Infants' Sleep: Israeli Parents' Knowledge, Attitudes and Practices.

The purpose of the study was to assess Israeli parents' knowledge of and attitudes towards practices promoting infants' safe sleep and their compliance with such practices. Researchers visited the homes of 335 parents in 59 different residential locations in Israel and collected their responses to structured questionnaires. SPSS 25 statistical package for data analysis was used. Attitude scales were created after the reliability tests and scaled means of parental attitudes were compared between independent groups differentiated by gender, ethnicity, and parental experience. A logistic regression was run to predict the outcome variable of babies' sleep positions. The total knowledge score was significantly higher for women (56.3%) than for men (28.6%; p < 0.001). Arabs were more committed to following recommendations (29.3%) than Jews (26.9%; p < 0.001). Consistent with safe sleep recommendations, 92% of the sampled parents reported avoiding bedsharing and 89% reported using a firm mattress and fitted sheets. The risk of not placing a baby to sleep in a supine position was higher among older parents (adjusted odds ratio-AOR = 0.36, 95%CI 0.16-0.82), smoking fathers (AOR = 2.66, 95%CI 1.12-6.33), parents who did not trust recommendations (AOR = 4.03, 95%CI 1.84-8.84), parents not committed to following recommendations (AOR = 2.83, 95%CI 1.21-6.60), and parents whose baby slept in their room (AOR = 0.38, 95%CI 0.17-0.88). Knowledge of safe sleep recommendations was not associated with actual parental practices. Trust of and commitment to recommendations were positively correlated with safe sleep position practices. It is essential to develop ethnic-/gender-focused intervention programs.

The Sudden Infant Death Syndrome mechanism of death may be a non-septic hyper-dynamic shock.

BACKGROUND: Sudden Infant Death Syndrome (SIDS) mechanisms of death remains obscured. SIDS' Triple Risk Model assumed coexistence of individual subtle vulnerability, critical developmental period and stressors. Prone sleeping is a major risk factor but provide no clues regarding the mechanism of death. The leading assumed mechanisms of death are either an acute respiratory crisis or arrhythmias but neither one is supported with evidence, hence both are eventually speculations. Postmortem findings do exist but are inconclusive to identify the mechanism of death. WHAT DOES THE PROPOSED HYPOTHESIS BASED ON?: 1. The stressors (suggested by the triple risk model) share a unified compensatory physiological response of decrease in systemic vascular resistant (SVR) to facilitate a compensatory increase in cardiac output (CO). 2. The cardiovascular/cardiorespiratory control of the vulnerable infant during a critical developmental period may be impaired. 3. A severe decrease in SVR is associated with hyper-dynamic state, high output failure and distributive shock. THE HYPOTHESIS: Infant who is exposed to one or more stressors responds normally by decrease in SVR which increases CO. In normal circumstances once the needs are met both SVR and CO are stabilized on a new steady state. The incompetent cardiovascular control of the vulnerable infant fails to stabilize SVR which decreases in an uncontrolled manner. Accordingly CO increases above the needs to hyper-dynamic state, high output heart failure and hyper-dynamic shock. CONCLUSIONS: The proposed hypothesis provides an appropriate alternative to either respiratory crises or arrhythmia though both speculations cannot be entirely excluded.

Management of recurrent sinus disease in children with cystic fibrosis: a combined approach.

OBJECTIVE: To determine whether a combined approach (CA) consisting of functional endoscopic sinus surgery (FESS), Caldwell-Luc operation, and medial maxillectomy is beneficial for children with cystic fibrosis (CF) with refractory sinonasal disease previously treated with endoscopic procedures alone. STUDY DESIGN: Retrospective review and comparison of outcomes of CA and FESS alone for each CF patient. OUTCOMES MEASURED: sinonasal symptoms, endoscopic findings, number of hospitalizations, antibiotic courses, and forced expiratory volume in 1 second (FEV1). SETTING: Referral hospital. RESULTS: Fifteen children underwent CA between 1996 and 2000 (7 males, 8 females; 13.8 years mean age; 42 months average follow-up period). Significant decrease in number of hospitalizations and intravenous antibiotic courses, with increased mean FEV1 (from 70.2% preoperation to 89.3% postoperation, P < 0.0001) were found. Marked clinical improvement persisted for several years. CONCLUSION: Applying the CA after multiple failed endoscopic procedures in CF patients reduced morbidity and resulted in successful management of sinonasal disease. CA is suggested after multiple failed endoscopic procedures. Further studies of CA as a first-line procedure for difficult sinus cases in children with CF is recommended. EBM RATING: C-4.

Endoscopic findings in children with obstructive sleep apnea: effects of age and hypotonia.

Obstructive sleep apnea (OSA) syndrome is a common disorder among children and is often associated with significant morbidity. The causes of OSA are related to either fixed upper airway abnormalities such as adenotonsillar hypertrophy, or dynamic airway abnormalities such as laryngomalacia and pharyngeal wall collapse. The aim of the present study was to determine the prevalence of dynamic upper airway abnormalities, based on endoscopic findings, in normotonic and hypotonic children with polysomnographically documented OSA. The records of 39 consecutive children with OSA who underwent bronchoscopy (22 with normal tone, and 17 with hypotonia) were reviewed. The prevalence of dynamic defects among children with normal tone decreased with age. All 7 patients less than 1 year old had dynamic abnormalities (isolated or combined fixed/dynamic), compared to only 66% (6/9) of patients between 1-2 years old, and 17% (1/6) of children more than 2 years old. In contrast, dynamic abnormalities were very common among hypotonic children, independent of age. Since children with dynamic defects are less likely to respond to surgical treatments, it would be appropriate to identify these children prior to any intervention. Due to the higher frequency of dynamic defects in both infants (< 1 year) and hypotonic children, it may be appropriate to include endoscopy as part of the diagnostic evaluation of OSA in these subgroups.

Indications and outcomes of adenoidectomy in infancy.

Adenoid hypertrophy is one of the most common causes of pediatric obstructive sleep apnea. Although adenoidectomy is the only effective treatment for adenoid hypertrophy, it is rarely performed in infants less than 1 year old. This study reports on the successful use of adenoidectomy in 24 infants less than 1 year old with a triad of upper airway obstruction symptoms, findings of obstructing adenoids, and obstructive sleep apnea (but no other anomalies). This is a retrospective case series reviewing each infant's clinical data, including presenting symptoms (with special emphasis on apnea episodes), physical examination findings, and results of other investigations such as polysomnography, endoscopy, pH-metry, and echocardiography. With careful preoperative and postoperative monitoring, the 24 infants underwent adenoidectomy without complications. After the procedure, all showed marked improvement with complete disappearance of symptoms of upper airway obstruction, failure to thrive, and gastroesophageal reflux disease. Adenoidectomy was found to be sufficient and curative for such infants.

Pharyngeal wall collapse and multiple synchronous airway lesions.

Pharyngeal wall inspiratory collapse (PWIC) is a dynamic obstruction of the air column proximal to the glottis during inspiration. Our objectives were to assess PWIC's incidence and its contribution to the symptoms of upper airway obstruction (UAO), and to propose indications for intervention. In a retrospective review of consecutive endoscopic evaluations and clinical data of 108 infants with UAO, PWIC was diagnosed in 50 infants (46%). The most common presenting symptom was apnea (52%). The PWIC was accompanied by 2 to 7 synchronous airway abnormalities, most frequently laryngomalacia (78%). Generalized hypotonia was the most common associated systemic finding (80%). Severe PWIC cases required bi-level positive airway pressure (BiPAP). The severity of PWIC, measured by a newly developed classification, was positively correlated to apnea (p < .05) and the need for BiPAP (p < .054). Spontaneous recovery occurred within 36 months. The incidence of PWIC among infants with UAO is high, and its role in UAO deserves greater recognition. Better diagnosis of PWIC will improve the treatment of UAO.