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Preterm infants have immature respiratory control and resulting intermittent hypoxia (IH). The extent of IH after stopping routine caffeine treatment and the potential for reducing IH with extended caffeine treatment are unknown.To determine (1) the frequency of IH in premature infants after discontinuation of routine caffeine treatment and (2) whether extending caffeine treatment to 40 weeks' postmenstrual age (PMA) reduces IH.A prospective randomized clinical study was conducted at 16 neonatal intensive care units in the United States, with an 18-month enrollment period. Preterm infants (32 weeks' gestation) previously treated with caffeine were randomized to extended caffeine treatment or usual care (controls) at a PMA of at least 34 weeks but less than 37 weeks. Continuous pulse oximeter recordings were obtained through 40 weeks' PMA. Oximeter data were analyzed by persons masked to patient group.Continued treatment with caffeine.Number of IH events and seconds with less than 90% hemoglobin oxygen saturation (Sao2) per hour of recording.Our analysis included 95 preterm infants. In control infants, the mean (SD) time at less than 90% Sao2 at 35 and 36 weeks' PMA was 106.3 (89.0) and 100.1 (114.6) s/h, respectively. The number of IH events decreased significantly from 35 to 39 weeks' PMA (P = .01). Extended caffeine treatment reduced the mean time at less than 90% Sao2 by 47% (95% CI, -65% to -20%) to 50.9 (48.1) s/h at 35 weeks and by 45% (95% CI, -74% to -17%) to 49.5 (52.1) s/h at 36 weeks.Substantial IH persists after discontinuation of routine caffeine treatment and progressively decreases with increasing PMA. Extended caffeine treatment decreases IH in premature infants.clinicaltrials.gov Identifier: NCT01875159.

BACKGROUND: Information on causes of death (CODs) for patients with multiple sclerosis (MS) in the United States is sparse and limited by standard categorizations of underlying and immediate CODs on death certificates. Prior research indicated that excess mortality among MS patients was largely due to greater mortality from infectious, cardiovascular, or pulmonary causes. OBJECTIVE: To analyze disease categories in order to gain insight to pathways, which lead directly to death in MS patients. METHODS: Commercially insured MS patients enrolled in the OptumInsight Research database between 1996 and 2009 were matched to non-MS comparators on age/residence at index year and sex. The cause most-directly leading to death from the death certificate, referred to as the "principal" COD, was determined using an algorithm to minimize the selection of either MS or cardiac/pulmonary arrest as the COD. Principal CODs were categorized into MS, cancer, cardiovascular, infectious, suicide, accidental, pulmonary, other, or unknown. Infectious, cardiovascular, and pulmonary CODs were further subcategorized. RESULTS: 30,402 MS patients were matched to 89,818 controls, with mortality rates of 899 and 446 deaths/100,000 person-years, respectively. Excluding MS, differences in mortality rate between MS patients and non-MS comparators were largely attributable to infections, cardiovascular causes, and pulmonary problems. Of the 95 excessive deaths (per 100,000 person-years) related to infectious causes, 41 (43.2%) were due to pulmonary infections and 45 (47.4%) were attributed to sepsis. Of the 46 excessive deaths (per 100,000 person-years) related to pulmonary causes, 27 (58.7%) were due to aspiration. No single diagnostic entity predominated for the 60 excessive deaths (per 100,000 person-years) attributable to cardiac CODs. CONCLUSIONS: The principal COD algorithm improved on other methods of determining COD in MS patients from death certificates. A greater awareness of the common CODs in MS patients will allow physicians to anticipate potential problems and, thereby, improve the care that they provide.

Importance A strong association between infant bed sharing and sudden infant death syndrome or unintentional sleep-related death in infants has been established. Occurrences of unintentional sleep-related deaths among infants appear to be increasing. Objectives To determine the trends and factors associated with infant bed sharing from 1993 through 2010, including the association of physician advice on bed sharing. Design National Infant Sleep Position study conducted with annual telephone surveys. Setting The 48 contiguous states. Participants Nighttime caregivers of infants born within 7 months of each survey administration. Approximately 1000 interviews were completed annually. Main Outcomes and Measures Infant bed sharing as a usual practice. Results Of 18 986 participants, 11.2% reported an infant sharing a bed as a usual practice. Bed sharing increased from 1993 (6.5%) to 2010 (13.5%). Although bed sharing increased significantly among white respondents from 1993 to 2000 ( P P = .48). Black and Hispanic respondents reported an increase in bed sharing throughout the study period, with no difference between the earlier and later periods ( P = .63 and P = .77, respectively). After accounting for the study year, factors associated with increase in infant bed sharing as a usual practice included maternal educational level of less than high school compared with college or greater (adjusted odds ratio, 1.42 [95% CI, 1.12-1.79]); black (3.47 [2.97-4.05]), Hispanic (1.33 [1.10-1.61]), and other (2.46 [2.03-2.97]) maternal race or ethnicity compared with white race; household income of less than $20 000 (1.69 [1.44-1.99]) and $20 000 to $50 000 (1.29 [1.14-1.45]) compared with greater than $50 000; living in the West (1.61 [1.38-1.88]) or the South (1.47 [1.30-1.66]) compared with the Midwest; infants younger than 8 weeks (1.45 [1.21-1.73]) or ages 8 to 15 weeks (1.31 [1.17-1.45]) compared with 16 weeks or older; and being born prematurely compared with full-term (1.41 [1.22-1.62]). Almost 46% of the participants reported talking to a physician about bed sharing. Compared with those who did not receive advice from a physician, those who reported their physicians had a negative attitude were less likely to have the infant share a bed (adjusted odds ratio, 0.66 [95% CI, 0.53-0.82]), whereas a neutral attitude was associated with increased bed sharing (1.38 [1.05-1.80]). Conclusions and Relevance Our finding of a continual increase in bed sharing throughout the study period among black and Hispanic infants suggests that the current American Academy of Pediatrics recommendation about bed sharing is not universally followed. The factors associated with infant bed sharing may be useful in evaluating the impact of a broad intervention to change behavior.

OBJECTIVE: Our purpose was to evaluate the impact of home uterine activity monitoring on pregnancy outcomes among women at high risk for preterm labor and delivery. STUDY DESIGN: Women at high risk for preterm labor at three centers were randomly assigned to receive high-risk prenatal care alone (not monitored) or to receive the same care with twice-daily home uterine activity monitoring without increased nursing support (monitored). There were 339 women with singleton gestations randomized with caregivers blinded to group assignment. The two groups were medically and demographically similar at entry into the study. RESULTS: Women in the monitored group had prolonged pregnancy survival ( p = 0.02) and were less likely to experience a preterm delivery (relative risk 0.59; p = 0.04). Infants born to monitored women with singleton gestations were less likely to be of low birth weight ( p = 0.003), and were less likely to be admitted to a neonatal intensive care unit (relative risk 0.5, p = 0.01). CONCLUSION: These data show, among women with singleton gestations at high risk for preterm delivery, that the use of home uterine activity monitoring alone, without additional intensive nursing care, results in improved pregnancy outcomes, including prolonged gestation, decreased risk for preterm delivery, larger-birth-weight infants, and a decreased need for neonatal intensive care. (Am J Obstet Gynecol 1996;175:1281-5.)

Objectives: Documented monitoring was used to evaluate prospectively (1) the level of compliance among infants in whom cardiorespiratory monitoring was clinically indicated and (2) factors that might influence compliance: diagnosis, socioeconomic status, maternal age and education, and alarms. Study design: Sixty-seven infants (51% female, 49% term) were sequentially enrolled, and monitoring was prescribed for the following indications: siblings of sudden infant death syndrome victims (16%), apnea of prematurity (45%), and apparent life-threatening events or apnea of infancy (39%). Demographic data, alarm and event data, and a summary report of monitor use from the first monitor download were obtained. Results: Maternal age, education, and insurance status did not differ significantly by indication for monitoring. The median number of monitor alarms per 10 hours of use was 0.7 for apnea or bradycardia and 0.6 for loose lead alarms. Monitors were available for use in the home from 2 to 106 days (median, 11 days). Median hours of monitor use per full day in the home was 15.5 hours. Of 67 infants, 58 used the monitor for at least part of every day in the home. The number of hours of monitor use per day did not differ significantly by diagnostic category, chronologic age, alarms, maternal age, education, or insurance type. This study population of infants at increased risk of sudden infant death syndrome had excellent compliance; 75% of the infants were monitored more than 10.5 hours per day, and 25% were monitored more than 21 hours per day. Conclusions: Documented monitoring provides an objective measure of compliance. These data provide a potential goal for level of compliance with home cardiorespiratory monitoring. (J PEDIATR 1995;127:384-8)

Objective. To test the hypothesis that the occurrence of a neonatal cry exhibiting a high first formant is a risk factor for sudden infant death syndrome (SIDS) and to evaluate the association between SIDS and other acoustic cry variables. Method. We recorded cries and obtained medical and demographic data for 21 880 apparently healthy term newborns. Two cries were recorded between days 2 and 7 of life, after a painful stimulus at the time of routine blood drawing. Acoustic variables were measured with an automated computer-based analysis system. Twelve infants died of SIDS. Age at death ranged from 19 days to 6.5 months. Autopsies were performed in all cases. At least one cry was analyzed for all 12 infants who died of SIDS and 20 167 infants without SIDS. Two cries were analyzed for 9 infants who died of SIDS and 14 235 infants without SIDS. Results. Newborns whose first cries exhibited a high first formant were more likely to die of SIDS than infants whose first cries did not have this characteristic (relative risk, 3.5; 95% confidence interval [CI] 1.1 to 12). The relative risk for SIDS increased to 8.8 (95% CI, 2.2 to 35) for newborns whose second cries showed that this characteristic persisted. Newborns with the combination of both a high first formant and a high number of mode changes on both of two cries had a relative risk of 32 (95% CI, 8.7 to 120). Conclusions. We have shown an association between alterations in neonatal cry acoustics and SIDS. Cry analysis represents a potentially important research tool that, when studied in relation to other physiologic measures, may lead to an improved understanding of SIDS.

Objectives: To determine the relationship between the advice mothers receive about infant sleep position and the actual position they place their infants in to sleep and to understand modifiers of that relationship, especially beliefs about infant comfort and safety. Design: Cross-sectional, face-to-face interviews. Setting: Women, Infants, and Children centers in the United States from 2006 to 2008. Participants: A t otal o f 2 299 p redominantly African American mothers of infants younger than 8 months. Main Exposure: Advice received and beliefs about infant sleep position. Outcome Measure: Usually supine infant sleep position. Results: Advice for exclusively supine infant sleep position from family (OR, 1.6; 95% CI, 1.17-2.17), doctors (OR, 2.28; 95% CI, 1.77-2.93), nurses (OR, 1.46; 95% CI, 1.151.84), or the media (OR, 1.54; 95% CI, 1.22-1.95) was associated with usually placing an infant supine to sleep. Additional sources of advice for exclusively supine position significantly increase the odds that an infant will be placed supine. Mothers who believe an infant is comfortable supine are more likely to place their infants on their backs to sleep (OR, 4.05; 95% CI, 2.51-6.53). Mothers who believe an infant will choke on its back are less likely to place their infants supine (OR, 0.36; 95% CI, 0.24-0.54). Conclusion: Among predominantly African American mothers, increasing advice for exclusively supine sleep and addressing concerns about infant comfort and choking remain critical to getting more infants on their back to sleep.

As part of a large, multicenter study of newborn cry analysis and Sudden Infant Death Syndrome, we examined the effects of in utero cocaine exposure on ten acoustical cry characteristics. Newborn cry recording and medical record review was performed for 23 948 newborns. Cocaine use during pregnancy (determined by record review) was identified in 438 (1.8%) women (310 by self-report only; 128 newborns also had positive urine assay). A demographically similar group of 373 newborns, selected from the 23 510 newborns without known cocaine exposure, made up the comparison group. Cry analysis was technically possible for 768 recordings: 404 cocaine-exposed and 364 non-exposed controls. Comparison of cocaine-exposed vs control newborns, after adjustment for potential confounding variables, found significant differences including: fewer cry utterances (P = .001), more short cries (P = .02), and less crying in the hyperphonation mode (P = .01), for the cocaine-exposed neonates. As reported in other studies, cocaine-exposed newborns also were significantly lower in birth weight, length, and head circumference. Newborns who had positive urine tests for cocaine suffered the greatest effects on both cry and growth parameters. These findings suggest a pattern of underaroused neurobehavioral function and are consistent with the emerging picture of the adverse neurobehavioral effects of cocaine. Developmental outcome studies are in progress to determine if acoustical analysis of the newborn cry can be used to identify cocaine-exposed newborns who are at highest risk for poor outcome.

To determine trends and factors associated with choice of infant sleeping position.Annual nationally representative telephone surveys from 1993 through 2007.Forty-eight contiguous states of the United States.Nighttime caregivers of infants born within the last 7 months; approximately 1000 interviews were given each year. Main Outcome Measure Whether infant is usually placed supine to sleep.For the 15-year period, supine sleep increased (P.001) and prone sleep decreased (P.001) for all infants, with no significant difference in trend by race. Since 2001, a plateau has been reached for all races. Factors associated with increased supine sleep between 1993 and 2007 included time, maternal race other than African American, higher maternal educational level, not living in Southern states, first-born infant, and full-term infant. The effect of these variables was reduced when variables related to maternal concerns about infant comfort, choking, and advice from physicians were taken into account. Between 2003 and 2007, there was no significant yearly increase in supine sleep. Choice of sleep position could be explained almost entirely by caregiver concern about comfort, choking, and advice. Race no longer was a significant predictor.Since 2001, supine sleep has reached a plateau, and there continue to be racial disparities. There have been changes in factors associated with sleep position, and maternal attitudes about issues such as comfort and choking may account for much of the racial disparity in practice. To decrease sudden infant death syndrome rates, we must ensure that public health measures reach the populations at risk and include messages that address concerns about infant comfort and choking.

Reliability of classification performance is important for many biomedical applications. A classification model which considers reliability in the development of the model such that unreliable segments are rejected would be useful, particularly, in large biomedical data sets. This approach is demonstrated in the development of a technique to reliably determine sleep and wake using only the electrocardiogram (ECG) of infants. Typically, sleep state scoring is a time consuming task in which sleep states are manually derived from many physiological signals. The method was tested with simultaneous 8-h ECG and polysomnogram (PSG) determined sleep scores from 190 infants enrolled in the collaborative home infant monitoring evaluation (CHIME) study. Learning vector quantization (LVQ) neural network, multilayer perceptron (MLP) neural network, and support vector machines (SVMs) are tested as the classifiers. After systematic rejection of difficult to classify segments, the models can achieve 85%-87% correct classification while rejecting only 30% of the data. This corresponds to a Kappa statistic of 0.65-0.68. With rejection, accuracy improves by about 8% over a model without rejection. Additionally, the impact of the PSG scored indeterminate state epochs is analyzed. The advantages of a reliable sleep/wake classifier based only on ECG include high accuracy, simplicity of use, and low intrusiveness. Reliability of the classification can be built directly in the model, such that unreliable segments are rejected.

In 1,079 infants monitored for700,000 hr at home for apnea or bradycardia, we found an association between infants having multiple events exceeding conventional or a priori defined more extreme thresholds and less favorable developmental outcome at 1 year of age than infants with few or no events. If it is necessary to prevent such events to minimize risk for developmental morbidity, there is reason to determine whether there are disturbances in advance of the apnea or bradycardia that herald their onset. In the 85 infants with at least 1 extreme event and 1 conventional event, we hypothesized that apnea and bradycardia do not occur de novo but rather are preceded by cardiorespiratory and hemoglobin O2 saturation changes. We compared recorded time intervals preceding these events, and we analyzed three preceding time intervals for each conventional and extreme event, and each non-event recording: Time-2 hr: up to 2 hr before; Time-1 hr: up to 1 hr before; and Time-75 sec: the 75 sec immediately preceding each event. O2 saturation progressively decreased preceding both conventional and extreme events, and progressive increases occurred in heart and breathing rate variability. Duration of respiratory pauses and of periodic breathing progressively increased preceding conventional events, respiratory rate variability increased immediately preceding conventional events and at 1 hr preceding extreme events, and O2 saturation decreased immediately preceding both conventional and extreme events. Thus, conventional and extreme events do not occur de novo but rather are preceded by autonomic instability of the cardiorespiratory system.

Background Anemia, which is common in the critically ill, is often treated with red-cell transfusions, which are associated with poor clinical outcomes. We hypothesized that therapy with recombinant human erythropoietin (epoetin alfa) might reduce the need for red-cell transfusions. Methods In this prospective, randomized, placebo-controlled trial, we enrolled 1460 medical, surgical, or trauma patients between 48 and 96 hours after admission to the intensive care unit. Epoetin alfa (40,000 U) or placebo was administered weekly, for a maximum of 3 weeks; patients were followed for 140 days. The primary end point was the percentage of patients who received a red-cell transfusion. Secondary end points were the number of red-cell units transfused, mortality, and the change in hemoglobin concentration from baseline. Results As compared with the use of placebo, epoetin alfa therapy did not result in a decrease in either the number of patients who received a red-cell transfusion (relative risk for the epoetin alfa group vs. the placebo group, 0.95; 95% confidence interval [CI], 0.85 to 1.06) or the mean (±SD) number of red-cell units transfused (4.5±4.6 units in the epoetin alfa group and 4.3±4.8 units in the placebo group, P = 0.42). However, the hemoglobin concentration at day 29 increased more in the epoetin alfa group than in the placebo group (1.6±2.0 g per deciliter vs. 1.2±1.8 g per deciliter, P

Heart rate, heart rate variability (HRV), and sleep state are some of the common physiologic parameters used in studies of infants. HRV is easily derived from infant electrocardiograms (ECG), but sleep state scoring is a time consuming task using many physiological signals. We propose a technique to reliably determine sleep and wake using only the ECG. The method would be tested with simultaneous ECG and polysomnograph (PSG) determined sleep scores from the Collaborative Home Infant Monitoring Evaluation (CHIME) study. The advantages include high accuracy, simplicity of use, and low intrusiveness, with design including rejection to increase reliability valuable for determining sleep-wake states in highly sensitive groups such as infants. Learning vector quantization and multi-layer perceptron (MLP) neural networks are tested as the predictors. The manual PSG scored test set has 38,121 (67.8%) sleep and 18,076 (32.2%) wake epochs for a total of 56,197 epochs. The MLP classification of the entire test set resulted in 77.7% agreement with the PSG sleep epochs and 79.0% with wake. The rejection scheme applied to the MLP resulted in 28.9% of sleep and wake epochs meeting the rejection criterion. Of the remaining 39,946 epochs 86.0% are in agreement with the PSG sleep epochs and 85.4% with wake. After systematic rejection of difficult to classify segments, this model can achieve 85%-86% correct classification while rejecting only 30% of the data. This is an improvement of about 7.8% over a traditional model without rejection

STUDY OBJECTIVE: To examine (1) sleep architecture of infants at varied risk for sudden infant death syndrome, (2) delays or advances in preterm infants at term postmenstrual age, (3) whether ventilatory support and gestational age alter sleep, (4) whether steroids alter sleep, (5) confounding influences of sex, small for gestational age, and maternal smoking. DESIGN: Overnight polysomnography. DEPENDENT VARIABLES: Percentage of active sleep, quiet sleep, indeterminate, and awake time per total recording time; mean and longest duration of state epochs; number of episodes > or = 10 minutes; and sleep efficiency. SETTING: Collaborative Home Infant Monitoring Evaluation (CHIME). PARTICIPANTS: Two hundred one preterm and 198 term infants between 33 and 58 weeks postmenstrual age during polysomnography. Fifty-one term infants with an apparent life-threatening event without known etiology (apnea of infancy), 59 subsequent siblings of babies who died of sudden infant death syndrome, and 88 healthy term infants. RESULTS: Tracings of infants with apnea of infancy and healthy term infants were similar. Subsequent siblings of babies who died of sudden infant death syndrome spent less time in quiet sleep. Preterm infants (< or = 37 weeks postmenstrual age) exhibited immature architecture compared with infants of term postmenstrual age. The latter exhibited similar sleep except that they had a lower percentage of quiet sleep and longer mean indeterminate and longest indeterminate episodes. Preterm infants with the youngest gestational age lagged behind older preterm infants. Neither sex nor use of steroids affected sleep. Assisted ventilation was associated with a delay in maturation, small-for-gestational age status with increased active sleep, and smoking with increased awake time. CONCLUSION: With few exceptions, asymptomatic premature infants do not exhibit significant delays in sleep architecture compared with term infants at comparable postmenstrual age. The preterm infant with an early gestational age and morbidity exhibited delayed sleep architecture.

Objective. Sleep-disordered breathing (SDB) in children is reportedly associated with problem behaviors suggestive of attention-deficit/hyperactivity disorder; however, there are few data on the relation of SDB to problem behaviors in the general pediatric population. The goal of this study was to assess the prevalence of SDB symptoms in 5-year-old children and their relation to sleepiness and problem behaviors.Methods. A population-based, cross-sectional survey was conducted of a birth cohort of children who were born in eastern Massachusetts. Subjects were 3019 5-year-old children (1551 boys, 1468 girls) who were enrolled in the Infant Care Practices Study and whose mothers were contacted within 3 months of their child’s fifth birthday. A parent-completed questionnaire was used to ascertain the presence and intensity of snoring and other SDB symptoms and the presence of daytime sleepiness and problem behaviors. Parent-reported hyperactivity, inattention, and aggressiveness were each assessed by a single question that was validated against the Conners’ Parent Rating Scale. SDB was defined as frequent or loud snoring; trouble breathing or loud, noisy breathing during sleep; or witnessed sleep apnea.Results. Parent-reported hyperactivity (19%) and inattention (18%) were common, with aggressiveness (12%) and daytime sleepiness (10%) reported somewhat less often. SDB symptoms were present in 744 (25%) children. Compared with children without snoring or other symptoms of SDB, children with SDB symptoms were significantly more likely to have parent-reported daytime sleepiness (odds ratio [OR]: 2.2; 95% confidence interval [CI]: 1.7–2.8) and problem behaviors, including hyperactivity (OR: 2.5; CI: 2.0–3.0), inattention (OR: 2.1; 95% CI: 1.7–2.6), and aggressiveness (OR: 2.1; 95% CI: 1.6–2.6). These associations remained significant after adjustment for sex, race/ethnicity, maternal education level, maternal marital status, household income, and respiratory health history.Conclusions. SDB symptoms are common in 5-year-old children and are associated with an increased risk of daytime sleepiness and with problem behaviors suggestive of attention-deficit/hyperactivity disorder.

Objective: Otitis media (OM) is an extremely common pediatric diagnosis. Several risk factors have been associated with OM, but the relationship between OM and race/ethnicity remains controversial. We sought to define the relationship between OM diagnosis and race/ethnicity in infants. Methods: By multivariable logistic regression, we evaluated the association between OM diagnosis and race/ethnicity in 11,349 non-low-birthweight infants who were participants in a prospective cohort study of infant care practices. Results: As in previous studies, breastfeeding was associated with a decreased risk of OM diagnosis while other factors were independently associated with a substantially increased risk of OM diagnosis: out-of-home daycare, multiple children living in the home, and mother’s multiparity. Daycare was associated with a “dose effect” in that the risk of OM diagnosis increased with an increasing number of children in the daycare. While the crude analysis suggested little relation of OM diagnosis and race/ethnicity, the association was confounded by several covariates including maternal marital status, number of children living in the home, breastfeeding status, and maternal age. After adjustment for relevant confounders, Black (OR 0.74; 95% CI 0.61–0.89) and Asian infants (OR 0.77; 95% CI 0.57–1.0]) were less likely to be diagnosed with OM than White infants. Conclusions: This large prospective study confirms previous risk factors for OM and demonstrates a strong “dose effect” of the size of daycare centers on OM. The study also demonstrates that the association between race/ethnicity and OM diagnosis is confounded by social factors. After adjusting for such factors, Black and Asian infants are less likely to be diagnosed with OM than White infants. The reason for this racial disparity remains unknown.

The relationship between heart rate variability (HRV) parameters is unclear and the optimum parameters to use for clinical application are not known. To address this problem, adult data are only available for a few of the numerous HRV parameters, and few data are available for infants. The purpose of this paper is to study the correlation of common HRV measurements for infants. Eight-hour polysomnogram recordings for 110 infants from the CHIME study are used to calculate HRV parameters for non-overlapping, successive 5 minute segments in the same sleep slates. For each pair of HRV parameters in each sleep state, Pearson's correlation coefficient is computed for each individual and the bootstrap method is applied to calculate correlation for all infants. Results show high correlations between parameters where expected within and across domains. Some differences are noted compared to adult data.

Objectives. To describe sleep positions among low birth weight infants, variations in sleep position according to birth weight, and changes in sleep position over time. To analyze risk factors and influences associated with prone sleep.Design. Prospective cohort study.Setting. Massachusetts and Ohio, 1995–1998.Study Participants. Mothers of 907 low birth weight infants.Results. At 1, 3, and 6 months after hospital discharge, the prevalence of prone sleeping was 15.5%, 26.8%, and 28.3%, respectively. The corresponding rates for supine sleeping were 23.8%, 37.9%, and 50.2% and for side sleeping were 57.3%, 32.4%, and 20.6%. Very low birth weight (VLBW) infants (Conclusions. Prone sleep decreased among low birth weight infants from 1995 to 1998. However, VLBW infants, who are at very high risk for sudden infant death syndrome, are more likely to sleep prone than larger low birth weight infants.

Objective. Prone sleeping among infants has been associated with an increased risk of sudden infant death syndrome. The objective of this study was to compare factors associated with sleep position in 1995–1996 and 1997–1998 and to assess secular trends in use of prone infant sleep position from 1995 through 1998 among families stratified by race and education.Methods. A prospective cohort study was conducted in eastern Massachusetts and northwest Ohio of 12 029 mothers of infants who weighed ≥2500 g at birth. Descriptive statistics and multivariate odds ratios were used to relate maternal and infant characteristics to prone and supine sleeping.Results. A total of 14 206 mothers (25% of those eligible) were enrolled. A total of 12 029 mothers (85% of enrolled) responded to the 1-month and 11 552 mothers (81% of enrolled) responded to the 3-month follow-up questionnaire. A decline in use of the prone sleep position and increase in use of the supine position was observed during the 4 years of the study. Factors associated with prone and supine sleep position were similar in 1995–1996 and 1997–1998. In 1997–1998, use of prone sleeping at 1 month of age reached the goal of ≤10% only among infants of white and Asian women, married women, women who were older than 25 years, women who were college graduates, and women with incomes >$55 000 per year. At 3 months of age, however, prone sleeping increased to 12% to 17% in these groups. These same groups were most likely to use the supine position; 38% to 45% were supine at 1 month, increasing to 56% to 64% by 3 months of age. However, as of the end of 1998, approximately 27% of infants of non-college-educated black and Hispanic mothers were placed to sleep in the prone position and only 20% to 30% were being placed to sleep in the supine position at 3 months of age.Conclusions. Recommendations to avoid prone sleep position and especially the recommendation that supine sleep position is preferred have not been effectively delivered to black and Hispanic families and to families of low-income and less than a college education.

Infants at low and increased risk for sudden infant death syndrome (SIDS) from five clinical centers in the United States are being studied at home using a cardiorespiratory monitor that stores physiologic data surrounding detected events and normative data unrelated to events. The monitor records breathing waveforms by inductance plethysmography (IP), and transthoracic impedance (TTT), ECG, beat-beat heart rate, hemoglobin oxygen saturation, and times of monitor use. Comparisons with simultaneously recorded overnight polysomnograms (PSG) in hospital validated the ability of this device to detect cardiorespiratory events including upper airway obstruction. Parental compliance in using this complicated instrument is slightly lower than that reported for conventional home cardiorespiratory monitors.

Infant arousal scoring based on the Atlas Task Force definition of transient EEG arousal was evaluated to determine (1). whether transient arousals can be identified and assessed reliably in infants and (2). whether arousal and no-arousal epochs scored previously by trained raters can be validated reliably by independent sleep experts. Phase I for inter- and intrarater reliability scoring was based on two datasets of sleep epochs selected randomly from nocturnal polysomnograms of healthy full-term, preterm, idiopathic apparent life-threatening event cases, and siblings of Sudden Infant Death Syndrome infants of 35 to 64 weeks postconceptional age. After training, test set 1 reliability was assessed and discrepancies identified. After retraining, test set 2 was scored by the same raters to determine interrater reliability. Later, three raters from the trained group rescored test set 2 to assess inter- and intrarater reliabilities. Interrater and intrarater reliability kappa's, with 95% confidence intervals, ranged from substantial to almost perfect levels of agreement. Interrater reliabilities for spontaneous arousals were initially moderate and then substantial. During the validation phase, 315 previously scored epochs were presented to four sleep experts to rate as containing arousal or no-arousal events. Interrater expert agreements were diverse and considered as noninterpretable. Concordance in sleep experts' agreements, based on identification of the previously sampled arousal and no-arousal epochs, was used as a secondary evaluative technique. Results showed agreement by two or more experts on 86% of the Collaborative Home Infant Monitoring Evaluation Study arousal scored events. Conversely, only 1% of the Collaborative Home Infant Monitoring Evaluation Study-scored no-arousal epochs were rated as an arousal. In summary, this study presents an empirically tested model with procedures and criteria for attaining improved reliability in transient EEG arousal assessments in infants using the modified Atlas Task Force standards. With training based on specific criteria, substantial inter- and intrarater agreement in identifying infant arousals was demonstrated. Corroborative validation results were too disparate for meaningful interpretation. Alternate evaluation based on concordance agreements supports reliance on infant EEG criteria for assessment. Results mandate additional confirmatory validation studies with specific training on infant EEG arousal assessment criteria.

ContextHome monitors designed to identify cardiorespiratory events are frequently used in infants at increased risk for sudden infant death syndrome (SIDS), but the efficacy of such devices for this use is unproven.ObjectiveTo test the hypothesis that preterm infants, siblings of infants who died of SIDS, and infants who have experienced an idiopathic, apparent life-threatening event have a greater risk of cardiorespiratory events than healthy term infants.DesignLongitudinal cohort study conducted from May 1994 through February 1998.SettingFive metropolitan medical centers in the United States.ParticipantsA total of 1079 infants (classified as healthy term infants and 6 groups of those at risk for SIDS) who, during the first 6 months after birth, were observed with home cardiorespiratory monitors using respiratory inductance plethysmography to detect apnea and obstructed breathing.Main Outcome MeasuresOccurrence of cardiorespiratory events that exceeded predefined conventional and extreme thresholds as recorded by the monitors.ResultsDuring 718 358 hours of home monitoring, 6993 events exceeding conventional alarm thresholds occurred in 445 infants (41%). Of these, 653 were extreme events in 116 infants (10%), and of those events with apnea, 70% included at least 3 obstructed breaths. The frequency of at least 1 extreme event was similar in term infants in all groups, but preterm infants were at increased risk of extreme events until 43 weeks' postconceptional age.ConclusionsIn this study, conventional events are quite common, even in healthy term infants. Extreme events were common only in preterm infants, and their timing suggests that they are not likely to be immediate precursors to SIDS. The high frequency of obstructed breathing in study participants would likely preclude detection of many events by conventional techniques. These data should be important for designing future monitors and determining if an infant is likely to be at risk for a cardiorespiratory event.

Purpose The purpose of this article was to determine the prevalence of iron, vitamin B12, and folate deficiency and to evaluate the erythropoietin (EPO) response to anemia in a cohort of long-term intensive care unit (ICU) patients. Materials and Methods : All patients admitted to three academic medical center multidisciplinary ICUs were screened for eligibility into a randomized trial of EPO for the treatment of ICU anemia. On their second or third ICU day, patients enrolled in this trial had EPO levels drawn and were screened for iron, B12, and folate deficiency. Weekly EPO levels were obtained throughout patients' ICU stay. Results : A total of 184 patients were screened for iron, B12, and folate deficiency. Sixteen patients (9%) were iron deficient by study criteria, 4 (2%) were B12 deficient, and 4 (2%) were folate deficient. Mean hemoglobin and reticulocyte percents of the remaining 160 patients were 10.3±1.2 g/dL and 1.66±1.09%, respectively. In most patients, serum iron and total iron binding capacity levels were very low, whereas ferritin levels were very high. Mean and median day 2 EPO levels were 35.2±35.6 mIU/mL and 22.7 mIU/mL, respectively (normal=4.2–27.8). Serial EPO levels in most persistently anemic patients remained within the normal range. Conclusions In this cohort, screening for iron, B12, and folate deficiency identified potentially correctable abnormalities in more than 13% of patients and should be considered in those who are anticipated to have long ICU stays. Even at an early point of critical illness, most patients had iron studies consistent with anemia of chronic disease (ACD), as well as a blunted EPO response that may contribute to this ACD-like anemia of critical illness.

Infant polysomnography (IPSG) is an increasingly important procedure for studying infants with sleep and breathing disorders. Since analyses of these IPSG data are subjective, an equally important issue is the reliability or strength of agreement among scorers (especially among experienced clinicians) of sleep parameters (SP) and sleep states (SS). One basic issue of this problem was examined by proposing and testing the hypothesis that infant SP and SS ratings can be reliably scored at substantial levels of agreement, that is, kappa (kappa) > or = 0.61. In light of the importance of IPSG reliability in the collaborative home infant monitoring evaluation (CHIME) study, a reliability training and evaluation process was developed and implemented. The bases for training on SP and SS scoring were CHIME criteria that were modifications and supplements to Anders, Emde, and Parmelee (10). The kappa statistic was adopted as the method for evaluating reliability between and among scorers. Scorers were three experienced investigators and four trainees. Inter- and intrarater reliabilities for SP codes and SSs were calculated for 408 randomly selected 30-second epochs of nocturnal IPSG recorded at five CHIME clinical sites from healthy full term (n = 5), preterm (n = 4), apnea of infancy (n = 2), and siblings of the sudden infant death syndrome (SIDS) (n = 4) enrolled subjects. Infant PSG data set 1 was scored by both experienced investigators and trained scorers and was used to assess initial interrater reliability. Infant PSG data set 2 was scored twice by the trained scorers and was used to reassess inter-rater reliability and to assess intrarater reliability. The kappa s for SS ranged from 0.45 to 0.58 for data set 1 and represented a moderate level of agreement. Therefore, rater disagreements were reviewed, and the scoring criteria were modified to clarify ambiguities. The kappa s and confidence intervals (CIs) computed for data set 2 yielded substantial inter-rater and intrarater agreements for the four trained scorers; for SS, the kappa = 0.68 and for SP the kappa s ranged from 0.62 to 0.76. Acceptance of the hypothesis supports the conclusion that the IPSG is a reliable source of clinical and research data when supported by significant kappa s and CIs. Reliability can be maximized with strictly detailed scoring guidelines and training.

Studies have shown that the birth weight of infants is correlated with the birth weights of their siblings and their mothers. We investigated whether the birth weights of mothers and index children were jointly associated with the risk of low birth weight in the siblings of the index children.We used data on the live-birth cohort of the 1988 National Maternal and Infant Health Survey. The analysis included 1691 white and 1461 black mothers, each of whom had two or more live-born, singleton children. Multiple logistic regression with generalized-estimation equations was used to assess the risk of low birth weight among an index child's siblings. Four groups were studied: that in which neither the mother nor the index child had low birth weight (group 1), that in which only the mother had low birth weight (group 2), that in which only the index child had low birth weight (group 3), and that in which both the mother and the index child had low birth weight (group 4). There was adjustment for other maternal and infant covariates.Among white siblings in groups 1, 2, 3, and 4, 3.6, 8.3, 21.2, and 38.9 percent, respectively, had low birth weight, as compared with 8.0, 19.0, 31.1, and 57.1 percent of black siblings. When group 1 was used as the reference group, the adjusted odds ratios (and 95 percent confidence intervals) for low birth weight in groups 2, 3, and 4 were 2.5 (1.4 to 4.3), 6.8 (4.7 to 9.8), and 15.4 (9.2 to 25.5), respectively, among white siblings and 2.6 (1.8 to 3.8), 4.7 (3.5 to 6.4), and 13.9 (9.2 to 20.9) among black siblings. These associations were consistently found for birth weights below 1500 g and those ranging from 1500 to 2499 g in both races and after stratification for the mother's age, parity, education, cigarette-smoking status, and weight and height before pregnancy and the infant's sex.Although selection and recall biases cannot be excluded with certainty, our data suggest a strong familial aggregation of low birth weight among both whites and blacks in the United States.

To report longitudinal home recordings of hemoglobin O(2) saturation by pulse oximetry (Spo(2)) during unperturbed sleep in preterm and term infants.We recorded continuous pulse oximetry during the first 3 minutes of each hour of monitor use (nonevent epochs) for 103 preterm infants born at1750 g and ≤ 34 weeks postmenstrual age (PMA), and 99 healthy term infants.Median baseline Spo(2) was approximately 98% for both the preterm and term groups. Episodes of intermittent hypoxemia occurred in 74% of preterm and 62% of term infants. Among infants with intermittent hypoxemia, the number of seconds/hour of monitoring90% Spo(2) was initially significantly greater in the preterm than the term group and declined with age at a similar rate in both groups. The 75(th) to 95(th) percentiles for seconds/hour of Spo(2)90% in preterm infants were highest at 36 weeks PMA and progressively decreased until 44 weeks PMA, after which time they did not differ from term infants.Clinically inapparent intermittent hypoxemia occurs in epochs unperturbed by and temporally unrelated to apnea or bradycardia events, especially in preterm infants at 36 to 44 weeks PMA.

Background As part of the Collaborative Home Infant Monitoring Evaluation, a home monitor was developed to record breathing, heart rate, other physiologic variables, and the time the monitor was used. Objective To determine the frequency of monitor use, factors that influence use, and validity of a model developed to predict use. Design We developed a model to predict monitor use using multiple linear regression analysis; we then tested the validity of this model to predict adherence for the first week of monitoring and for the subsequent 4-week period (weeks 2-5). Setting Clinical research centers in Chicago, Ill; Cleveland, Ohio; Honolulu, Hawaii; Los Angeles, Calif; and Toledo, Ohio. Patients Preterm infants, infants younger than 1 month with a history of autopsy-confirmed sudden infant death syndrome in a sibling, and infants with an idiopathic apparent life-threatening event were divided into 2 cohorts based on enrollment date. Main Outcome Measure Mean hours of monitor use per week. Results In cohort 1, the variables available before monitoring were only weakly associated with total hours of monitor use in weeks 2 to 5 (total model r 2 = 0.08). However, when hours of monitor use in week 1 were included as a variable to predict monitor use in weeks 2 to 5, the r 2 increased to 0.64 for hours of monitor use per week. Conclusions Our data show that monitor use in the first week was the most important variable for predicting subsequent monitor use. The study suggests that a major focus of home monitoring should be adherence in the first week, although it remains to be tested whether this adherence can be altered.

The incidence of sudden infant death syndrome has decreased in the United States as the percentage of infants sleeping prone has decreased, but persisting concerns about the safety of supine sleeping likely contribute to prone sleeping prevalence rates that remain higher than 10%.To document health outcomes in infants aged 1 to 6 months in relation to sleep position.Prospective cohort study.Massachusetts and Ohio, from February 21, 1995, to December 31, 1998.A total of 3733 infants with consistent sleep positions at ages 1, 3, and 6 months.Descriptive statistics and multiple logistic regression analysis relating sleep position at each follow-up age to symptoms in the prior week (fever, cough, wheezing, stuffy nose, trouble breathing or sleeping, diarrhea, vomiting, or spitting up) and outpatient visits in the prior month (ear infection, breathing problem, vomiting, spitting up, colic, seizure, accident, or injury).No symptoms or outpatient visits were significantly more common among infants sleeping on the side or supine than in infants sleeping prone, and 3 symptoms were less common: (1) fever at 1 month in infants sleeping in the supine (adjusted odds ratio [OR], 0.56; 95% confidence interval [CI], 0.34-0.93) and side positions (OR, 0.48; 95% CI, 0.28-0.82); (2) stuffy nose at 6 months in the supine (OR, 0.74; 95% CI, 0.61-0.89) and side positions (OR, 0.82; 95% CI, 0.68-0.99); and (3) trouble sleeping at 6 months in the supine (OR, 0.57; 95% CI, 0.44-0.73) and side positions (OR, 0.69; 95% CI, 0.53-0.89). Also, outpatient visits for ear infections were less common at 3 and 6 months in infants sleeping in the supine position (OR, 0.64; 95% CI, 0.46-0.88; and OR, 0.73; 95% CI, 0.58-0.92, respectively) and at 3 months in the side position (OR, 0.68; 95% CI, 0.49-0.96).No identified symptom or illness was significantly increased among nonprone sleepers during the first 6 months of life. These reassuring results may contribute to increased use of the supine position for infant sleeping.

Background Bed sharing with parents has been described as both beneficial to infant well-being and as a potentially lethal situation. Objective To examine trends in bed sharing between infants and caregivers, and the factors that influence this behavior. Design Annual nationally representative telephone surveys conducted between 1993 and 2000. Setting The 48 contiguous United States. Participants Nighttime caregivers of infants born within 7 months prior to interview between 1993 and 2000. Approximately 1000 interviews were conducted each year for a total sample of 8453 nighttime caregivers. Main Outcome Measures Where and with whom the infant usually slept at night in the preceding 2 weeks. Results Forty-five percent of infants spent at least some time at night on an adult bed in the last 2 weeks. Between 1993 and 2000, the proportion of infants usually sharing an adult bed at night increased from 5.5% to 12.8%. More than 90% of infants who "usually" slept on an adult bed shared it with their parents. In a multivariate analysis, factors associated with increased probability of routine bed sharing included: maternal age less than 18 years (odds ratio [OR] = 2.26; 95% confidence interval [CI], 1.22-4.21), maternal race or ethnicity reported as black (OR = 4.04; 95% CI, 3.04-5.36) or as Asian or "other" (OR = 2.72; 95% CI, 1.74-4.22), household income less than $20 000 (OR = 1.49; 95% CI, 1.15 = 1.92), living in the Southern states compared with living in the Midwest (OR, 1.59; 95% CI = 1.23, 2.06), and infant age less than 8 weeks (OR = 1.60; 95% CI, 1.10-2.33). Living in the Mid-Atlantic compared with the Midwest (OR = 0.63; 95% CI, 0.44-0.90), and being born with low birthweight and preterm (OR = 0.32; 95% CI, 0.14-0.74) were associated with decreased probability of routine bed sharing. Conclusions Bed sharing as a routine practice is growing in the United States. Given that this practice seems to be widespread and strongly influenced by cultural factors, more studies of the consequences of bed sharing are needed to inform health care providers and parents on the risks and benefits.

ContextAnemia is common in critically ill patients and results in a large number of red blood cell (RBC) transfusions. Recent data have raised the concern that RBC transfusions may be associated with worse clinical outcomes in some patients.ObjectiveTo assess the efficacy in critically ill patients of a weekly dosing schedule of recombinant human erythropoietin (rHuEPO) to decrease the occurrence of RBC transfusion.DesignA prospective, randomized, double-blind, placebo-controlled, multicenter trial conducted between December 1998 and June 2001.SettingA medical, surgical, or a medical/surgical intensive care unit (ICU) in each of 65 participating institutions in the United States.PatientsA total of 1302 patients who had been in the ICU for 2 days and were expected to be in the ICU at least 2 more days and who met eligibility criteria were enrolled in the study; 650 patients were randomized to rHuEPO and 652 to placebo.InterventionStudy drug (40 000 units of rHuEPO) or placebo was administered by subcutaneous injection on ICU day 3 and continued weekly for patients who remained in the hospital, for a total of 3 doses. Patients in the ICU on study day 21 received a fourth dose.Main Outcome MeasuresThe primary efficacy end point was transfusion independence, assessed by comparing the percentage of patients in each treatment group who received any RBC transfusion between study days 1 and 28. Secondary efficacy end points identified prospectively included cumulative RBC units transfused per patient through study day 28; cumulative mortality through study day 28; change in hemoglobin from baseline; and time to first transfusion or death.ResultsPatients receiving rHuEPO were less likely to undergo transfusion (60.4% placebo vs 50.5% rHuEPO; P

ContextThe success and simplicity of the 1994 national "Back to Sleep" campaign to reduce sudden infant death syndrome provides an opportunity to study which elements determine whether a behavior will change in the desired direction in response to a public health intervention.ObjectiveTo examine sociodemographic characteristics, motivation, and message exposure to ascertain which factors influenced a caregiver's choice of infant sleep position after implementation of the campaign.DesignAnnual nationally representative telephone surveys conducted between 1994 and 1998.SettingThe 48 contiguous United States.ParticipantsNighttime caregivers of infants born within the 7 months prior to interview between 1994 and 1998. Approximately 1000 interviews were conducted each year.Main Outcome MeasuresThe position the infant was usually placed in for sleep, sleep position recommendations received from specific sources, and reasons reported for position choice.ResultsBetween 1994 and 1998, prone placement declined from 44% to 17% among white infants and from 53% to 32% among black infants. Supine placement increased from 27% to 58% among white infants and from 17% to 31% among black infants. During this period, reports of supine recommendations from at least 1 source doubled from 38% to 79%. From 1995 to 1998, 86% of caregivers who placed the infant prone reported receiving only nonprone recommendations. Infant comfort was given as a reason for prone placement by 82% of these caregivers. In multivariate analysis, physician recommendation of "supine not prone" had the strongest influence and was associated with decreased prone placement (odds ratio [OR], 0.25 [95% confidence interval {CI}, 0.16-0.39]) and increased supine placement (OR, 3.37 [95% CI, 2.38-4.76]). Recommendations from all 4 sources (the physician, neonatal nurse, reading materials, and radio/television) further increased the probability of supine placement (OR, 6.01 [95% CI, 4.57-7.90]). Other factors independently associated with increased prone and decreased supine placement included maternal black race, parity of more than 1, and living in a southern or mid-Atlantic state.ConclusionsAccording to our study, as of 1998, approximately one fifth of infants were still placed prone, and only half were placed supine. Recommendations of supine placement during infancy by physicians at well-baby checks and by neonatal nursery staff and print and broadcast media have increased the proportion of infants placed supine. Caregiver beliefs regarding perceived advantages of prone sleeping should be addressed to attain further reduction in prone placement.

Context.—Prone sleeping by infants has been associated with an increased risk of sudden infant death syndrome.Objective.—To document the prevalence of and identify risk factors for prone sleeping during the first 6 months of life.Design.—Prospective cohort study.Setting.—Eastern Massachusetts and northwest Ohio.Study Participants.—A total of 7796 mothers of infants weighing 2500 g or more at birth.Main Outcome Measures.—Maternal and infant characteristics related to prone sleeping at 1 month and 3 months of age.Results.—Between 1 month and 3 months of age, prone sleeping increased from 18% to 29%. At 1 month, prone sleeping was associated with the following maternal characteristics: non-Hispanic black or Hispanic race/ethnicity, younger age, less education, and higher parity. At 3 months, switching from nonprone to prone position was associated with mother's race/ethnicity of non-Hispanic black (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.2-2.3) or Hispanic (OR, 1.5; 95% CI, 1.1-2.2); younger maternal age (compared with mothers >34 years: 18-24 years, OR, 1.6; 95% CI, 1.2-2.2

The Back to Sleep campaign was begun in mid-1994 to reduce the prevalence of prone infant sleeping from 40-50% to < 10%. Using data from an ongoing longitudinal study of early infant care practices, we assessed trends in prone sleeping from 6/95 - 9/97. Mother-infant pairs are recruited at birth hospitals in Massacusetts and Ohio and followed for six months. Descriptive data are collected at enrollment; information on sleep position and other infant care practices is collected by follow-up mail/phone questionnaire. From 6/95 - 12/95 mothers of 1607 three month (9-16 weeks) old infants (birthweight≥ 2500g) responded to a question asking the position their infant was placed to sleep on the previous night. From 1/97 - 9/97 mothers of 2028 three month old infants responded to this question. In each year, 80% of mothers were White, 10% Black, and 10% Hispanic. Stratified analyses were performed for prevalence of prone sleeping in 1995 and 1997. Relative risks and 95% confidence intervals (CI) presented in the Table describe the reduction in prevalence of prone sleeping from 1995 to 1997. Trends were similar for Black and Hispanic infants, so data were pooled. There was a significant reduction in the prevalence of prone sleeping across all strata. The greatest decline was observed among infants of highly educated(high = college degree), minority mothers. These associations between race, education, and prone sleeping remain after controlling for other factors through multiple logistic regression. The prevalence of prone sleeping is approaching the target of 10% among infants of highly educated mothers regardless of race/ethnicity, however, prone sleeping remains higher among infants of less educated mothers, especially minorities. These data may be useful in directing future efforts for the Back to Sleep campaign.

Accuracy of the Respiratory Inductance Plethysmography (RIP) Collaborative Home Infant Monitoring Evaluation (CHIME) Monitor in Identifying Obstructed Breaths ♦ 1972

Ability to Predict a Family's Use of a Home Respiratory Inductance Plethysmography (RIP) Monitor † 687

Although there are numerous reports of cardiorespiratory patterns in infants on home monitors, there are no data to determine if experts actually agree on the description of these patterns. To assess agreement among observers in describing cardiorespiratory variables, four senior investigators and five trained technicians each independently assessed physiologic tracings recorded in the homes of 18 infants enrolled in a multicenter study. The monitor utilized respiratory inductance plethysmography and recorded a tracing(75 s. preceding the onset and 30 s. following resolution of events) whenever it detected apnea ≥16 s. or a heart rate 0.90 for technicians). Agreement in measurement of apnea duration was initially relatively low (intra-class correlation (ICC) 0.33), but following additional training ICC increased to 0.83. Agreement in measurement of bradycardia duration was consistently excellent (ICC 0.86-0.99). Agreement in measurement of the lowest heart rate during a bradycardia was better for technicians than investigators (ICC 0.77 vs. 0.65). With additional training there was total agreement among technicians (ICC 1.0). When classifying apnea as including ≥1, ≥2 or≥3 out-of-phase breaths, agreement was low for investigators (kappas 0.33, 0.22 and 0.11), while the technicians following training were able to achieve better agreement especially in categorization of apneas with ≥3 out-of-phase breaths (kappa 0.67). While researchers and clinicians commonly describe events based on cardiorespiratory recordings, agreement amongst experienced individuals may be poor. This lack of agreement between experts may seriously impair comparison of studies and mandates careful definition of variables, intensive training and demonstrated reliability in the conduct of studies. (NICHD HD 29067 29071 28971 29073 29060 29056 34625)

Apnea duration: Respiratory Inductance Plethysmography (RIP) and Transthoracic Impedance (TTI) Pneumography vs. Polysomnography (PSG) † 1791

PRETERM INFANTS HAVE PROLONGED APNEAS WITH OBSTRUCTION AND ASSOCIATED OXYGEN DESATURATION AT HOME. 1012

Longitudinal Assessment of Oxygen Saturation and Sleep Position in Healthy Term Infants During the First 6 Months of Life † 1180

The effects of fetal cocaine exposure on newborn cry characteristics were studied in 80 cocaine-exposed and 80 control infants. The groups were stratified to be similar on maternal demographic characteristics and maternal use of other illegal substances and alcohol during pregnancy. The hypothesis was that excitable cry characteristics were related to the direct effects of cocaine, while depressed cry characteristics were related to the indirect effects of cocaine secondary to low birthweight. Structural equation modeling (EQS) showed direct effects of cocaine on cries with a longer duration, higher fundamental frequency, and a higher and more variable first formant frequency. Indirect effects of cocaine secondary to low birthweight resulted in cries with a longer latency, fewer utterances, lower amplitude, and more dysphonation. Cocaine-exposed infants had a lower birthweight, shorter length, and smaller head circumference than the unexposed controls. Findings were consistent with the notion that 2 neurobehavioral syndromes, excitable and depressed, can be described in cocaine-exposed infants, and that these 2 syndromes are due, respectively, to direct neurotoxic effects and indirect effects secondary to intrauterine growth retardation.

Summary We followed 137 children who were found to have persistent otitis media with effusion (POME) one month after the diagnosis of acute otitis media. Subjects were randomly assigned to either treatment with erythromycin ethylsuccinate and sulfisoxizole or to no treatment. Follow-up utilizing pneumatic otoscopy and tympanometry showed that treated patients were more likely to have normal findings, and less likely to develop acute otitis media during the month following treatment. These data indicate that children with POME one month following acute otitis media may benefit from an additional course of antibiotics.