010). Regular use of sedatives was described in 4% (5 of 132) of the children who slept poorly. Among the "poor sleepers," 21% (33 of 132) had failed 1 or more years at school. School achievement difficulties were encountered significantly more often among the poor sleepers than among the children without sleep problems (P = .001). Of the families with children suffering from sleep problems, 28% expressed a desire for counseling.(ABSTRACT TRUNCATED AT 250 WORDS)
Belgium↗
Sleep characteristics in milk-intolerant infants.
We have shown that there is a relation between allergy to cow's milk and chronic sleeplessness in infants. In the present report we describe the sleep characteristics of children with allergy-related sleep disruption. We compared the polygraphic characteristics of nine infants studied before and after the exclusion of milk from the diet. The infants had a mean age of 18.3 +/- 13.3 and 25.4 +/- 12.7 weeks at the first and the second recording, respectively. Diagnosis of allergy was based on clinical observation. Sleep normalized after milk was withdrawn, deteriorated after a challenge with milk, and normalized again on a second trial of milk elimination. Before the change in diet, the infants' polygraphic recording showed frequent arousals (8-22), short sleep cycles, and a large amount of NREM1 sleep. Gastroesophageal reflux and sleep apnea were not responsible for the sleep fragmentation. After milk was excluded from the diet for 7 weeks, the infants showed striking changes in sleep quality. There was a significant decrease in number of arousals (-41.7%) and an increase in total sleep time (+22.7%) and in NREM2 and 3 sleep (+387.9%). NREM1 sleep decreased significantly (-42.1%). During the second recordings, these sleep values could not be distinguished from those of 40 age-matched controls studied in the same laboratory environments. We do not know if the observed modifications in sleep could reflect immunologic changes within the central nervous system.
Arousal↗
Problems in management of infants with an apparent life-threatening event.
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Apnea↗
Management of an infant with an apparent life-threatening event.
Our clinical experience agrees with most of the recent literature that infants with an apparent life-threatening event (ALTE) form a heterogeneous entity. A specific medical or surgical cause for the event could be found in 61% of the cases. Only 14% of the infants with an apparently severe event entered a home monitoring program. The other infants were treated whenever appropriate. All infants survived the first year of life. Home monitoring was shown to require continuous assistance to the parents. The follow-up of the infants up to 10 years after the ALTE reveals no neurodevelopmental abnormality in most of the infants. A systematic exclusional study of the infants with an ALTE, together with appropriate treatment programs, could thus provide the possibility of a good survival for most infants.
Female↗
Infant with an apparent life-threatening event and possible risk for sudden infant death syndrome.
Pediatricians may be asked by anxious parents to care for their infant who survived a possible sudden death. The child was found unresponsive, pale or cyanotic, and apparently not breathing. The accident occurred unexpectedly, and only a prompt intervention by one of the caretakers permitted a normalization of the child's behavior. The following line discuss some aspects of the prevention of a sudden infant death. There are based on articles and reviews that appeared in the recent literature [1-3], as well as on our local experience. The purpose of these notes is to give the pediatrician some information on the practical aspects of the management of such infants with an apparent life-threatening event. The manuscript ends with some comments about the possible identification of high risk infants on the basis of the available neurophysiological data.
Humans↗
Polysomnographic studies of infants who subsequently died of sudden infant death syndrome.
The polygraphic findings from 11 future victims of sudden infant death syndrome (SIDS) are reported and compared with those of matched pairs of control infants. The recordings had been done to alleviate parental anxiety about sleep apnea. Four infants had siblings who were victims of SIDS. Two infants were studied 3.5 to 9.5 weeks before their deaths because of an unexplained apparent life-threatening event that had occurred during sleep. For each victim of SIDS, two control infants were selected from the 2,000 infants who had been tested in the same hospitals. They were matched for sex, gestational age, postnatal age, and weight at birth with the SIDS victims. Their polygraphic recordings had been performed within similar conditions. Each record was allocated a random code number and was analyzed without knowledge of the patient's identity by two independent scorers. Most sleep and cardiorespiratory variables studied did not differentiate SIDS victims from control infants. Only four variables significantly characterized the future SIDS victims: the maximal duration of central apneas, the number of sighs followed by a central apnea, the presence of obstructive apneas, and the presence of mixed apneas. Central apneas were longer during all sleep states in the SIDS victims compared with their matched controls, but none exceeded 14 seconds. Sighs immediately followed by an apnea were significantly less frequent in the future SIDS group. Obstructive and mixed sleep apneas were seen in eight of 11 SIDS victims and in only three of 22 control infants.(ABSTRACT TRUNCATED AT 250 WORDS)
Female↗
Transepidermal water loss during sleep in infants.
Transepidermal water evaporation rate (ER) was measured in 207 infants with a mean postnatal age of 12.7 +/- 10.6 weeks. Measurements were made from the forehead with the use of an Evaporimeter during polygraphic sleep recordings performed under standard conditions. ER values were computed in g/m2 X h. Evaporation rates were significantly lower during rapid eye movement (REM) sleep (8.5 +/- 4.4 g/m2 X h), compared to values measured during quiet wakefulness (11.6 +/- 7.4) or non-REM (NREM) sleep (11.2 +/- 7.6). The differences were not related to age, sex, weight, or rectal temperature, as shown by a covariance analysis. These data, recorded in normal infants, indicate the need to consider the state of sleep or wakefulness of the subjects when comparing results of water evaporation studies.
Humans↗
Difficulty in initiating and maintaining sleep associated with cow's milk allergy in infants.
To confirm that sleeplessness in infants can be related to an undiagnosed allergy to cow's milk proteins, 71 infants were studied. Group I consisted of 20 infants referred for chronic insomnia that had appeared in the early days of life. Group II was made up of 31 infants admitted for skin or digestive symptoms attributed to cow's milk intolerance; 13 of these infants were shown to sleep as poorly as the infants of group I. Group III consisted of 20 infants with no history of sleep disturbance or milk allergy. The three groups of infants were comparable for sex and age. Laboratory tests revealed immunologic reactions to milk in all the infants in groups I and II. The sleep of the insomniac infants (group I, and the 13 "poor sleepers" in group II) became normal after cow's milk was eliminated from the diet. Insomnia reappeared when the infants in group I were challenged with milk. We conclude that infants with clinically evident milk allergy may suffer from sleeplessness and that when no evident cause for a chronic insomnia can be found in an infant the possibility of milk allergy should be given serious consideration.
Animals↗
Continuous transepidermal water loss measurement in sleeping infants.
Transepidermal water evaporation rate was measured continuously in 8 infants with the use of an evaporimeter during one night of polygraphic sleep recording. Evaporation rates were significantly lower during REM than during NREM sleep. In both sleep stages it decreased during the night with the lowest values between 02.00 and 04.00 h. Evaporation values showed cyclic changes which were studied by measuring minute-by-minute differences between the maximum and the minimum values (the "amplitude variability") and the number of evaporation peaks per minute (the "peak density"). Both the "amplitude variability" and the "peak density" were smaller in REM than in NREM sleep. The "amplitude variability" decreased during the night with lowest values seen between 02.00 and 04.00 h. These changes in evaporation rates could reflect autonomic nervous system activity as well as basal metabolic activity and should be taken into account whenever such measurements are performed in sleeping infants.
Female↗