Infant Sleep and Obstructive Sleep Apnoea

Syndrome

Albert M. LiDepartment of PaediatricsPrince of Wales Hospital

Chinese University of Hong Kong

• Infant sleep- normal sleep pattern

- contrast with sleep of children and adults

• Touch / Massage - evidence of benefits

- possible mechanisms

• Childhood obstructive sleep apnoea

• Effects of massage and use of oil on growth, blood flow and sleep pattern in infants.

Agarwal KN, Gupta A, Pushkarna R, et al. Indian J Med Res 2000;112:212-217

• Full term born healthy infants, n =125

• Age 6 +/- 1 weeks, weight > 3kg

• Five groups; herbal oil, sesame oil, mustard oil or mineral oil for massage daily for 4 weeks, and a control group

• Anthropometric measurements, femoral artery blood flow and sleep pattern

• Sesame oil group had significant increase in length, midarm and midleg circumferences by 1.0, 0.9 and 0.7cm respectively, p < 0.05

• Significant increase in femoral flow in the sesame group

• Massage improved post massage sleep duration

• Massage for preterm and / or low birth-weight infants – improved daily weight gain by 5.1g (95% CI 3.5, 6.7), reduced length of stay in hospital by 4.5 days (95% CI 2.4, 6.5), positive effects on postnatal complications and weight at 4 – 6 months.

Vickers A, Ohlsson A, Lacy JB, et al. Cochrane Database Syst Rev. 2004;(2):CD000390

• Greater bone mineralisation and more optimal behavioural and motor responses for infants given massage compared to controls.

Moyer-Mileur L, Luetkemeier M, Boomer L, et al. J Pediatr 1995;127:620-625

Field T, Schanberg SM, Scafidi F, et al. Pediatrics 1986;77:654-658

Scafidi F, Field T, Schanberg S. J Dev Behav Pediatr 1993;14:176-180

Ottenbacher K, Muller L, Brandt D, et al. J Dev Behav Pediatr 1987;8:68-77

Mechanisms of action

• Massage increases activity of the vagus nerve which may lead to an increase in food absorption hormones such as insulin.

Diego MA, Field T, Hernandez-Rief M. J Pediatr 2005;147:50-55

• Massage promotes the quiet alert state and it during the quiet alert state that infants learn best and start to communicate.35

• An increase in the number and cytoxicity of natural killer cells in the massaged group.

Massage enhances bonding and the release of oxytocin which has been shown to promote maternal well behaviour. Glover V, Onozawa K, Hodgkinson A. Semin Neonatol 2002;7:495-500

Epidemiology

• Prevalence of childhood OSAS reported to range from 0.7% to 10.3%.

Ali et al, Arch Dis Child 1993

Gislason et al, Chest 1995

Redline et al, Am J Respir Crit Care Med 1999

Brunetti et al, Chest 2001

Rosen et al, J Pediatr 2003

Children Adults

Clinical characteristics

Peak age

Sex ratio

Preschoolers

Equal (“M>F”)

Elderly

Mainly males

Aetiology Adenotonsillar hypertrophy Obesity

Weight Failure to thrive, normal or obese Obese

Excessive daytime somnolence

Uncommon Very common

Neurobehavioural Hyperactivity

Poor attention span

Impaired vigilance

Cognitive impairment

Polysomnographic features

Obstruction

Sleep architecture

State with OSA

Hypopnoeas and apnoeas

Normal

REM

Apnoeas

Altered

REM or non-REM

Treatment T&A (most cases) CPAP

UVPP (selected cases)

• Childhood OSAS and even snoring are associated with

behavioural, learning problems, poor attention span, hyperactivity and even lower than average intelligent quotient.

• Evidence to suggest reversibility of such neuro-cognitive dysfunction following treatment.

     Halbower AC, Mark Mahone E. Sleep Med Rev 2006;10:97-107

  Row BW, Kheirandish L, Neville JJ, et al. Pediatr Res 2002;52:449-453

      Macey PM, Henderson LA, Macey KE, et al. Am J Respir Crit Care Med 2002;166:1382-1387

   Gozal D, Kheirandish L. Am J Respir Crit Care Med 2005;17:1325-1327

297 first-grade children whose school performance was in the lowest 10th percentile

underwent assessment and overnight sleep study.

Gozal, D. Pediatrics 1998;102:616-620

Gozal, D. Pediatrics 1998;102:616-620

Adjusted odds ratios for the presence of incident hypertension at 4-year follow-up according to the apnea-hypopnea index (AHI) at baseline. P for trend=0.002. Based on data from Peppard PE et al

Marcus CL, Greene MG, Carroll JL. Am J Respir Crit Care Med. 1998;157:1098-1103

Chan JYS, Li AM, Lo AFC, et al. (submitted for publication)

Control OSA p-value

BW (kg) 33.09±10.02 38.68±11.45 0.045

SBP (mmHg) 99.78±10.54 106.12±12.71 0.04

DBP (mmHg) 64.75±9.23 72.03±12.55 0.01

AHI 0.55±0.88 7.08±6.54 <0.001

RIMP 29.02±4.42 32.10±6.40 0.036

RVSAI 20.80±6.16 24.76±8.18 0.036

RVDAI 34.69±9.57 38.45±11.30 NS

RVFA (%) 39.46±10.5 35.42±10.4 NS

LV mass index (g/m2)

79.50±20.86 83.53±19.49 NS

E/A 2.01±0.53 2.02±0.67 NS

IVRT(msec) 56.43±12.02 57.42±7.86 NS

Less commonly seen nowadays.

Gold standard for

diagnosis is overnight

sleep study.

• One-night sleep study is cost effective and able to correctly identify over 80% of positive cases.

Li AM, Wing YK, Cheung A, et al. Chest 2004;226:1467-1472

Treatment

• Adenotonsillectomy offers cure in up to 85% of cases.

• Medical treatments may be indicated for mild cases.

• NIPPV recognised therapy for childhood OSAS especially for obese children.

Li AM, Tsang TWT, Chan DFY, et al. (submitted for publication)

r = 0.4, p = 0.003

70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 NEU%

30.0

25.0

20.0

15.0

10.0

5.0

0.0

OAI