Rosemary S. Horne

Description:Paediatric sleep medicine has rapidly evolved and expanded over the past half century as it became increasingly recognised as a unique field related to but distinct from adult sleep medicine. In looking forward to the next years, the focus of the following discussion is two-fold: to summarise a brief history of the field, recent developments and current trends, and to present a blueprint for the future across various key domains. Using Bronfenbrenner's Ecological Systems Theory as a model for the interaction between the five interconnected ecosystems and sleep in children, we discuss a variety of topics relevant for the present state and future of paediatric sleep medicine. Such topics include the potential effects of climate change and war on children's sleep, the development of public policy initiatives-such as sleep education in schools and in communities, and global efforts to reduce the epidemic of insufficient sleep. Indeed, insufficient sleep contributes to a myriad of negative medical, mental health, functional, and safety consequences. We also focus on the development of paediatric sleep medicine-specific educational initiatives and training programmes, and we showcase professional organisations such as the International Paediatric Sleep Association that are dedicated to the global expansion of paediatric sleep medicine. Finally, we address the need for further interdisciplinary collaborations, identify critical research gaps and explore the potential role of artificial intelligence and other new technologies in paediatric sleep research, including standardisation of sleep measurements, and novel methods of monitoring sleep in children.

Description:Objective: Preterm infants frequently experience short apneas which can occur in isolation or in a repetitive pattern termed periodic breathing. We assessed the consequences of the amount of time spent with short apneas on developmental outcomes at 2 years of age. Methods: Preterm infants (N = 23) born between 28 and 32 weeks gestational age were studied during daytime sleep in the supine position at 32-36 weeks post menstrual age (PMA), 36-40 weeks PMA, 3 months and 6 months corrected age. The percentage of total sleep time (TST) spent with apneas at each study was calculated. Infants were divided into those below and above the median cumulative time spent with apneas over the 4 studies (28.4% TST) and developmental assessments (Bayley Scales of Infant Development III, Early Childhood Behavior Questionnaire, Child Behavior Check List) at 2 years of age were compared with ANCOVA. Results: The above median group tended to have lower unadjusted scores for motor composite, social emotional composite and adaptive behavior composite on the Bayley's. After adjusting for confounders and %TST spent with apneas, the motor composite score was significantly lower in the above median group (p < 0.05). Perceptual Sensitivity was lower in the above median group (p < 0.05). Conclusions: In clinically stable very preterm infants, who had been discharged home with no concerns of respiratory instability, those infants who spent more time with short apneas, particularly periodic breathing, had reduced motor outcomes at 2 years of age. Our findings add to a growing literature suggesting that short apneas and periodic breathing are not benign.

Description:Children with Prader-Willi syndrome are at increased risk of both obstructive and central sleep apnoea. In addition, these children have impaired autonomic control, which may be exacerbated by sleep apnoea. The aim of this study was to compare autonomic control using heart rate variability and nocturnal dipping of heart rate in children with Prader-Willi syndrome and typically developing children. We identified 50 children with Prader-Willi syndrome and matched them for age, obstructive and central apnoea-hypoponea index, body mass index and sex to 50 typically developing children. All children underwent overnight polysomnography. Time and frequency domain heart rate variability were analysed during N2, N3, REM and total sleep, and nocturnal dipping of heart rate from wake was calculated. Children with Prader-Willi syndrome had reduced time domain heart rate variability in REM, reduced low frequency power in N2, higher heart rate in REM and total sleep (p < 0.05 for all) and reduced fall in heart rate from wake to REM (p < 0.05). When stratified into age groups, similar results were found in children ≤ 1 and > 1 ≤ 6 years, with no differences between groups in children > 6 years of age. The significant reduction in LF power and nocturnal dipping indicates children with Prader-Willi syndrome have delayed maturation of autonomic control, particularly below 6 years of age. Investigating the impact of age on heart rate variability longitudinally and treatments such as growth hormone remains to be elucidated.

Description:Children with Down syndrome (DS) have a dampened heart rate (HR) response at obstructive respiratory event termination compared with typically developing children. Whether improving obstructive sleep apnoea (OSA) severity improves the HR response to both obstructive and central events remains unknown. Twenty-four children (3-19 years at baseline) were included. Children were grouped into improved (decrease in obstructive apnoea-hypopnoea index to ≤ 50% of baseline; n = 12; seven treated between studies) and unimproved (n = 12; two treated between studies) 2 years following baseline study. Beat-to-beat HR was averaged 10 s before (pre), during, and the peak after (post) each obstructive and central event during sleep, expressed as percentage change. A total of 1018 obstructive respiratory events were analysed during total sleep; 583 events were analysed at baseline and 435 at follow-up. A total of 330 central events were analysed during total sleep; 164 central events were at baseline and 166 were at follow-up. In the unimproved group, the % change in HR from during the event to post-event was smaller at follow-up for both obstructive (mean 16.8%, 95% CI [17.4%, 20.6%] vs. 22.3% [21.1%, 26.0%] and central events: 15.8% [13.6%, 17.9%] vs. 26.1% [22.4%, 29.9%]; p < 0.05 for both). % change remained unchanged between studies in the improved group. These results suggest that the dampened HR response to respiratory events seen in children with DS worsens over time when OSA does not improve, adding weight to the need for diagnosis and management of OSA in this population.

Description:Respiratory syncytial virus (RSV) is the leading cause of severe acute lower respiratory tract infection (LRTI) in infants and young children, resulting in an estimated 33 million infections annually, >3 million hospitalizations, and >100 000 deaths in children under 5 years globally, with a mortality rate of up to 9% in low-resource countries, which have 99% of the global RSV mortality.1 RSV infection is associated with an increased risk of respiratory failure, admission to the ICU, mechanical ventilation, use of oxygen therapy, and death.2, 3 Severe RSV-LRTI in early childhood increases the risk of long-term respiratory disorders such as repeated wheezing or asthma.4-6 Most children have had serologically proven RSV infection by age 2 years, representing a major healthcare burden.7, 8 RSV epidemics increase health resource utilization (HRU). For example, the early arrivals of the RSV epidemic seasons during 2022 and 2023 overlapped with the coronavirus disease 2019 (COVID-19) and influenza epidemics and resulted in severe pressure and impact on the healthcare systems of multiple countries.9-12 Risk factors such as socio-economic status influence morbidity and mortality from acute RSV infection, with low- and middle-income countries being disproportionately impacted.13 Young age at time of infection is a key risk factor. A systematic analysis of the global burden of RSV mortality found that 45% of the 101 400 RSV-caused deaths in children under 5 years of age occurred in infants during the first 6 months of life and that 3.6% of all deaths among infants 2–6 months of age were caused by RSV.1 Premature infants and infants with underlying disease are at high risk for severe RSV infection; however, most of the RSV burden occurs in previously healthy infants.14, 15 There is therefore a need to protect all infants from RSV infection, which can greatly reduce HRU, thereby reducing pressure on the healthcare system, especially during the RSV epidemic season. RSV infection in infants has been identified as a major global priority, but currently, there are no effective anti-RSV drugs or vaccines licensed for infants. An earlier RSV monoclonal antibody (mAb) product, palivizumab, is available but needs to be given intramuscular monthly and is recommended for only a small proportion of infants with certain underlying medical conditions. A solution to tackle this unmet need for all-infant protection (AIP) against RSV has yet to be widely implemented.16 Recent advances in RSV prevention, including long-acting prophylactic mAbs and maternal RSV vaccination, show significant promise. We are on the cusp of a new era in RSV prevention. Maternal vaccination can protect infants born during or immediately before RSV season, with protection waning after a few months. Real-world evidence has shown that prophylactic mAbs represent an avenue for effectively protecting all infants during their first RSV season.17-19 Pivotal clinical trials and real-world evidence during the first RSV season demonstrated good safety and effectiveness of prophylactic mAbs for preventing LRTIs and associated hospitalizations.19-22 As of June 2024, more than a dozen countries, including the United States, Spain, the United Kingdom, Luxembourg, and Austria, recommend prophylactic mAbs for the prevention of RSV in infants and young children. These evidence-based recommendations are from national immunization technical advisory groups. Countries will conduct evaluations in their immunization programs to ensure the accessibility of prophylactic mAbs for all infants and some young children.23-36 In view of the global burden of RSV disease among infants, in September 2024, the World Health Organization and its Strategic Advisory Group of Experts on Immunization (SAGE) recommended that “all countries introduce passive immunization for the prevention of severe RSV disease in young infants.”37 Thus, all infants are the key target population for protection from RSV-LRTI, and prophylactic mAbs represent the best available preventive measure.