Assessment and treatment of pediatric behavioral sleep disorders in Canada.

OBJECTIVES/BACKGROUND: This paper outlines the current state of Canadian training, clinical services, research, and advocacy initiatives related to non-respiratory sleep disorders, with a specific focus on insomnia, the most common sleep problem in children. METHODS: Information for this narrative review was collected from peer-reviewed publications, web-resources, and personal communications and experiences. RESULTS: It is estimated that approximately one-third of Canadian children and youth present with insomnia, and that this is impacting their physical and mental health, as well as learning in school. Training in pediatric sleep is limited and highly inconsistent within and across disciplines. While there are some publicly and privately funded pediatric sleep services available, these are mostly focused on respiratory sleep problems and are not equally accessible across the country. CONCLUSIONS: Pediatric assessment and treatment services for non-respiratory sleep disorders needs to be more integrated into the Canadian health care system.

Can hypocapnia reduce cerebral embolization during cardiopulmonary bypass?

BACKGROUND: Cerebral embolization is a major cause of central nervous dysfunction after cardiopulmonary bypass. Experimental studies demonstrate that reductions in arterial carbon dioxide tension (PaCO2) can reduce cerebral embolization during cardiopulmonary bypass. This study examined the effects of brief PaCO2 manipulations on cerebral embolization in patients undergoing cardiac valve procedures. METHODS: Patients were prospectively randomized to either hypocapnia (PaCO2 = 30 to 32 mm Hg, n = 30) or normocapnia (PaCO2 = 40 to 42 mm Hg, n = 31) before aortic cross-clamp removal. With removal of the aortic cross-clamp embolic signals were recorded by transcranial Doppler ultrasonography for the next 15 minutes. RESULTS: Despite significant differences in PaCO2, groups did not differ statistically in total cerebral emboli counts. The mean number of embolic events was 107 +/- 100 (median, 80) in the hypocapnic group and 135 +/- 115 (median, 96) in the normocapnic group, respectively (p = 0.315). CONCLUSIONS: Due to the high between-patient variability in embolization, reductions in PaCO2 did not result in a statistically significant decrease in cerebral emboli. In contrast to experimental studies, the beneficial effect of hypocapnia on cerebral embolization could not be demonstrated in humans.

Changes of tissue creatine concentrations upon oral supplementation of creatine-monohydrate in various animal species.

Creatine is a nutritional supplement with major application as ergogenic and neuroprotective substrate. Varying supplementation protocols differing in dosage and duration have been applied but systematic studies of total creatine (creatine and phosphocreatine) content in the various organs of interest are lacking. We investigated changes of total creatine concentrations in brain, muscle, heart, kidney, liver, lung and venous/portal plasma of guinea pigs, mice and rats in response to 2-8 weeks oral creatine-monohydrate supplementation (1.3-2 g/kg/d; 1.4-2.8% of dietary intake). Analysis of creatine and phosphocreatine content was performed by high performance liquid chromatography. Total creatine was determined as the sum of creatine and phosphocreatine. Presupplementation total creatine concentrations were high in brain, skeletal and heart muscle (10-22 micromol/g wet weight), and low in liver, kidney and lung (5-8 micromol/g wet weight). During creatine supplementation, the relative increase of total creatine was low (15-55% of presupplementation values) in organs with high presupplementation concentrations, and high (260-500% of presupplementation values) in organs with low presupplementation concentrations. The increase of total creatine concentrations was most pronounced after 4 weeks of supplementation. In muscle, brain, kidney and lungs, an additional increase (p<0.01) was observed between 2-4 and 2-8 weeks of supplementation. Absolute concentrations of phosphocreatine increased, but there was no increase of the relative (percentual) proportion of phosphocreatine (14-45%) during supplementation. Statistical comparison of total creatine concentrations across the species revealed no systematically differences in organ distribution and in time points of supplementation. Results suggest that in organs with low presupplementation creatine levels (liver, kidney), a major determinant of creatine uptake is an extra-intracellular concentration gradient. In organs with high presupplementation total creatine levels like brain, skeletal and heart muscle, the maximum capacity of creatine accumulation is low compared to other organs. A supplementation period of 2 to 4 weeks is necessary for significant augmentation of the creatine pool in these organs.

Cerebral blood flow velocities in an infant with moyamoya disease.

Moyamoya disease is a progressive cerebrovascular disorder with bilateral occlusion of the basal circulation and development of collateral blood supply. In a 6-month-old female with multifocal ischemic infarctions, transcranial pulsed Doppler sonography revealed extremely high and low cerebral blood flow velocities, dampened waveforms, reversed flow, and musical murmurs. Magnetic resonance angiography revealed different degrees of vascular stenosis and an abnormal collateral network. Moyamoya disease was confirmed by conventional angiography at the age of 10.5 months. Pulsed-wave transcranial Doppler sonography is a noninvasive screening method in infants at risk of moyamoya disease.

Cerebral Doppler sonography of the neonate. A résumé after 20 years and future aspects.

Up until recently the evaluation of CVR (analysis of pulsatility) had been a priority in Doppler sonography. In preterm and term infants with open fontanels and sutures this information is restricted despite its value in extreme situations. Continuous Doppler sonography allows a new approach to monitoring pathophysiologic processes. In connection with improved data recording and processing as well as progress in monitoring blood pressure and central venous pressure, new noninvasive methods of surveillance become possible. Thanks to these methods experimental and clinical research has increasingly gained insight on the autonomic nervous system over the last few years (e.g., m- and r-wave analysis during continuous measurement of arterial blood pressure and heart rate). Already well-known and newly developed functional tests (e.g., tilting test, CO2-reactivity, phase shift, and so forth) will further improve our understanding of physiologic processes and help us develop individual therapy concepts for the newborn.

[Communication barriers in the management of immigrants and their children. An analysis and possible solutions based on case reports]. / Kommunikationsbarrieren in der Betreuung von MigrantInnen und deren Kindern. Analyse and Lösungsvorschläge anhand von Fallbeispielen.

Up to 41% of patients treated in health care institutions and hospitals in Vienna are non-German-speaking. As one half of the foreign population of Vienna speaks little or no German, their treatment in health care institutions is a difficult issue. Based on exemplary case reports, linguistic and socio-cultural communication barriers in health care are presented and the problematic area of foreign-language communication is analysed. Misunderstandings due to communication barriers not only have a negative financial impact on health care economy, they also complicate the individual care of these patients. Based on the experience gained thus far and in concurrence with the developments in other European countries, the use of professional interpreters who combine their role as linguistic intermediaries with the cultural features of foreign-language patients (community interpreters) should be encouraged. The use of specifically trained internal hospital staff is recommended as well. A concept to coordinate central organisations that provide interpreters in the public field may substantially enhance the quality and efficiency of health care in this special situation.

[Pregnancy and neonatal screening in Austria]. / Schwangeren- und Neugeborenenscreening in Osterreich.

In Austria neonatal mortality remains higher than in comparable industrial countries. For this reason the Austrian Academy of Sciences published a study (Köck Ch., Kytir J., Münz R.: Risiko Süglingstod, Plädoyer für eine gesundheitspolitische Reform, Franz Deuticke, Wien 1988) comprising a historical review, an analysis of the present situation and proposals for improvement of the public health care programmes for pregnant women, mothers and neonates. Furthermore, current Austrian health policy is criticized on the basis of two concrete examples (the neonatal mass screening programme for inherited metabolic diseases and compulsory ultrasound screening in pregnancy). However, the authors reach their conclusions from incompletely cited and subjectively (partly falsely) interpreted scientific literature, with misleading consequences. Reviewing the literature in a more complete way, we wish to point out the superficial character of the research carried out by the authors. This kind of work should not serve as a basis for decisions in public health policy.

[4th Austrian SIDS Consensus-Consultation and the Viennese SIDS prevention campaign "Secure Sleep"]. / Osterreichisches SIDS-Konsensus-Gespräch anlässlich der Wiener SIDS-Präventionskampagne "Sicheres Schlafen".

Despite numerous investigations the pathophysiologic mechanisms of SIDS have not been fully elucidated. In large epidemiologic studies highly variable SIDS mortality rates were noted between different countries and cultures. This presumably is due not only to differences in diagnostics and classification of SIDS but also in lifestyle and newborn care. The common denominator is the identification and prevention of the main risk factors: smoking, sleeping in the prone position, over-heating, wrong "bedding". SIDS prevention campaigns that have focussed upon these risk factors have led to a dramatic reduction in the incidence of SIDS. In preparation for the SIDS prevention campaign of Vienna ("Safe Sleep") the content, strategy and procedure of the Austrian prevention campaigns were analysed. The current focus is to convey a clear and uniform message in personal conversations before and after birth of the child. These conversations with parents are the most important tool to detect SIDS related anxiety and a possibly increased risk of SIDS. In the last 30 years various polysomnographic parameters were published that were associated with an increased risk of SIDS. Today there is international consent that polysomnography is not an efficient screening method to demonstrate increased risk of SIDS. Therefore the use of polysomnography, besides research purposes, has been limited to investigating clinical symptoms of infants and children. Concerning monitoring it is important to note that--in contrast to the undisputed importance of monitoring breathing disorders--the effectiveness in SIDS prevention is unproven. State of the art are instruments that monitor heart and breathing rate and have adequate storage functions. The duration of monitoring should encompass the symptomatic period as well as a safety period of three months. The monitor should not be routinely prescribed for a year. The guiding principle is "As short as possible with stringent indication". Prerequisite for the monitoring is good instruction of the parents and a continuous consultation by competent outpatient clinics.

[Viennese SIDS prevention campaign-- a quality management project]. / Die Wiener SIDS-Präventionskampagne als Qualitätsmanagementprojekt.

At the 4th Austrian SIDS Consensus Meeting (1998), consultation was the focus of attention. Secure sleep, the Vienna SIDS prevention campaign, is an information campaign in cooperation with the children's hospitals of Vienna with the aim of reducing the incidence of SIDS in and around Vienna. The campaign was intended to spread awareness concerning care measures to reduce SIDS as well as to reduce SIDS related anxiety (SRA) among anxious parents. The Vienna SIDS prevention campaign is a quality management project, the core of which is consultation. Demands upon the structural quality of a SIDS consultation office include the expertise, communication skills and psychological competence of the consulting team. This can be achieved through interdisciplinary continuing education, international networking and training in communication skills. Priority is given to supporting care for the client by an interdisciplinary team headed by a case manager with the required communication skills. The qualitative outcome is defined by a primary objective medical goal (reduction of SIDS mortality) and a secondary subjective psychological goal (reduction of SRA). It also includes raising effectiveness and efficiency through optimal consultation and, finally, reducing costs by saving expenditure for monitors. The quality of SIDS consultation can be measured by evaluating satisfaction in patients as well as among co-workers.

[Evaluation of the cardiorespiratory monitor SpiroGuard C for infants. Improved registration of respiratory events by new sensors and intelligent alarm management system]. / Evaluierung des Herz-Atem-Uberwachungsgerätes SpiroGuard C für Säuglinge. Verbesserte Erfassung von respiratorischen Ereignissen durch neue Sensorik und intelligentes Alarmmanagement?

OBJECTIVES: The SpiroGuard C is a commercially available cardiorespiratory monitor working with field plethysmography, wireless signal transmission and a novel alarm management system. In order to determine the recognition rates for central, mixed and obstructive apneas, a prospective clinical trial was performed comparing frequency and kind of signals from the monitor with those simultaneously registered by polysomnographic studies. DESIGN: Normal respiratory and alarm signals of the monitor under investigation were integrated into a polysomnographic setting. All central, mixed and obstructive apneas lasting more than 10 seconds as well as all alarms obtained from the monitor were evaluated. RESULTS: 47 series of monitor recordings could be evaluated in parallel to polysomnographic studies: the detection rate for central apneas was 298/328 (90.85%), for mixed apneas 9/41 (21.95%) and for obstructive apneas 0/36 (0%). Out of the total of 708 registered alarms 359 (50.71%) were false alarms, 307 (43.36%) were apnea-related and 42/708 (5.93%) were alarms due to technical problems. 177 of the 359 false alarms (49.30%) occurred during apneas that were shorter than 10 seconds, 119 (33.15%) were related to bad signal quality, and 55 (15.32%) were caused by movement artifacts. CONCLUSION: The recognition rate for central apneas was high (> 90%), while sensitivity for mixed and obstructive apneas was not satisfactory. Approximately half of the alarms were false alarms. These could be reduced by setting the apnea detection time to > 15 seconds, by tighter fastening of the respiration belt (improving the signal transmission), and by turning off the instrument when the child is awake and physically active. The wireless system renders the SpiroGuard C an attractive alternative for home monitoring.

[The value of prenatal ultrasound screening exemplified by abnormalities of the urogenital system. Data from the Styrian malformation register 1985 to 1987]. / Der Wert des pränatalen Ultraschall-Screenings am Beispiel von Fehlbildungen des Urogenitalsystems. Daten aus dem Steirischen Fehlbildungsregister 1985 bis 1987.

Over a three-year period (1985 to 1987), the number of fetal malformations was entered into Styrian Malformation Register (SMR). The data were compared with those of the Austrian Ministry of Health. The SMR collected 137 cases of urinary tract malformations, but only six appeared in the Health Ministry statistics. This discrepancy resulted from the different data collection methods. Presently only a small percentage of fetal abnormalities is officially registered. Using the example of urinary tract malformations this paper shows the value of prenatal ultrasound screening. Such infants must be treated soon after delivery to avoid progression of parenchymal damage. Ultrasound examinations should not be restricted to pregnant women at defined risk. Registration of all prenatally diagnosed--or missed--malformations is a quality-control measurement and improves prenatal diagnosis.

[Prevalence of sleep disorders in school children between 11 and 15 years of age]. / Häufigkeit von Schlafstörungen bei Schulkindern zwischen 11 und 15 Jahren.

UNLABELLED: Little is known about sleep disorders in children and adolescents that might affect physical and emotional well-being. Depending on age and size of the cohort group, and differences in questionnaires, prevalence varies between 1-43% in international studies. We examined the prevalence of symptoms characteristic of sleep disorders in school aged children with a questionnaire which allows indication of symptoms by the children themselves. METHODS: An anonymous questionnaire, based on the German Dresden questionnaire, with 22 questions concerning the main symptoms of obstructive sleep apnea syndrome (OSAS), general symptoms of para- and insomnia as well as sociodemographic data, was developed. 332 pupils (age: 11-15 y, mean: 12.75 y; median: 12 y; 56% female, 44% male) in 2 high schools in Vienna were investigated. RESULTS: 28% (n = 93/332) of the examined group reported snoring (the main symptom of OSAS) and/or insomnia (night waking almost every night) or parasomnia (nightmares, night terrors or sleepwalking almost every night). 15% (n = 14/93) of this subgroup reported snoring and para- or insomnia coincidentally. Girls were affected more frequently than boys by nocturnal awakening (79% vs. 56%, p < 0.001) and nightmares (64% vs. 52%, p < 0.01). The snoring group (21% (71/332) of all examined children) was affected more frequently by mouth dryness (16% vs. 4%, p < 0.001), pallor (7% vs. 3%, p < 0.01), night sweats (6% vs. 1%, p < 0.05) and from the following sleep disorders: nightmares (10% vs. 2%, p < 0.01), night terrors (4% vs. 1.5%, p < 0.001), sleepwalking (1.4% vs. 1%, p < 0.05) and nocturnal awakening (16% vs. 5%, p < 0.01). DISCUSSION: Almost every fifth child reports about at least one main symptom characteristic of OSAS. The statistically significant relation between symptoms of OSAS and non-organic sleep disorders shows the necessity of interdisciplinary focusing on sleep disorders. Further epidemiological studies need to be carried out in order to clarify the role of sleep anamnesis in the diagnosis and management of sleep disorders during childhood.

SIDS related anxiety--a risk factor analysis.

BACKGROUND: The growing public interest in the Sudden Infant Death Syndrome (SIDS) has led to a new psychological problem--SIDS related anxiety (SRA). General public awareness, unfavourable experience in the past, present problems with the infant or insufficient support from the family may lead or contribute to SRA. OBJECTIVE: The study was conducted to explore which of these factors contribute most to the development of SRA. PATIENTS AND METHODS: Families visiting our outpatient clinic during 18 months were interviewed by means of a structured questionnaire. We assessed demographic data, obstetric history, experience of child loss, pregnancy and delivery complications, infant morbidity, family-child interaction, family support and the relation of each of these single factors to SRA. RESULTS: Of 169 families, 58% (98/169) admitted to suffer from SRA and 21% (32/156) from severe SRA. We found a strong and significant relationship between previous experience of child loss and SRA (OR: 2.95, 95% CI: 1.43-6.09, P < 0.005) and between pregnancy complications and SRA (OR: 2.19, 95% CI: 1.18-4.08, P < 0.05). There were no significant relationships between SRA and either delivery complications, child morbidity, impaired family-child interaction or insufficient support from the family. CONCLUSIONS: SRA occurs in an unexpectedly large proportion of families visiting a SIDS counseling clinic. SRA must be taken seriously, and psychological or psychotherapeutic help should be offered. Prevention of SRA should include psychological care for families who experience loss of children or high-risk pregnancies.

[Heart rate variability--physiology, methods of registration and application in pediatric sleep laboratory]. / Herzfrequenzvariabilität--Methoden, Physiologie und Applikation im pädiatrischen Schlaflabor.

Heart rate variability (HRV) has become the focus of interest of a multitude of investigations being a parameter that can easily be recorded. Accepted clinical indications in adults include evaluation of diabetic neuropathy and prediction of prognosis after myocardial infarction in adults. In children, HRV is regularly being registered in the pediatric sleep laboratory in sleep related breathing disorders, after apparent life threatening events, or in infants with assumed increased risk for sudden infant death syndrome. However, uniform interpretation criteria have not been established in these situations, at least partially due to insufficient understanding of physiology and pathophysiology of HRV in this age group. In this overview, current knowledge on HRV in infants and children is summarized and its clinical relevance discussed. In addition, technical requirements and methods of analysis which have a major impact on calculated parameters are being presented.

[Congenital metabolic diseases as a cause of acute illnesses in the neonatal period]. / Angeborene Stoffwechselerkrankungen als Ursache akuter Krankheitsbilder in der Neugeborenenperiode.

Inborn errors of metabolism occurring in the neonatal period both comprise diseases with clinical onset immediately after birth and diseases with clinical onset after a symptom free interval. Organ damage caused by inherited metabolic diseases can occur already in utero or--depending on oral food intake--during the first postnatal days. Unselective screening methods are applied in neonatal mass screening programs for the early detection of metabolic diseases. In cases of unspecific clinical symptoms selective screening procedures may provide an effective diagnostic tool. If a patient with suspected metabolic disease dies, body fluids and organ biopsies should be preserved for further investigations. The establishment of a genotypspecific (enzyme) diagnosis needs time and cost consuming biochemical procedures. It is a prior condition for prenatal diagnosis in further pregnancies.

[Orthostasis in halothane anesthesia. A model situation for studying cerebrovascular autoregulation in infants]. / Orthostasemanöver während Halothannarkose. Eine Modellsituation zur Untersuchung der zerebrovaskulären Autoregulation bei Säuglingen.

Halothane causes impairment of cerebrovascular reactivity and autoregulation. We used transcranial Doppler sonography (TCD) to investigate the reaction patterns of cerebral blood flow velocities (CBFV) during a standardized orthostatic maneuver after premedication and during halothane anesthesia in infants. After premedication orthostasis led to no significant changes in CBFV. During halothane anesthesia CBFV was significantly higher than after premedication, and orthostasis induced a significant decrease in CBFV compared to values obtained in horizontal position. Heart rate and mean blood pressure were significantly lower than before medication during halothane anesthesia. The observed changes in CBFV during halothane anesthesia represent a characteristic pattern of impaired cerebral autoregulation. The changes in CBFV and heart rate demonstrate that neither systemic nor cerebral hemodynamics compensate for hydrostatic inducement during halothane anesthesia. The tilting test is a useful tool for determining cerebral autoregulation capacity in infants.

Position dependent changes of cerebral blood flow velocities in premature infants.

UNLABELLED: The supine or prone positioning of infants has been a cause of much controversy. Recently it has been postulated that the position dependent hypoperfusion of the brainstem represents a possible cause of sudden infant death. To demonstrate position dependency and maturational changes of cerebral perfusion in premature newborn infants we investigated cerebral blood flow velocities (CBFV) in the main supratentorial and brainstem cerebral arteries. Measurements of CBFV were done with transfontanellar colour-coded Doppler sonography in the internal carotid artery (ICA), basilar artery (BA), and vertebral artery (VA) in the prone (head centered-baseline) and supine positions (maximal rotation to both sides) in 23 premature infants aged between 3-5 days of life. We performed follow-up measurements in 17 infants 7-10 days later and in 16 infants at the corrected age of 1 month. There was no difference in mean CBFVs between the prone and supine position at the first investigation. At the third investigation, CBFVs were significantly higher in the supine compared to the prone position. The CBFVs of the ICA were higher than in the BA and VA. This difference was not influenced by the body position but increased with post-natal age more in the VA (159%) than in the BA (129%) and ICA (128%). Position dependency was not seen in the ICA perfusion. In the prone position, five infants showed an incomplete steal effect in the contralateral VA. There was no significant side difference in the CBFVs of the ICA and VA, but in the resistance indices in the VA (left > right). CONCLUSION: in premature newborns, position dependent changes of cerebral blood flow velocity develop with maturation and are most pronounced in the vertebrobasilar system. These changes are possibly due to compression of the vertebral artery by neck movement and suggest an individual risk of brainstem perfusion deficits that may be aggravated with age and head rotation in a prone position.

[Diagnostic imaging in neonatal stroke]. / Bildgebende Diagnostik des Neonatal stroke.

UNLABELLED: A cerebral artery infarction is an important differential diagnosis in the newborn with neurological abnormalities. Based on clinical data, its incidence is estimated to be 1 in 4000 newborns. Since the course is often subclinical, the true incidence is probably higher. DIAGNOSIS: Cerebral ultrasound and Doppler sonography as readily available screening tools play a central role in the initial diagnosis of neonatal cerebral infarction. Definitive diagnosis is made by computed tomography or magnetic resonance imaging. Beside symptomatic anticonvulsive therapy, treatment aims at the prevention of secondary ischemic injury. DISCUSSION: Three term infants with different clinical courses of neonatal stroke are presented to sensitize the clinician and the radiologist for this probably underdiagnosed entity. The role of imaging modalities in the diagnosis and follow-up of neonatal cerebral infarction is discussed.