David P. Southall

Fourteen cases of imposed upper airway obstruction.

Imposed upper airway obstruction was diagnosed as the cause of recurrent and severe cyanotic episodes in 14 patients. Episodes started between 0.8 and 33 months of age (median 1.4) and occurred over a period of 0.8 to 20 months (median 3.5). Diagnosis was made by covert video surveillance, instituted after either (a) the observation that episodes began only in the presence of one person, or (b) characteristic findings on physiological recordings, lasting between 12 hours and three weeks, performed in hospital or at home. Surveillance was undertaken for between 15 minutes and 12 days (median 24 hours) and resulted in safety for the patient and psychiatric assessment of the parent: mother (n = 12), father (n = 1), and grandmother (n = 1). These revealed histories of sexual, physical, or emotional abuse (n = 11), self harm (n = 9), factitious illness (n = 7), eating disorder (n = 10), and previous involvement with a psychiatrist (n = 7). Management of the abusing parents is complex, but recognition of their psychosocial characteristics may allow earlier diagnosis. Imposed upper airway obstruction should be considered and excluded by physiological recordings in any infant or young child with recurrent cyanotic episodes. If physiological recordings fail to substantiate a natural cause for episodes, covert video surveillance may be essential to protect the child from further injury or death.

The Relationship between Bradycardia, Apnea, and Hypoxemia in Preterm Infants

ABSTRACT: The pathogenesis of bradycardias in preterm infants is poorly understood. Because their pathogenesis may involve both apnea and hypoxemia, we set out to analyze the proportion of bradycardias that were associated with an apneic pause and/or a fall in arterial oxygen saturation (Sao2), and the temporal sequence of the three phenomena, in overnight tape recordings of Sao2 (Nellcor N100 in beat-to-beat mode), breathing movements, nasal airflow, and ECG in 80 preterm infants at the time of discharge from hospital. A bradycardia was defined as a fall in heart rate of ≥33% from baseline for ≥4 s, an apneic pause as a cessation of breathing movements and/or airflow for ≥4 s, and a desaturation as a fall in Sao2 to ≤80%. A total of 193 bradycardias were found in 46 (58%) of the recordings (median, three per recording; range 1–18). There was a close relationship between bradycardias, apneic pauses, and desaturations: 83% of bradycardias were associated with apneic pauses and 86% with desaturations. Where all three phenomena occurred in combination, the time from the onset of apnea to the onset of the fall in Sao2 was shorter (median interval, 0.8 s; range −4.9-+11.5 s) than that from the onset of apnea to the onset of bradycardia (median, 4.8 s; range −4.0-+14.0 s). Hence, most bradycardias (86%) commenced after the onset of the fall in Sao2. We conclude that bradycardia, apnea, and hypoxemia are closely linked phenomena in preterm infants.

Upper Airway Obstruction With Hypoxaemia And Sleep Disruption In Down Syndrome

Six of 12 children with Down syndrome (DS) tested by means of long‐term tape‐recordings of oxygen saturation, breathing movements and expired CO2 were found to have previously undetected and severe upper airway obstruction during sleep. In five cases the obstruction occurred in the pharynx and in the sixth it was due to bilateral choanal stenosis. When compared with age‐matched controls, overnight tape‐recordings showed episodes of abnormal arterial hypoxaemia and an abnormally elevated end‐tidal CO2. Episodes of obstruction were most marked during sleep associated with a non‐regular breathing pattern. Abnormal episodes of hypoxaemia were associated with continued breathing movements. Sometimes there was no airflow (complete obstruction); at other times airflow continued normally or was reduced in amplitude (partial obstruction). During episodes of partial or complete airway obstruction the inspiratory waveform showed a characteristic shape. These results show sleep‐related upper airway obstruction to be an often undetected complication of DS and all necessary measures should be taken to overcome the obstruction when it reaches the stage of producing abnormal hypoxaemia. Choanal dilatation and tracheostomy were successful in treating two of the children. Tonsillectomy and adenoidectomy were successful for one child, but only of marginal benefit for two others.

Apnoeic episodes induced by smothering: two cases identified by covert video surveillance.

Recurrent cyanotic episodes associated on some occasions with loss of consciousness due to cerebral hypoxia were investigated by long term tape recordings of breathing activity, oxygen saturation, air flow, electrocardiographic activity, and in some cases electroencephalographic activity. In 51 infants and children the mechanisms for the cyanotic episodes were identified (prolonged expiratory apnoea in 45, sleep related airway obstruction in three, seizure induced apnoea in one, behaviour induced apnoea in one). In one child apnoea was suspected as being caused by suffocation (smothering) by the mother. This was confirmed after enlisting the help of the police, who undertook covert video surveillance during cyanotic episodes. Each cyanotic episode was associated with a pattern of disturbance on the multichannel tape recordings which may be pathognomonic of this type of apnoea. A second infant with cyanotic episodes in whom smothering was suspected was referred for similar investigation after the availability of video recordings became established. Maternal smothering was again supported by specific patterns on multichannel tape recordings and confirmed by video surveillance. Diagnosis by video surveillance produces unequivocal evidence in these cases and avoids the need for medical and nursing staff to confront the mother with a possibly incorrect suspicion or in a court of law.

Arterial oxygen saturation in healthy term neonates

Our objective was to determine arterial oxygen saturation as measured by pulse oximetry (SpO2) in healthy term neonates during their first 4 weeks of life. Overnight recordings of SpO2 (Nellcor N200), photoplethysmographic (pulse) wave-forms from the oximeter and breathing movements were performed in 60 term infants. They were studied initially during their 1st week of life (median age 4 days, range 1–7) and then again during their 2nd–4th week (median age 17 days, range 8–27). Median baseline SpO2, measured during regular breathing, was 97.6% (range 92–100) during week 1 versus 98.0% (86.6–100) during week 2–4 (P>0.05). Episodes of desaturation, defined as a fall in SpO2 to ≤80% for ≥4 s, were found in 35% of recordings obtained in week 1 compared to 60% of those obtained in week 2–4 (P<0.01). Their frequency increased from a median of 0 (0–41) per 12 h of recording at the initial recording to 1 (0–165) at follow up (P<0.01). Analysis of the data by week of life showed a peak in desaturation frequency in the 2nd week of life. The infants with extreme values at follow-up (e.g. a baseline SpO2 of 86.6%, 5th percentile 91.9%, or a desaturation frequency of 165 per 12 h of recording, 95th percentile 32) had had values well within the normal range during their initial recording (a baseline SpO2 of 94.4%, or a desaturation frequency of 4). Most of the desaturations in the infants with extreme values were associated with periodic apnoea. These results demonstrate only relatively minor developmental changes in oxygenation in term neonates during the first 4 weeks of life. The clinical significance of outlying values, i.e. a low baseline SpO2 or a high number of episodic desaturations, remains to be determined.ConclusionThese healthy term neonates had values for baseline oxygen saturation and desaturation frequency that were not substantially different from those observed in older infants.

Arterial oxygen saturation in preterm neonates without respiratory failure

To obtain normal data on arterial oxygen saturation as measured by pulse oximetry (SpO2; Nellcor N200), we obtained 12-hour tape recordings of SpO2, photoplethysmographic waveforms, instantaneous pulse rate, and observations of breathing movements on 55 preterm neonates (25 girls) who had been admitted to one of four special care baby units but had no signs of respiratory distress and were breathing room air at 24 hours of age. Their median gestational age at birth was 35 weeks (range, 30 to 36), and their median age at the time of study 1 day (range, 1 to 7). Median baseline SpO2, measured only during regular breathing, was 99.4% (range, 90.7 to 100; 5th percentile, 95.5). Ten recordings (18%) contained a total of 83 episodes of desaturation (defined as a fall in SpO2 to < or = 80% for > or = 4 seconds). The 95th percentile for desaturation frequency was eight per recording. One infant had 55 episodes of desaturation and thus accounted for two thirds of all episodes observed. Only one of the episodes of desaturation in this infant, and none of those in the other nine infants, had been noted clinically, nor had the abnormally low baseline SpO2 (90.7%) in one infant. Baseline SpO2 in these nondistressed preterm neonates was higher than might be expected, given the SpO2 levels currently recommended for preterm infants with respiratory failure. A minority of infants, however, had a low baseline SpO2 or a high frequency of episodes of desaturation, the potential effects of which remain to be determined.

Epidemiology and Pathophysiology of Apnoea of Prematurity

In preterm infants, reliance on the detection of apnoeic pauses and/or bradycardia results in significant amounts of hypoxaemia remaining undetected. In addition, recordings of breathing movements and ECG do not have predictive value for subsequent sudden infant death. In recent years, the ability to continuously monitor and record arterial oxygen saturation (SaO2) has produced important information regarding the mechanisms for respiratory events in the preterm population. Normal data on SaO2 (Nellcor N-200) and breathing movements have been collected in 160 preterm infants. Median baseline SaO2 during regular breathing was 99.5% (range 88.7-100) at the time of discharge from SCBU and 100% (95.3-100) at follow-up 6 weeks later. Episodic desaturations (SaO2 < or = 80% for > or = 4 s) ranged between 0 and 355 episodes per 12-hour recording. In a study of a separate group of 16 preterm infants with recurrent cyanotic episodes of unknown cause, the total number of abnormal hypoxaemic episodes was markedly increased. These hypoxaemic episodes were associated with three breathing pattern: (i) absent breathing movements; (ii) continued breathing movements, but absent airflow, and (iii) continuous airflow and breathing movements. Thus, preterm infants with cyanotic episodes have an increased number of clinically unapparent hypoxaemic episodes, some of which occur with continued breathing and airflow. In another study of 79 patients who had been born preterm and had a history of an apparent life-threatening event, 43 (54%) had abnormal oxygenation on multichannel recordings, including 23% with clinically undetected baseline hypoxaemia.(ABSTRACT TRUNCATED AT 250 WORDS)

The Child-Friendly Healthcare Initiative (CFHI): Healthcare Provision in Accordance With the UN Convention on the Rights of the Child

Objective. Although modern medical technology and treatment regimens in well-resourced countries have improved the survival of sick or injured children, most of the worlds families do not have access to adequate health care. Many hospitals in poorly resourced countries do not have basic water and sanitation, a reliable electricity supply, or even minimal security. The staff, both clinical and nonclinical, are often underpaid and sometimes undervalued by their communities. In many countries there continues to be minimal, if any, pain control, and the indiscriminate use of powerful antibiotics leads to a proliferation of multiresistant pathogens. Even in well-resourced countries, advances in health care have not always been accompanied by commensurate attention to the childs wider well-being and sufficient concerns about their anxieties, fears, and suffering. In accordance with the United Nations Convention on the Rights of the Child,1 the proposals set out in this article aim to develop a system of care that will focus on the physical, psychological, and emotional well-being of children attending health care facilities, particularly as inpatients. Design of the Program. To develop in consultation with local health care professionals and international organizations, globally applicable standards that will help to ensure that practices in hospitals and health centers everywhere respect childrens rights, not only to survival and avoidance of morbidity, but also to their protection from unnecessary suffering and their informed participation in treatment. Child Advocacy International will liase closely with the Department of Child and Adolescent Health and Development of the World Health Organization (WHO) and the United Nations Childrens Fund (UNICEF) in the implementation of the pilot scheme in 6 countries. In hospitals providing maternity and newborn infant care, the program will be closely linked with the Baby Friendly Hospital Initiative of WHO/UNICEF that aims to strengthen support for breastfeeding. United Nations Childrens Fund, United Nations Convention on the Rights of the Child, child protection, breastfeeding, pain control, palliative care, child abuse.

Home event recordings of oxygenation, breathing movements, and heart rate and rhythm in infants with recurrent life-threatening events

For an evaluation of the usefulness of event recording in identifying mechanisms for apparent life-threatening events, 94 infants (median age, 3.1 months; range, 0.5 to 12 months) with a history of two or more apparent life-threatening events of hitherto unknown cause underwent event recording of transcutaneous oxygen pressure, arterial oxygen saturation, (not recorded in all patients), breathing movements, pulse waveforms, electrocardiogram, and instantaneous heart rate. Recordings were triggered by a fall in transcutaneous oxygen pressure to less than 20 mm Hg. During a median duration of event recording of 1.3 months (0.1 to 10 months), 52 events were recorded in 34 patients; 7 of the events had to be excluded because of uninterpretable signals. The following mechanisms were identified in the remaining 30 patients (45 events): a sudden change in skin perfusion but without hypoxemia (6 in 5 patients), hypoxemia induced by an epileptic seizure (6 in 5 patients), hypoxemia induced by suffocation by a parent (4 in 4 patients), and parental fabrication of events and medical history (7 in 6 patients). In the remaining 22 events in 12 patients, the precise mechanism of events could not be identified. Analysis of these as-yet-unexplained events showed prolonged abnormal hypoxemia (a fall in transcutaneous oxygen pressure to between 4 and 18 mm Hg and a fall in arterial oxygen saturation to 5% to 75%), lasting for 40 to 500 seconds in all. Only five of these events involved prolonged (> 20 seconds) apneic pauses, and only four an episode of bradycardia (heart rate < 80 or 60 beats/min). Thus event recording identified various mechanisms of apparent life-threatening events. In the events that remained unexplained, prolonged apneic pauses or episodes of bradycardia were found in only a minority. The identification of hypoxemia therefore may be more relevant to the early detection of these events than the identification of apnea or bradycardia or both. The relevance of these findings with regard to sudden infant death syndrome remains to be determined.

Oxygen saturation during the first 24 hours of life

AIM To determine normative data for arterial oxygen saturation, measured by pulse oximetry (SpO2), in healthy full term infants throughout their first 24 hours of life. METHODS Long term recordings of SpO2, pulse waveform, and breathing movements were made on 90 infants. Recordings were analysed for baseline SpO2, episodes of desaturation (SpO2 ⩽ 80%), apnoeic pauses of ⩾ four seconds, and periodic apnoea (⩾ three apnoeic pauses, each separated by ⩽ 19 breaths). RESULTS Median baseline SpO2 was 98.3% (range 88.7–100). Longitudinal analysis at four hour intervals showed that SpO2 remained stable until 20–24 hours of age, when it became significantly lower (p < 0.03). Episodic desaturations were identified in 23 recordings. Nine prolonged desaturations (SpO2 ⩽ 80% for ⩾ 20 seconds) were identified in six recordings. Four desaturations fell to ⩽ 60%. Periodic apnoea was identified in 60% of recordings. CONCLUSION The range of SpO2 during the first 24 hours of life is similar to that found previously during the first month of life. The clinical significance of the prolonged episodes of desaturation observed justifies further investigation. Key messages During the first day of life, healthy term infants have baseline SpO2 values that are very similar to those of older infants, with a range from 89–100% Four healthy term infants each showed a severe oxygen desaturation; three of these events were not associated with an apnoeic pause Apnoeic pauses, experienced by most of these infants, are rarely associated with a fall in oxygen saturation to ⩽80% Nine infants had 10 apnoeic pauses of ⩾20 seconds, only one of which was associated with a fall in oxygen saturation to ⩽80%