Losing sleep influences dietary intake in children: a longitudinal compositional analysis of a randomised crossover trial.

BACKGROUND: Although inadequate sleep increases the risk of obesity in children, the mechanisms remain unclear. The aims of this study were to assess how sleep loss influenced dietary intake in children while accounting for corresponding changes in sedentary time and physical activity; and to investigate how changes in time use related to dietary intake. METHODS: A randomized crossover trial in 105 healthy children (8-12 years) with normal sleep (~ 8-11 h/night) compared sleep extension (asked to turn lights off one hour earlier than usual for one week) and sleep restriction (turn lights off one hour later) conditions, separated by a washout week. 24-h time-use behaviors (sleep, wake after sleep onset, physical activity, sedentary time) were assessed using waist-worn actigraphy and dietary intake using two multiple-pass diet recalls during each intervention week. Longitudinal compositional analysis was undertaken with mixed effects regression models using isometric log ratios of time use variables as exposures and dietary variables as outcomes, and participant as a random effect. RESULTS: Eighty three children (10.2 years, 53% female, 62% healthy weight) had 47.9 (SD 30.1) minutes less sleep during the restriction week but were also awake for 8.5 (21.4) minutes less at night. They spent this extra time awake in the day being more sedentary (+ 31 min) and more active (+ 21 min light physical activity, + 4 min MVPA). After adjusting for all changes in 24-h time use, losing 48 min of sleep was associated with consuming significantly more energy (262 kJ, 95% CI:55,470), all of which was from non-core foods (314 kJ; 43, 638). Increases in sedentary time were related to increased energy intake from non-core foods (177 kJ; 25, 329) whereas increases in MVPA were associated with higher intake from core foods (72 kJ; 7,136). Changes in diet were greater in female participants. CONCLUSION: Loss of sleep was associated with increased energy intake, especially of non-core foods, independent of changes in sedentary time and physical activity. Interventions focusing on improving sleep may be beneficial for improving dietary intake and weight status in children. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ANZCTR ACTRN12618001671257, Registered 10th Oct 2018, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367587&isReview=true.

Infant Sleep Hazards and the Risk of Sudden Unexpected Death in Infancy.

OBJECTIVE: To examine the effects of infant sofa-sleeping, recent use by caregivers of alcohol, cannabis, and/or other drugs, and bed type and pillows, on the risk of sudden unexpected death in infancy (SUDI) in New Zealand. STUDY DESIGN: A nationwide prospective case-control study was implemented between March 2012 and February 2015. Data were collected during interviews with parents/caregivers. "Hazards" were defined as infant exposure to 1 or more of sofa-sleeping and recent use by caregivers of alcohol, cannabis, and other drugs. The interaction of hazards with tobacco smoking in pregnancy and bed sharing, including for very young infants, and the difference in risk for Maori and non-Maori infants, also were assessed. RESULTS: The study enrolled 132 cases and 258 controls. SUDI risk increased with infant sofa-sleeping (imputed aOR [IaOR] 24.22, 95% CI 1.65-356.40) and with hazards (IaOR 3.35, 95% CI 1.40-8.01). The SUDI risk from the combination of tobacco smoking in pregnancy and bed sharing (IaOR 29.0, 95% CI 10.10-83.33) increased with the addition of 1 or more hazards (IaOR 148.24, 95% CI 15.72-1398), and infants younger than 3 months appeared to be at greater risk (IaOR 450.61, 95% CI 26.84-7593.14). CONCLUSIONS: Tobacco smoking in pregnancy and bed sharing remain the greatest SUDI risks for infants and risk increases further in the presence of sofa-sleeping or recent caregiver use of alcohol and/or cannabis and other drugs. Continued implementation of effective, appropriate programs for smoking cessation, safe sleep, and supplying safe sleep beds is required to reduce New Zealand SUDI rates and SUDI disparity among Maori.

The effect of mild sleep deprivation on diet and eating behaviour in children: protocol for the Daily Rest, Eating, and Activity Monitoring (DREAM) randomized cross-over trial.

BACKGROUND: Although insufficient sleep has emerged as a strong, independent risk factor for obesity in children, the mechanisms by which insufficient sleep leads to weight gain are uncertain. Observational research suggests that being tired influences what children eat more than how active they are, but only experimental research can determine causality. Few experimental studies have been undertaken to determine how reductions in sleep duration might affect indices of energy balance in children including food choice, appetite regulation, and sedentary time. The primary aim of this study is to objectively determine whether mild sleep deprivation increases energy intake in the absence of hunger. METHODS: The Daily, Rest, Eating, and Activity Monitoring (DREAM) study is a randomized controlled trial investigating how mild sleep deprivation influences eating behaviour and activity patterns in children using a counterbalanced, cross-over design. One hundred and ten children aged 8-12 years, with normal reported sleep duration of 8-11 h per night will undergo 2 weeks of sleep manipulation; seven nights of sleep restriction by going to bed 1 hr later than usual, and seven nights of sleep extension going to bed 1 hr earlier than usual, separated by a washout week. During each experimental week, 24-h movement behaviours (sleep, physical activity, sedentary behaviour) will be measured via actigraphy; dietary intake and context of eating by multiple 24-h recalls and wearable camera images; and eating behaviours via objective and subjective methods. At the end of each experimental week a feeding experiment will determine energy intake from eating in the absence of hunger. Differences between sleep conditions will be determined to estimate the effects of reducing sleep duration by 1-2 h per night. DISCUSSION: Determining how insufficient sleep predisposes children to weight gain should provide much-needed information for improving interventions for the effective prevention of obesity, thereby decreasing long-term morbidity and healthcare burden. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12618001671257 . Registered 10 October 2018.

Comparison of 12-hour and 24-hour oximetry recordings in preterm infants.

AIM: To compare the overnight 12-hour oximetry component of 24-hour oximetry recordings with the complete 24-h recording in terms of cardiorespiratory status data in preterm infants. METHODS: Preterm infants from the Wellington neonatal intensive care unit underwent a 24-h pulse oximetry recording immediately prior to discharge home. Each recording was edited to resemble a 12-h overnight recording and compared to the full 24-h recording. Differences in a range of cardiorespiratory variables were assessed as to whether they were statistically significant and, if so, likely to be clinically significant. RESULTS: The nadirs for heart rate and SpO2 (both P < 0.001), the time spent <80% SpO2 (P = 0.017) and highest heart rate (P < 0.001) were significantly different between the two recordings. Only the heart rate nadir differed by more than 5%, suggesting that this may be of clinical significance (median (interquartile range) 54 (28-69) for 24-h recording vs. 78 (54-96) for 12-h recording). CONCLUSION: The 24-h oximetry reports were clinically similar to 12-h recordings for the majority of variables, and therefore, we suggest that 12-h oximetry studies are sufficient for determining cardiorespiratory status in infants.

Relationship between parent knowledge of child sleep, and child sleep practices and problems: A pilot study in a children's hospital cohort.

AIM: To describe parent reports of sleep practices, and examine associations with parent knowledge of child sleep, and whether children's sleep practices differ between parents who underestimated, overestimated or accurately estimated children's sleep needs. METHODS: Parents of children aged 2-12 years (n = 115) attending hospital inpatient or day wards were approached and asked to report child sleep routines, sleep problems, parent education, household income and parent knowledge of child sleep via questionnaire. RESULTS: Younger age was associated with earlier bedtimes and wake times, shorter sleep latencies, longer sleep durations and greater sleep problems (P < 0.05). Parents from higher income homes reported earlier bedtimes and wake times, shorter sleep latencies and fewer sleep problems (P < 0.05). Parents with higher education reported shorter sleep latencies (P < 0.05). Parents with greater knowledge about child sleep reported earlier weekday and weekend bedtimes (r s ≥ 0.26) and wake times (r s ≥ 0.21) and greater consistency between their child's weekend and weekday sleep routines (P < 0.05). In comparison with parents who correctly estimated their child's sleep needs: parents who underestimated reported later weekday bedtimes (on average, 46 min), and longer sleep latencies (17 min); parents who overestimated reported longer sleep latencies (22 min). These findings remained significant when controlling for child age (P < 0.05). CONCLUSION: Parents with increased sleep knowledge, higher incomes and higher levels of education were more likely to report earlier bedtimes, wake times and more consistent sleep routines for their children.

Oximetry for preterm infants at neonatal discharge: What is current practice in New Zealand and Australia?

AIM: The aim of the study was to survey level 2 and 3 neonatal units in Australasia to determine the prevalence of oximetry studies at discharge for preterm infants, how these oximetry studies are performed, and which measures are included in an oximetry report. METHODS: A 10-question online survey was created using Survey Monkey regarding use of predischarge oximetry and e-mailed to 46 neonatal units (all level 2 and three units in NZ and all level 3 units in Australia). RESULTS: The response rate was 59% (27/46) with a NZ response rate of 78% (18/23). There was variation in the groups of infants receiving predischarge oximetry studies, with one fifth of responding neonatal units never performing oximetry at discharge. Of the units using predischarge oximetry screening, infants being discharged home on supplemental oxygen were the only group for which all units perform predischarge oximetry. Masimo (Masimo, Irvine, California, USA) is the most common oximeter brand and profox Associates, Inc. (PROFOX Associates, Inc., Escondido, CA 92025, USA) the most common analysis software used. Measures included in oximetry reports vary between units, with profox Associates, Inc.'s default event definition of 'a drop in saturation by four or more' being the most commonly reported desaturation definition. CONCLUSIONS: These findings indicate a need for guidelines to standardise preterm infant oximetry monitoring at neonatal discharge. Further research is required to determine the utility of predischarge oximetry and to establish which infants should be screened.

Sudden unexpected death in infancy: biological mechanisms.

Sudden unexpected death in infancy (SUDI) covers both explained and unexplained deaths. Unexplained cases or SIDS are likely to have multiple neural mechanisms contributing to the final event. The evidence ranges from subtle physiological signs related to autonomic control, to findings at autopsy of altered neurotransmitter systems, including the serotonergic system, a network that has an extensive homeostatic role in cardio-respiratory and thermoregulatory control. Processes may be altered by the vulnerability of the infant due to age, poor motor ability, or a genetic predisposition. The fatal event may occur in response to an environmental stress. A single final physiological route to death seems unlikely. An understanding of the reasons for explained SUDI also reminds us that a thorough investigation is required after each death occurs.

Current definitions for neonatal apnoea: are they evidence based?

Apnoea is defined as cessation of breathing with implicit pathophysiology. This review considers definitions of neonatal apnoea currently available and explores the evidence to support their use. For preterm and term infants, apnoea definitions appear arbitrary, are not supported by guidelines and vary from study to study. Although most alarms on infant breathing monitors are set to alert after a respiratory pause >20s duration is detected, this time period is the equivalent of 17 missed breaths in a preterm infant. Apnoea is likely to be better defined by associated consequence than by pause duration alone in this age group; however, the degree of change in heart rate or oxygen saturation that defines a respiratory pause as pathological is yet to be defined. Further research is required to determine the characteristics that differentiate respiratory events of clinical consequence from normal respiratory variability in term and preterm infants.

Sleep position does not appear to influence the risk of extreme cardiorespiratory events in vulnerable infants.

Implications for practice and research: Extreme cardiorespiratory events can be documented during sleep and are more common in immature preterm infants. The supine sleep position does not appear to decrease the risk of Sudden Infant Death Syndrome (SIDS) by decreasing the risk of extreme cardiorespiratory events in vulnerable infants. Reasons for the physiological advantage of the supine sleep position remain speculative and require ongoing study despite decreases in SIDS death rates in recent years.

Where does the time go when children don't sleep? A randomized crossover study.

OBJECTIVE: This study aimed to describe how mild sleep deprivation in children changes time spent physically active and sedentary. METHODS: In 2018 through 2020, children (n = 105) with normal sleep were randomized to go to bed 1 hour earlier (extension) or 1 hour later (restriction) than their usual bedtime for 1 week, each separated by a 1-week washout. Twenty-four-hour movement behaviors were measured with waist-worn actigraphy and expressed in minutes and proportions (percentages). Mixed-effects regression models determined mean differences in time use (95% CI) between conditions. Time gained from sleep lost that was reallocated to other movement behaviors in the 24-hour day was modeled using regression. RESULTS: Children (n = 96) gained ~49 minutes of awake time when sleep was restricted compared with extended. This time was mostly reallocated to sedentary behavior (28 minutes; 95% CI: 19-37), followed by physical activity (22 minutes; 95% CI: 14-30). When time was expressed as a percentage, the overall composition of movement behavior remained similar across both sleep conditions. CONCLUSIONS: Children were not less physically active when mildly sleep deprived. Time gained from sleeping less was proportionally, rather than preferentially, reallocated to sedentary time and physical activity. These findings suggest that decreased physical activity seems unlikely to explain the association between short sleep and obesity in children.

Effect of Sleep Changes on Health-Related Quality of Life in Healthy Children: A Secondary Analysis of the DREAM Crossover Trial.

Importance: Little is known regarding the effect of poor sleep on health-related quality of life (HRQOL) in healthy children. Objective: To determine the effect of induced mild sleep deprivation on HRQOL in children without major sleep issues. Design, Setting, and Participants: This prespecified secondary analysis focused on HRQOL, a secondary outcome of the Daily Rest, Eating, and Activity Monitoring (DREAM) randomized crossover trial of children who underwent alternating weeks of sleep restriction and sleep extension and a 1-week washout in between. The DREAM trial intervention was administered at participants' homes between October 2018 and March 2020. Participants were 100 children aged 8 to 12 years who lived in Dunedin, New Zealand; had no underlying medical conditions; and had parent- or guardian-reported normal sleep (8-11 hours/night). Data were analyzed between July 4 and September 1, 2022. Interventions: Bedtimes were manipulated to be 1 hour later (sleep restriction) and 1 hour earlier (sleep extension) than usual for 1 week each. Wake times were unchanged. Main Outcomes and Measures: All outcome measures were assessed during both intervention weeks. Sleep timing and duration were assessed using 7-night actigraphy. Children and parents rated the child's sleep disturbances (night) and impairment (day) using the 8-item Pediatric Sleep Disturbance and 8-item Sleep-Related Impairment scales of the Patient-Reported Outcomes Measurement Information System questionnaire. Child-reported HRQOL was assessed using the 27-item KIDSCREEN questionnaire with 5 subscale scores and a total score. Both questionnaires assessed the past 7 days at the end of each intervention week. Data were presented as mean differences and 95% CIs between the sleep restriction and extension weeks and were analyzed using intention to treat and an a priori difference in sleep of at least 30 minutes per night. Results: The final sample comprised 100 children (52 girls [52%]; mean [SD] age, 10.3 [1.4] years). During the sleep restriction week, children went to sleep 64 (95% CI, 58-70) minutes later, and sleep offset (wake time) was 18 (95% CI, 13-24) minutes later, meaning that children received 39 (95% CI, 32-46) minutes less of total sleep per night compared with the sleep extension week in which the total sleep time was 71 (95% CI, 64-78) minutes less in the per-protocol sample analysis. Both parents and children reported significantly less sleep disturbance at night but greater sleep impairment during the day with sleep restriction. Significant standardized reductions in physical well-being (standardized mean difference [SMD], -0.28; 95% CI, -0.49 to -0.08), coping in a school environment (SMD, -0.26; 95% CI, -0.42 to -0.09), and total HRQOL score (SMD, -0.21; 95% CI, -0.34 to -0.08) were reported by children during sleep restriction, with an additional reduction in social and peer support (SMD, -0.24; 95% CI, -0.47 to -0.01) in the per-protocol sample analysis. Conclusions and Relevance: Results of this secondary analysis of the DREAM trial indicated that even 39 minutes less of sleep per night for 1 week significantly reduced several facets of HRQOL in children. This finding shows that ensuring children receive sufficient good-quality sleep is an important child health issue. Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12618001671257.

Predictors for achieving optimal sleep in healthy children: Exploring sleep patterns in a sleep extension trial.

STUDY OBJECTIVES: Earlier bedtimes can help some children get more sleep, but we don't know which children, or what features of their usual sleep patterns could predict success with this approach. Using data from a randomized crossover trial of sleep manipulation, we sought to determine this. METHODS: Participants were 99 children aged 8-12years (49.5% female) with no sleep disturbances. Sleep was measured by actigraphy at baseline and over a restriction or extension week (1 hour later or earlier bedtime respectively), randomly allocated and separated by a washout week. Data were compared between baseline (week 1) and extension weeks only (week 3 or 5), using linear or logistic regression analyses as appropriate, controlling for randomization order. RESULTS: One hour less total sleep time than average at baseline predicted 29.7 minutes (95% CI: 19.4, 40.1) of sleep gained and 3.45 (95% CI: 1.74, 6.81) times higher odds of successfully extending sleep by >30 minutes. Per standardized variable, less total sleep time and a shorter sleep period time were the strongest predictors (significant odds ratios (ORs) of 2.51 and 2.28, respectively). Later sleep offset, more variability in sleep timing and lower sleep efficiency also predicted sleep gains. The sleep period time cut-point that optimized prediction of successful sleep gains was <8 hours 28 minutes with 75% of children's baseline sleep in that range. CONCLUSIONS: Children with a baseline sleep period time <8½ hours a night obtained the most sleep from earlier bedtimes maintained over a week, demonstrating experimentally the value of earlier bedtimes to improve sleep. CLINICAL TRIALS REGISTRY: Australian New Zealand Clinical Trial Registry, ACTRN12618001671257, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367587&isReview=true.

The effect of modest changes in sleep on dietary intake and eating behavior in children: secondary outcomes of a randomized crossover trial.

BACKGROUND: Insufficient sleep duration increases obesity risk in children, but the mechanisms remain unclear. OBJECTIVES: This study seeks to determine how changes in sleep influence energy intake and eating behavior. METHODS: Sleep was experimentally manipulated in a randomized, crossover study in 105 children (8-12 y) who met current sleep guidelines (8-11 h/night). Participants went to bed 1 h earlier (sleep extension condition) and 1 h later (sleep restriction condition) than their usual bedtime for 7 consecutive nights, separated by a 1-wk washout. Sleep was measured via waist-worn actigraphy. Dietary intake (2 24-h recalls/wk), eating behaviors (Child Eating Behavior Questionnaire), and the desire to eat different foods (questionnaire) were measured during or at the end of both sleep conditions. The type of food was classified by the level of processing (NOVA) and as core or noncore (typically energy-dense foods) foods. Data were analyzed according to 'intention to treat' and 'per protocol,' an a priori difference in sleep duration between intervention conditions of ≥30 min. RESULTS: The intention to treat analysis (n = 100) showed a mean difference (95% CI) in daily energy intake of 233 kJ (-42, 509), with significantly more energy from noncore foods (416 kJ; 6.5, 826) during sleep restriction. Differences were magnified in the per-protocol analysis, with differences in daily energy of 361 kJ (20, 702), noncore foods of 504 kJ (25, 984), and ultraprocessed foods of 523 kJ (93, 952). Differences in eating behaviors were also observed, with greater emotional overeating (0.12; 0.01, 0.24) and undereating (0.15; 0.03, 0.27), but not satiety responsiveness (-0.06; -0.17, 0.04) with sleep restriction. CONCLUSIONS: Mild sleep deprivation may play a role in pediatric obesity by increasing caloric intake, particularly from noncore and ultraprocessed foods. Eating in response to emotions rather than perceived hunger may partly explain why children engage in unhealthy dietary behaviors when tired. This trial was registered at Australian New Zealand Clinical Trials Registry; ANZCTR as CTRN12618001671257.

Respiratory events in preterm infants prior to discharge: with and without clinically concerning apnoea.

PURPOSE: This study aimed to determine the characteristics of respiratory events in preterm infants with clinically concerning apnoea at or beyond 35 weeks postmenstrual age and to compare these findings with a group of preterm infants ready for discharge, without clinically concerning apnoea. METHODS: Infants born at <32 weeks of gestation and who underwent nap polysomnography at or beyond 35 weeks corrected age prior to discharge were included. Cases were preterm infants with clinically concerning apnoea, and control infants were preterm infants asymptomatic for apnoea. Infants with upper airway obstruction, congenital malformations or apnoea associated with sepsis were excluded. Studies were retrospectively reviewed for length, type and frequency of apnoea. The relationship between sleep state and changes in oxygen saturation was compared between groups. Peri-natal and demographic data were also compared. RESULTS: Data were complete for 16 case and 18 control infants. Gestational age was similar at birth and at time of study, but cases had a lower birth weight (p = 0.04) and higher weight at study (p = 0.04). There were no group differences in the mean duration, type or numbers of apnoea. The duration of the longest apnoea was greater in case infants (17.4 s vs. 12.3 s, p = 0.02). Lowest oxygen saturation (p < 0.05) and average minimum oxygen saturation (p < 0.05) were lower in case infants. CONCLUSIONS: Preterm infants with clinically concerning apnoea have similar amounts and types of apnoea but lower oxygen saturation after apnoea compared with controls. The use of oxygen saturation monitoring is more useful than respiratory monitoring alone in recognising these events.

Effect of position on oxygen saturation and requirement in convalescent preterm infants.

AIMS: To document the effect of position on oxygen saturation and changes in oxygen requirement in convalescent preterm infants. METHODS: Twelve infants born ≥24 and ≤32 weeks gestation, extubated and without congenital anomaly were studied using nap polysomnography in prone and supine, twice weekly until discharge. Mean oxygen saturation (SpO(2)), minimum SpO(2) , mean minimum SpO(2) and time with SpO(2) < 90% were measured in active sleep. RESULTS: Eight male and four female infants [median gestation 28 (24-31) weeks and median birthweight 1059 (715-1840) g] had 39 studies. For 21 of 39 studies, the infant was on respiratory support. Four infants had chronic lung disease (CLD). SpO(2) varied with postmenstrual age (PMA) (p = 0.003) but not with position (p = 0.36), and PMA did not influence the effect of position on SpO(2) (p = 0.19). SpO(2) was lower for those with CLD (p < 0.0001) and those on respiratory support (p < 0.001), but there was no effect of position (p = 0.97 and p = 0.67, respectively). From 36 weeks PMA, a change to supine did not increase oxygen requirement. CONCLUSION: In preterm infants, PMA and residual respiratory disease have greater effects on oxygenation than position. A supine sleep position is not disadvantageous for preterm infants at discharge.

Obstructive sleep apnea risk factors and symptoms in children with a known parental obstructive sleep apnea diagnosis.

OBJECTIVE: To document symptoms and risk factors of obstructive sleep apnea (OSA) in children who have a parent diagnosed with OSA and compare them to an age and sex matched sample where parents are low risk for OSA. METHODS: We recruited 25 children with a parent diagnosed with OSA (P-OSA) and 29 age and gender matched children from the community whose parents scored low risk for OSA (P-NOSA). Comparisons were made using the OSA-18 questionnaire, anthropometric measurements, and mallampati score. Statistical analysis included t-tests for OSA-18 score and BMI measures and non parametric analysis for mallampati score. OSA-18 domain scores were analysed using T-test and Bonferroni correction for multiple comparisons. RESULTS: Fifty-six percent of the P-OSA group had a mallampati score of III/IV compared to 11% in the P-NOSA sample (p = 0.005). There was a significant difference in BMI between the P-OSA sample (mean ± SD 19.5 ± 5.7 kg/m2) and the P-NOSA sample (16.95 ± 2.08 kg/m2, p = 0.002). Forty-four percent of P-OSA children were found to be either overweight or obese (BMI z-score). None of the P-NOSA children fell into this category. No significant difference was found between the P-OSA and P-NOSA samples on the OSA-18 score (P-OSA 36.5 ± 8.1, P-NOSA 29.2 ± 9.1, p = 0.07). Five children in the P-OSA sample scored >60 but no P-NOSA children scored >60. CONCLUSIONS: This study suggests that children with a parent diagnosed with OSA are more likely to have risk factors of pediatric OSA compared to age and sex matched children of parents without OSA but do not have more symptoms.

Eating in the absence of hunger in children with mild sleep loss: a randomized crossover trial with learning effects.

BACKGROUND: While insufficient sleep duration has emerged as a strong, independent risk factor for obesity, the mechanisms remain unclear. One possibility is greater "eating in the absence of hunger" (EAH) or energy intake beyond the point of satiety, when tired. OBJECTIVE: The aim was to determine whether mild sleep loss increases EAH in children. METHODS: A crossover study was undertaken in 105 healthy children (8-12 y) with normal sleep (∼8-11 h/night). After randomization, children went to bed 1 h earlier (sleep extension) or 1 h later (sleep restriction) than their usual bedtime, over 2 intervention weeks separated by a 1-wk washout. At the end of each intervention week, children underwent an EAH feeding experiment involving a preloading meal until satiation, followed by an ad libitum buffet (of highly palatable snacks) to measure EAH, with each food item weighed before and after consumption. RESULTS: Ninety-three children completed the EAH experiment. There was no evidence of a difference in energy intake from EAH between sleep restriction and extension conditions when analyzed as a crossover design. However, a learning effect was found, with children eating significantly less (-239 kJ; 95% CI: -437, -41 kJ; P = 0.018) during the preload phase and significantly more (181 kJ; 95% CI: 38, 322 kJ; P = 0.013) in the ad libitum phase in the second week. No significant differences were seen using an underpowered parallel analysis for energy intake during the ad libitum phase when sleep deprived (106 kJ; 95% CI: -217, 431 kJ; P = 0.514). CONCLUSIONS: Our findings suggest that measuring a difference in eating behavior in relation to sleep proved unsuitable using the EAH experiment in a crossover design in children, due to a learning effect. This trial was registered at the Australian New Zealand Clinical Trials Registry (http://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367587&isReview=true) as ACTRN12618001671257 .

Simultaneous sudden unexpected death in infancy of twins: case report.

Simultaneous sudden infant death syndrome (SIDS) in twins is an extremely rare event. Some believe these are natural deaths, whereas others suggest they are unnatural. We report monozygotic twins dying at 12 weeks of age. Extensive investigation concluded that the cause of death was natural. Our case fulfilled the criteria of simultaneous SIDS in twins. However, thermal stress due to excessive thermal insulation, use of a pillow and placing twins in the same cot all represent a potentially unsafe sleeping environment. We recommend the term "simultaneous sudden unexpected death in infancy of twins" to describe such cases.

Risk factors for and timing of death of extremely preterm infants.

This study examined risk factors for timing and cause of death for extremely preterm infants > or = 23 weeks and < 28 weeks. There were 479 liveborn infants and 98 deaths reviewed over a ten-year period. Thirty-two deaths (33%) occurred on the first day of life and 72 (75%) in the first month of life. Lower gestation and intrauterine growth restriction were significant risk factors for death. Most deaths occurred in the first month of life and at the lowest gestation in the first week.

The influence of bed-sharing on infant physiology, breastfeeding and behaviour: A systematic review.

This review aimed to better understand the underlying physiology of the risks and benefits of bed-sharing. Eight databases were searched using terms relating to adult-infant/baby, bed-sharing/co-sleeping combined with outcome terms for physiology, sleep, cardiovascular, respiratory, temperature and behaviour. Of 836 papers identified, 59 papers representing 48 cohorts met inclusion criteria. Objective data using various methodologies were available in 27 papers and subjective data in 32 papers. Diverse measures were reported using variable definitions of bed-sharing. Identified physiological and behavioural differences between bed-sharing and cot-sleeping included increased behavioural arousals, warmer in-bed temperatures and increased breastfeeding duration in bedshare infants as well as differences in infant overnight sleep architecture, cardiorespiratory control and cortisol responses to stress. We concluded that many differences are context-specific, and dependent on the subjective view of the parents and their cultural values. Objective risk arises if the infant is unable to mount an appropriate physiological or behavioural response to their micro-environment. More studies in the bed-sharing setting are needed to identify infant risk, the potential benefits of a safer environment, and how bed-sharing interacts with infant care practices other than sleep.