The Visual Scoring of Sleep in Infants 0 to 2 Months of Age

Abstract

In March 2014, the American Academy of Sleep Medicine (AASM) Board of Directors requested the Scoring Manual Editorial Board develop rules, terminology, and technical specifications for scoring sleep/wake states in full-term infants from birth to 2 mo of age, cognizant of the 1971 Anders, Emde, and Parmelee Manual for Scoring Sleep in Newborns. On July 1, 2015, the AASM published rules for scoring sleep in infants, ages 0-2 mo. This evidence-based review summarizes the background information provided to the Scoring Manual Editorial Board to write these rules. The Anders Manual only provided criteria for coding physiological and behavioral state characteristics in polysomnograms (PSG) of infants, leaving specific sleep scoring criteria to the individual investigator. Other infant scoring criteria have been published, none widely accepted or used.The AASM Scoring Manual infant scoring criteria incorporate modern concepts, digital PSG recording techniques, practicalities, and compromises. Important tenets are: (1) sleep/wake should be scored in 30-sec epochs as either wakefulness (W), rapid eye movement, REM (R), nonrapid eye movement, NREM (N) and transitional (T) sleep; (2) an electroencephalographic (EEG) montage that permits adequate display of young infant EEG is: F3-M2, F4-M1, C3-M2, C4-M1, O1-M2, O2-M1; additionally, recording C3-Cz, Cz-C4 help detect early and asynchronous sleep spindles; (3) sleep onsets are more often R sleep until 2-3 mo postterm; (4) drowsiness is best characterized by visual observation (supplemented by later video review); (5) wide open eyes is the most crucial determinant of W; (6) regularity (or irregularity) of respiration is the single most useful PSG characteristic for scoring sleep stages at this age; (7)

Review of sleep-EEG in preterm and term neonates

“…Recently, the American Academy of Sleep Medicine renewed their recommendations for neonatal EEG sleep scoring in infants zero to two months of age [35]. In contrast to what has been reported by other experts in the field [11,17,29,30], they recommend only to score the EEG pattern as discontinuous or continuous rather than identifying EEG patterns according to different sleep states, due to the complexity of the EEG patterns and high variability in scoring among raters.…”

“…5), and a low voltage irregular (LVI) pattern AS 2 (Fig. 6) following QS [29,30,35]. Delta brushes are predominantly occipital in AS 1 whereas AS 2 contains more rapid, lower amplitude theta and alpha activity.…”

“…A regular respiratory rate and no REMs are the most consistent non-cerebral features associated with QS. Chin EMG activity, tonic between QS and low between AS, can be present however this parameter might be absent or unreliable to observe until 48–50 weeks GA [35]. Table 2 summarizes the EEG and non-cerebral features used in literature to score sleep in (near) term neonates [17,29–31,48].…”

“…Significant re-organization of sleep state occurs after 48 weeks GA, with transition from neonatal to infant sleep and change in terminology from AS to REM and QS to NREM [35]. The TA pattern will disappear and will be replaced completely by HVS and midline central sleep spindle activity will appear during NREM.…”

Infants Sleep for Brain

“…Infants born at term average 16 to 18 hours per day sleeping, 50% of it in REM sleep. 2,3 Premature infants spend even more time asleep; 80% of it in REM sleep. The greater time spent sleeping in infancy and early childhood is thought to reflect the crucial role sleep (especially REM sleep) plays in fostering optimal brain development, cognition, and behavior.…”