Measuring the Burden of Infodemics: Summary of the Methods and Results of the Fifth WHO Infodemic Management Conference.

Background: An infodemic is excess information, including false or misleading information, that spreads in digital and physical environments during a public health emergency. The COVID-19 pandemic has been accompanied by an unprecedented global infodemic that has led to confusion about the benefits of medical and public health interventions, with substantial impact on risk-taking and health-seeking behaviors, eroding trust in health authorities and compromising the effectiveness of public health responses and policies. Standardized measures are needed to quantify the harmful impacts of the infodemic in a systematic and methodologically robust manner, as well as harmonizing highly divergent approaches currently explored for this purpose. This can serve as a foundation for a systematic, evidence-based approach to monitoring, identifying, and mitigating future infodemic harms in emergency preparedness and prevention. Objective: In this paper, we summarize the Fifth World Health Organization (WHO) Infodemic Management Conference structure, proceedings, outcomes, and proposed actions seeking to identify the interdisciplinary approaches and frameworks needed to enable the measurement of the burden of infodemics. Methods: An iterative human-centered design (HCD) approach and concept mapping were used to facilitate focused discussions and allow for the generation of actionable outcomes and recommendations. The discussions included 86 participants representing diverse scientific disciplines and health authorities from 28 countries across all WHO regions, along with observers from civil society and global public health-implementing partners. A thematic map capturing the concepts matching the key contributing factors to the public health burden of infodemics was used throughout the conference to frame and contextualize discussions. Five key areas for immediate action were identified. Results: The 5 key areas for the development of metrics to assess the burden of infodemics and associated interventions included (1) developing standardized definitions and ensuring the adoption thereof; (2) improving the map of concepts influencing the burden of infodemics; (3) conducting a review of evidence, tools, and data sources; (4) setting up a technical working group; and (5) addressing immediate priorities for postpandemic recovery and resilience building. The summary report consolidated group input toward a common vocabulary with standardized terms, concepts, study designs, measures, and tools to estimate the burden of infodemics and the effectiveness of infodemic management interventions. Conclusions: Standardizing measurement is the basis for documenting the burden of infodemics on health systems and population health during emergencies. Investment is needed into the development of practical, affordable, evidence-based, and systematic methods that are legally and ethically balanced for monitoring infodemics; generating diagnostics, infodemic insights, and recommendations; and developing interventions, action-oriented guidance, policies, support options, mechanisms, and tools for infodemic managers and emergency program managers.

High-Fidelity Simulation-Based Education: Description of an Original Crisis Resource Management and Sedation Learning for Dental Surgeons.

Dental surgery includes invasive procedures performed under sedation or monitored anesthesia care (MAC). It is associated with respiratory risks, resulting in death or neurological sequelae without prompt and appropriate management. Management of airway complications also implies mastering crisis resource management (CRM) principles, essentially non-technical skills to improve patient safety. In response to the need to enhance patient safety and to securely perform surgical procedures outside the operating room due to reduced surgical activity during the worldwide spread of the COVID-19 pandemic, we realized, in our simulation center, a course based on high fidelity simulation to teach procedural sedation and management of related complications. The simulation center accredited this educational program as a continuing professional development formation. The course includes technical skills practice, theoretical presentation, and mastering non-technical skills related to CRM principles. This brief report describes a relatively innovative teaching technique in dentistry, highlights its interest, and reports the subjective opinion of learners as to the pedagogical and professional impact of this training. A learner's satisfaction survey supports the utility of our sedation and CRM programs. A high degree of satisfaction and perceived value reflect robust learners' engagement. All medical specialties should encourage high-fidelity simulation continuing professional development courses that incorporate technical skills and crisis management principles.

Intrapandemic regional anesthesia as practice: a historical cohort study in patients undergoing breast cancer surgery.

BACKGROUND: The COVID-19 pandemic has markedly increased delays in oncologic surgeries because of the virus's impact on traditional anesthetic management. Novel protocols, developed to protect patients and medical professionals, have altered the ways and instances in which general anesthesia (GA) can be safely performed. To reduce virus exposure related to aerosol-generating procedures, it is now recommended to avoid GA when feasible and promote regional anesthesia instead. At our institution, we observed faster postoperative recovery in patients who received paravertebral blocks for breast cancer surgery instead of GA. This led us to formally evaluate whether regional anesthesia instead of GA helped improve time to hospital discharge. METHODS: We conducted a historical cohort study to retrospectively analyze two cohorts of patients: prepandemic vs intrapandemic. We obtained approval from our institutional ethics committee to review files of consecutive patients who underwent breast cancer surgery between 30 March 2020 and 30 June 2020 (intrapandemic group; N = 106) and consecutive patients-moving backwards-from 28 February 2020 to 6 December 2019 (prepandemic group; N = 104). The primary outcome was the length of time between the end of surgery to readiness for hospital discharge. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), the need for postoperative analgesia, and the duration of stay in the postanesthesia care unit (PACU). RESULTS: The median [interquartile range (IQR)] time to readiness for hospital discharge was significantly lower in patients who received paravertebral blocks for breast cancer surgery compared with GA (intrapandemic group, 119 [99-170] min vs prepandemic group, 191 [164-234] min; P < 0.001) as was the incidence of PONV (3% vs 11%; P = 0.03) and median [IQR] PACU durations of stay (29 [21-39] min vs 46 [37-63] min; P < 0.001). CONCLUSIONS: Patients who received paravertebral blocks for breast cancer surgery in the intrapandemic group were ready for hospital discharge earlier, spent less time in the PACU, and experienced less PONV than those who received GA in the prepandemic group. With growing surgical wait times, concerns related to aerosol-generating procedures, and recommendations to avoid GA when feasible, paravertebral blocks as the principal anesthetic modality for breast cancer surgery offered benefits for patients and medical teams.

RéSUMé: CONTEXTE: La pandémie de COVID-19 a considérablement augmenté les retards dans les chirurgies oncologiques en raison de l'impact du virus sur la prise en charge anesthésique traditionnelle. De nouveaux protocoles, mis au point pour protéger les patients et les professionnels de la santé, ont modifié les façons et les cas dans lesquels une anesthésie générale (AG) peut être réalisée en toute sécurité. Afin de réduire l'exposition au virus liée aux interventions génératrices d'aérosols, il est maintenant recommandé d'éviter l'AG lorsque possible et de privilégier l'anesthésie régionale. Dans notre établissement, nous avons observé une récupération postopératoire plus rapide chez les patientes ayant reçu des blocs paravertébraux pour une chirurgie de cancer du sein au lieu d'une AG. Cela nous a menés à évaluer de façon formelle si l'anesthésie régionale au lieu de l'AG avait contribué à réduire les délais jusqu'au congé de l'hôpital. MéTHODE: Nous avons réalisé une étude de cohorte historique afin d'analyser rétrospectivement deux cohortes de patientes : prépandémie vs intrapandémie. Nous avons obtenu l'approbation de notre comité d'éthique institutionnel pour examiner les dossiers de patientes consécutives ayant bénéficié d'une chirurgie de cancer du sein entre le 30 mars 2020 et le 30 juin 2020 (groupe intrapandémie; n = 106) et des patientes consécutives ­ en reculant ­ du 28 février 2020 au 6 décembre 2019 (groupe prépandémie; n = 104). Le critère d'évaluation principal était le délai entre la fin de la chirurgie et le moment où les patientes étaient prêtes à recevoir leur congé de l'hôpital. Les critères d'évaluation secondaires comprenaient l'incidence de nausées et vomissements postopératoires (NVPO), la nécessité d'une analgésie postopératoire et la durée de séjour en salle de réveil (SDR). RéSULTATS: Le délai médian [écart interquartile (ÉIQ)] jusqu'à la disposition au congé de l'hôpital était significativement plus court chez les patientes ayant reçu des blocs paravertébraux pour une chirurgie de cancer du sein plutôt qu'une AG (groupe intrapandémie, 119 [99-170] min vs groupe prépandémie, 191 [164­234] min; P < 0,001), tout comme l'incidence de NVPO (3 % vs 11 %; P = 0,03) et les durées médianes [ÉIQ] de séjour en salle de réveil (29 [21­39] min vs 46 [37­63] min; P < 0,001). CONCLUSION: Les patientes qui ont reçu des blocs paravertébraux pour une chirurgie de cancer du sein dans le groupe intrapandémie étaient prêtes à quitter l'hôpital plus tôt, ont passé moins de temps en salle de réveil et ont ressenti moins de NVPO que celles qui ont reçu une AG dans le groupe prépandémie. Avec des temps d'attente pour accès à la chirurgie de plus en plus longs, des préoccupations liées aux interventions génératrices d'aérosols et les recommandations d'éviter l'AG lorsque possible, les blocs paravertébraux ont offert des avantages aux patientes et aux équipes médicales en tant que principale modalité anesthésique pour la chirurgie de cancer du sein.

Impact of chronic treatment by ß1-adrenergic antagonists on Nociceptive-Level (NOL) index variation after a standardized noxious stimulus under general anesthesia: a cohort study.

During the perioperative period, nociception control is certainly one of the anesthesiologist's main objectives when assuming care of a patient. There exists some literature demonstrating that the nociceptive stimuli experienced during surgery are responsible for peripheral and central sensitization phenomena, which can in turn lead to persistent postsurgical pain. An individualized approach to the evaluation and treatment of perioperative nociception is beneficial in order to avoid the sensitization phenomena that leads to prolonged postoperative pain and to minimize the consumption of opiates and their adverse effects. In terms of sensitivity, specificity, and positive/negative predictive values when compared to heart rate (HR) and mean arterial pressure (MAP), recent literature has shown that the NOL variation (ΔNOL) is the best index to distinguish noxious from non-noxious stimuli. Chronic treatment with ß1-adrenergic antagonists may constitute a limitation to the use of the NOL index. ß1-adrenergic antagonists induce a depressive action on the heart rate, which results in a limitation of its variability after a noxious stimulus. Since heart rate and heart rate variability are two parameters integrated into the NOL index, the validity of the NOL index in a population of patients receiving ß1-adrenergic antagonists has not yet been determined. Our study sought to explore the NOL index, the BIS, and the heart rate variation in a group of patients under chronic treatment with ß1-adrenergic antagonists submitted to standardized noxious stimulus under general anesthesia. We then compared those results to a control group of patients from our previous study (CJA group) that received no ß1-adrenergic antagonist chronic treatment. The patients in this study were subjected to a standardized anesthetic protocol from induction up to 3 min after a standardized tetanic stimulus to the ulnar nerve at a frequency of 100 Hz and an amperage of 70 mA, for a duration of 30 s. Data were electronically recorded to obtain NOL, BIS, and heart rate values every 5 s for the duration of the protocol. The NOL maximal mean value reached after noxious stimulation was not different between our two cohorts (CJA: 30(14) versus BETANOL: 36(14) (p = 0.12)). There was no statistically significant difference between our cohorts in regards of the NOL AUC representing the variation of the NOL over a 180 s period (CJA: 595(356) versus BETANOL: 634(301) (p = 0.30)). However, a repeated measurement ANCOVA identified slight statistically significant differences between our cohorts in the peak of variation of the NOL index between 20 and 65 s after noxious stimulation, the NOL index of the cohort of beta-blocked patients being higher than the CJA patients. Moreover, the time to reach the maximum value was not different (CJA: 73(37) versus BETANOL: 63(41) (p = 0.35)). NOL sensitivity and specificity to detect a noxious stimulus under general anesthesia were similar in patients taking beta-blockers or not, and were better than those of heart rate and Bispectral index (AUC NOL 0.97, CI(0.92-1), versus AUC BIS 0.78, CI(0.64-0.89) and AUC HR 0.66, CI(0.5-0.8)). In conclusion, the NOL index is a reliable monitor to assess nociception in a population of patients under chronic beta-blocker therapy. Patients under such therapy achieve similar maximal NOL values over a 180 s period after a standardized noxious stimulus and the NOL variation over time, represented by the AUC is not significantly different from a cohort of non-beta-blocked patients. Whether the patient takes beta-blockers or not, sensitivity of the NOL index is greater than that seen for BIS index or heart rate to detect an experimental noxious stimulus under general anesthesia.

"Impact of Nociception Level (NOL) index intraoperative guidance of fentanyl administration on opioid consumption, postoperative pain scores and recovery in patients undergoing gynecological laparoscopic surgery. A randomized controlled trial".

STUDY OBJECTIVE: The Nociception Level (NOL) index uses a multiparametric approach to measure the balance between sympathetic and parasympathetic systems activity. Recently, a strong correlation between the NOL index response to nociceptive stimuli and the level of opioid analgesia during surgery was reported. Others observed that intraoperative doses of remifentanil and sufentanil were reduced when the NOL index was used. So far, no study has evaluated the impact of NOL-guided fentanyl antinociception in laparoscopic gynecological surgery. The primary hypothesis of this present study was to evaluate whether intraoperative NOL-guided fentanyl administration would reduce intra-operative opioid consumption. Secondary hypotheses were to assess whether this would lead to lower postoperative opioid consumption and pain scores, as well as improved postoperative outcomes. SETTING: University hospital, operating room. PATIENTS: 70 adult patients, ASA 1-3, scheduled for total laparoscopic hysterectomy. INTERVENTIONS: Patients were randomized into 2 groups: SOC (standardization of care) and NOL (using the NOL index to guide the administration of fentanyl). The depth of anesthesia was monitored with BIS™. Intraoperative fentanyl boluses were administered based on heart rate and mean arterial pressure variations in the SOC group, and NOL index for the NOL group. MEASUREMENTS: Fentanyl total intraoperative dose administered was collected and also averaged per hour. Pain scores and hydromorphone consumption were assessed in the post-anesthesia care unit and up to 24 h. MAIN RESULTS: Sixty-six patients completed the study, 33 in each group. Total intraoperative fentanyl administration was not different between the two groups (217 (70) in the NOL group vs 280 (210) in the SOC group (P = 0.11)). Nevertheless, intraoperative fentanyl administration per hour was reduced by 25% in the NOL-guided group compared to the SOC group: 81 (24) vs 108 (66) µg.h-1, respectively (P = 0.03). Hydromorphone consumption and pain scores in the post-anesthesia care unit and at 24 h were not significantly different between the two groups. CONCLUSION: NOL-guided analgesia allowed for a 22% reduction of the total amount of intraoperative fentanyl which was not significant. Nevertheless, results reported a significant reduction by 25% in the doses of fentanyl averaged per hour of surgery and administered in the NOL-guided group compared with the standardized practice in laparoscopic gynecological surgery. The pain measured postoperatively was similar in the two groups while the average postoperative consumption of opioids to achieve the same level of pain scores in post-anesthesia care unit and at 24 h was not significantly reduced. Further larger multicenter studies centered towards postoperative outcomes are needed.

Face transplantation: anesthesia and other organizational considerations.

In 2005, the first facial vascularized composite allotransplant was performed in France. In May 2018, our team at Maisonneuve-Rosemont Hospital, Montreal, Quebec, had the privilege to participate in the first facial transplant in Canada. Interdisciplinary collaboration, coordination, and communication formed the cornerstone of this medical undertaking and, ultimately, its success. This report details the anesthetic and organizational considerations of our experience.

RéSUMé: En 2005, la première allogreffe de tissu composite vascularisée faciale était réalisée en France. En mai 2018, notre équipe à l'Hôpital Maisonneuve-Rosemont, à Montréal, au Québec, a eu le privilège de participer à la première greffe faciale au Canada. La collaboration, la coordination et la communication interdisciplinaires ont constitué les pierres angulaires de ce projet médical et, ultimement, de son succès. Ce compte-rendu détaille les considérations anesthésiques et organisationnelles de notre expérience.

Comparing the Visual Perception According to the Performance Using the Eye-Tracking Technology in High-Fidelity Simulation Settings.

INTRODUCTION: We used eye-tracking technology to explore the visual perception of clinicians during a high-fidelity simulation scenario. We hypothesized that physicians who were able to successfully manage a critical situation would have a different visual focus compared to those who failed. METHODS: A convenience sample of 18 first-year emergency medicine residents were enrolled voluntarily to participate in a high-fidelity scenario involving a patient in shock with a 3rd degree atrioventricular block. Their performance was rated as pass or fail and depended on the proper use of the pacing unit. Participants were wearing pre-calibrated eye-tracking glasses throughout the 9-min scenario and infrared (IR) markers installed in the simulator were used to define various Areas of Interest (AOI). Total View Duration (TVD) and Time to First Fixation (TFF) by the participants were recorded for each AOI and the results were used to produce heat maps. RESULTS: Twelve residents succeeded while six failed the scenario. The TVD for the AOI containing the pacing unit was significantly shorter (median [quartile]) for those who succeeded compared to the ones who failed (42 [31-52] sec vs. 70 [61-90] sec, p = 0.0097). The TFF for the AOI containing the ECG and vital signs monitor was also shorter for the participants who succeeded than for those who failed (22 [6-28] sec vs. 30 [27-77] sec, p = 0.0182). DISCUSSION: There seemed to be a connection between the gaze pattern of residents in a high-fidelity bradycardia simulation and their performance. The participants who succeeded looked at the monitor earlier (diagnosis). They also spent less time fixating the pacing unit, using it promptly to address the bradycardia. This study suggests that eye-tracking technology could be used to explore how visual perception, a key information-gathering element, is tied to decision-making and clinical performance.

A randomized controlled trial comparing nociception level (NOL) index, blood pressure, and heart rate responses to direct laryngoscopy versus videolaryngoscopy for intubation: the NOLint project.

PURPOSE: The effect of direct laryngoscopy using a Macintosh blade (MAC) vs GlideScope™ videolaryngoscopy using a Spectrum LoPro blade (GVL) on nociceptive stimulation has not been quantitatively studied. This study used the new nociception level (NOL) index to compare the nociceptive response induced by GVL or MAC during laryngoscopy with or without intubation. METHODS: Patients underwent two laryngoscopies at four-minute intervals (L1, L2), one with GVL and the other with MAC (first randomization). A third laryngoscopy (L3) followed by tracheal intubation was performed four minutes after L2 (GVL or MAC, second randomization). Nociception was quantitatively assessed by NOL and standard hemodynamic parameters (heart rate [HR] and mean arterial pressure). For the crossover design, blade comparisons accounted for sequence and blade type. A possible carryover effect between laryngoscopies was assessed. RESULTS: In the 50 patients randomized, there was no carryover effect from one laryngoscopy to the next for all analyzed parameters. Nociception level index peak values were higher with MAC than GVL. Analysis of ΔNOL showed a lower nociceptive response with GVL for L1+L2 combined. Mean peak NOL values were significantly higher after L3+intubation than after L1+L2, for both GVL and MAC groups. Analysis of ΔHR values did not show a significant difference between GVL and MAC for any laryngoscopy. CONCLUSION: Laryngoscopy alone with GVL induces less nociception than with MAC. The NOL was more sensitive than HR at detecting nociceptive responses to MAC vs GVL. Additionally, and irrespective of which technique/blade was used, the combination of laryngoscopy + tracheal intubation produced a much greater nociceptive response than the laryngoscopy alone. TRIAL REGISTRATION: www.clinicaltrials.gov (NCT03277872); registered 29 August 2017.

RéSUMé: OBJECTIF: L'effet de la laryngoscopie directe avec une lame Macintosh (MAC) par rapport à la vidéolaryngoscopie à l'aide d'un GlideScope™ avec lame Spectrum LoPro (GVL) sur la stimulation nociceptive n'a pas été quantitativement étudié. Cette étude a utilisé le nouvel indice de niveau de nociception (NOL) pour comparer la réponse nociceptive induite par une laryngoscopie avec GVL ou MAC avec ou sans intubation. MéTHODE: Les patients ont subi deux laryngoscopies à des intervalles de quatre minutes (L1, L2), l'une par GVL et l'autre par MAC (première randomisation). Une troisième laryngoscopie (L3) suivie d'une intubation trachéale a été effectuée quatre minutes après L2 (GVL ou MAC, deuxième randomisation). La nociception a été quantitativement évaluée à l'aide de l'indice NOL, et les paramètres hémodynamiques standard (fréquence cardiaque [FC] et pression artérielle moyenne) ont été mesurés. Dans le volet croisé de l'étude, les comparaisons de lames ont tenu compte de la séquence et du type de lame. La possibilité d'un effet de persistance entre les laryngoscopies a été évaluée. RéSULTATS: Chez les 50 patients randomisés, il n'y a eu aucun effet de persistance d'une laryngoscopie à la suivante pour tous les paramètres analysés. Les valeurs maximales de l'indice de nociception étaient plus élevées avec les lames MAC qu'avec la vidéolaryngoscopie GVL. L'analyse de ΔNOL a montré une réponse nociceptive inférieure avec la vidéolaryngoscopie GVL pour L1+L2 combinés. Les valeurs maximales moyennes de NOL étaient significativement plus élevées après L3+intubation qu'après L1+L2, tant pour les groupes GVL que MAC. L'analyse des valeurs ΔFC n'a pas montré de différence significative entre les techniques GVL et MAC pour quelque laryngoscopie que ce soit. CONCLUSION: La laryngoscopie seule avec le GlideScope induit moins de nociception qu'avec une lame MAC. L'indice NOL était plus sensible que les FC pour détecter les réponses nociceptives à la laryngoscopie MAC vs GVL. En outre, et indépendamment de la technique/lame utilisée, la combinaison de laryngoscopie + intubation trachéale a produit une réponse nociceptive beaucoup plus importante que la laryngoscopie seule. ENREGISTREMENT DE L'éTUDE: www.clinicaltrials.gov (NCT03277872); enregistrée le 29 août 2017.

Impact of anesthesia management during cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy for the treatment of colorectal peritoneal carcinomatosis on intra- and postoperative outcomes: A systematic review protocol.

BACKGROUND: The impact of the anesthesia management during cytoreductive surgery (CRS) plus hyperthermic intraperitoneal chemotherapy (HIPEC) for the treatment of colorectal peritoneal carcinomatosis (CRPC) on postoperative outcomes might be of major importance in the process of postoperative recovery. It might have a significant impact on intra- and postoperative outcomes, but the evaluation of this impact seems to be under-reported. To investigate the question whether the anesthesia management was reported in previous studies done in this population and if it had any impact on postoperative outcomes, we propose to conduct a systematic review of the published literature. METHODS: For this review, we will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P). Medline/PubMed, Embase, EBM Reviews and the Cochrane Database of Systematic Reviews (CDSR) will be systematically consulted for eligible studies without age, gender, ethnic, and language restriction. The goal of this review will be to assess whether anesthesia monitoring, dosing, and analgesia protocols were reported in this literature on this specific procedure and whether the impact of the anesthesia management on intraoperative safety and postoperative recovery was evaluated. RESULTS: The results of this systematic review will allow to answer the initial question: has the impact of anesthesia management on intraoperative safety and patients' postoperative recovery already been studied and reported in the past for this type of major surgery? And does anesthesia have any impact on postoperative outcomes? DISCUSSION: In the hypothesis that the impact of anesthesia management on patients' postoperative recovery has never been studied, or very little reported in previous studies in this type of major surgery, it would be justified to conduct a randomized controlled trial on this specific objective. REGISTRATION: This systematic review protocol was registered in PROSPERO, under the registration number CRD42019124162.

Actigraphy data in pediatric research: the role of sleep diaries.

BACKGROUND: When assessing children's sleep using actigraphy, researchers usually rely on a sleep diary completed by a parent as an aid in scoring actigraphic data. However, parental nonadherence in completing the sleep diary may significantly reduce the amount of available data. The current study examined the agreement between actigraphic data scored with and without a sleep diary to evaluate the impact of not using a sleep diary when studying children's sleep with actigraphy. METHODS: Sixty children (aged 6-10 years; 36 girls) wore an actigraph for three to seven consecutive nights, and mothers were asked to complete a diary of their child's sleep during the same period. Actigraphy data were scored under two conditions (with and without diary) rated independently for each child by two different research assistants, who each scored 50% of the files in each condition. RESULTS: Group-level analyses and intraclass correlations revealed very strong convergence between the two scoring conditions: on all sleep variables (sleep duration, wake duration, and sleep efficiency), average mean differences were very small and intraclass correlations very high. Bland and Altman's (1999) approach allowed for a child-by-child examination of agreement between the two conditions and revealed that, although they cannot be considered interchangeable, the two conditions produce quite minimal differences in the estimation of sleep variables. CONCLUSIONS: The findings suggest that it is possible to use some actigraphy data for which no corresponding diary data are available, although this approach should be used sparingly.

Sleeping Toward Behavioral Regulation: Relations Between Sleep and Externalizing Symptoms in Toddlers and Preschoolers.

The aim of this study was to investigate the concurrent and longitudinal relations between sleep and externalizing symptoms among young children. Sixty-four families (mostly Caucasian; 36 boys) were met twice, when children were 2 (T1) and 4 years of age (T2). At T1, children wore an actigraph monitor for a 72-hr period, and both mothers and fathers completed the Child Behavior Checklist. At T2, both parents as well as the daycare educator filled the Child Behavior Checklist. At T1, longer sleep duration and higher sleep efficiency were associated with fewer externalizing symptoms as assessed by mothers. Results also indicated that higher sleep efficiency at T1 was related to fewer parent-reported externalizing symptoms at T2 (while controlling for prior externalizing symptoms). Relations between sleep efficiency at T1 and externalizing symptoms as assessed by mothers at T1 and by fathers at T2 were moderated by child sex, such that links were significant among boys only. Results pertaining to educators' reports were inconclusive. The current study highlights the importance of rapidly treating sleep difficulties, which are associated with persistent behavioral maladjustment, perhaps especially for boys.

Viii. Attachment and sleep among toddlers: disentangling attachment security and dependency.

Many scholars have proposed that parent-child attachment security should favor child sleep. Research has yet, however, to provide convincing support for this hypothesis. The current study used objective measures of sleep and attachment to assess the longitudinal links between mother-child attachment security and subsequent sleep, controlling for child dependency. Sixty-two middle-class families (30 girls) were met twice, when children were 15 months (Wave 1; W1) and 2 years of age (Wave 2; W2). At W1, mother-child attachment was assessed with the observer version of the Attachment Q-Sort. At W2, children wore an actigraph monitor for 72 hr. Results indicated that children more securely attached to their mothers subsequently slept more at night and had higher sleep efficiency, and these predictions were not confounded by child dependency. These findings suggest a unique role for secure attachment relationships in the development of young children's sleep regulation, while addressing methodological issues that have long precluded consensus in this literature.

Investigating the Convergence between Actigraphy, Maternal Sleep Diaries, and the Child Behavior Checklist as Measures of Sleep in Toddlers.

The current study examined associations among actigraphy, maternal sleep diaries, and the parent-completed child behavior checklist (CBCL) sleep items. These items are often used as a sleep measure despite their unclear validity with young children. Eighty middle class families (39 girls) drawn from a community sample participated. Children (M = 25.34 months, SD = 1.04) wore an actigraph monitor (Mini-Mitter(®) Actiwatch Actigraph, Respironics) for a 72-h period, and mothers completed a sleep diary during the same period. Eighty-nine percent of the mothers and 75% of the fathers also filled out the CBCL (1.5-5). Mother and father CBCL scores were highly correlated. Overall, good correspondence was found between the CBCL filled out by mothers and sleep efficiency and duration derived from maternal sleep diaries (r between -0.39 and -0.25, p ≤ 0.05). Good correspondence was also found between the CBCL filled out by fathers and sleep efficiency as derived from maternal sleep diaries (r between -0.39 and -0.24, p ≤ 0.05), but not with sleep duration (all results were non-significant). Very few correlations between actigraphy and the CLBL scores reached statistical significance. The Bland and Altman method revealed that sleep diaries and actigraphy showed poor agreement with one another when assessing sleep duration and sleep efficiency. However, diary- and actigraphy-derived sleep durations were significantly correlated. Consistent with findings among older groups of children, this study suggests that the CBCL sleep items, sleep diaries, and actigraphy tap into quite different aspects of sleep among toddlers. The choice of which measures to use should be based on the exact aspects of sleep that one aims to assess. Overall, despite its frequent use, the composite sleep score of the CBCL shows poor links to objective measures of sleep duration and sleep efficiency.

My mother is sensitive, but I am too tired to know: infant sleep as a moderator of prospective relations between maternal sensitivity and infant outcomes.

This study investigated the moderating role of infant sleep in the connections between maternal sensitivity and three indicators of infant functioning: attachment security, theory of mind, and executive functioning (EF). Maternal sensitivity was assessed when infants (27 girls and 36 boys) were 1 year of age. Infant sleep was assessed with actigraphy at age 2; attachment security, theory of mind, and EF were also assessed at age 2. Results indicated that maternal sensitivity was positively related to attachment security only among infants who got more sleep at night, and to conflict-EF and theory of mind only for infants who got greater proportions of their sleep during the night. These results suggest that sleep may enhance the benefits of maternal sensitivity for some aspects of infants' functioning, providing further support for the importance of sleep maturation as a salient developmental task of infancy.