Development of circadian sleep-wake rhythms in preterm and full-term infants

Melatonin: role in development

Melatonin is the mammalian fetus's window to periodicity of the outside world. Through melatonin, the fetus "knows" what time of year it is and, in all likelihood, also knows the time of day. The best known function of melatonin during development is to communicate information about photoperiod and thereby adaptively regulate reproductive development. A second likely function of melatonin during development, which may be related to but more widespread than the first, is to entrain the developing circadian pacemaker. Prenatal maternal entrainment occurs in all of the eutherian mammals in which it has been examined, and in Syrian hamsters exogenous melatonin during development causes entrainment. The broader distribution and greater abundance of melatonin receptors during development, relative to mature animals, suggests that developmental effects of melatonin are greater and more diverse. The human fetal suprachiasmatic nucleus expresses melatonin binding sites and is therefore likely to be affected by both endogenous and exogenous melatonin with consequences for the prenatal and postnatal expression and entrainment of circadian rhythms. Caution is warranted, not only concerning the use of exogenous melatonin during pregnancy and lactation but also concerning behavior that might disrupt the mother's endogenous melatonin rhythm.

Synchronizing circadian rhythms in early infancy

Entrainment to the 24-hour light-dark cycle is of adaptive significance to mammals. Human infants are no exception, but some postnatal care habits prevalent in developed countries can interfere with the physiological mechanisms underlying circadian synchronization. We describe the physiological mechanisms of entrainment to the light-dark cycle in fetuses and newborns, and some common parental care behaviors which subject the developing circadian system of the newborn to conflicting temporal cues. Improvements in parental care are proposed which may improve the circadian synchronization of newborns, and their parents or caregivers.

Posture and gastro-oesophageal reflux: a case for left lateral positioning

AIM

Prone posture is often recommended for symptomatic gastroesophageal reflux in young infants, but prone positioning has been associated with sudden infant death. The aim of this study was thus to establish the optimal alternative posture for reducing reflux.

METHODS

24 infants (< 5 months) with symptomatic gastro-oesophageal reflux were studied prospectively with 48 h pH monitoring. They were randomly assigned to one of the 24 permutations of the four positions (supine, prone, right, left). During the first 24 hours the infant was held horizontally, and then the permutation was repeated at 30 degrees head elevation, giving a total of eight study segments for each infant. Data were edited to remove all time when the infants were not in the prescribed positions. Results were evaluated using analysis of covariance.

RESULTS

Gastro-oesophageal reflux expressed as reflux index (mean % (SEM)) was significantly less in the prone and left lateral positions (6.72 (1.06) and 7.69 (1.03) respectively) than in the supine and right lateral positions (15.33 (2.33) and 12.02 (1.38); p < 0.001). Head elevation did not affect any variables significantly.

CONCLUSIONS

Head elevation may not always be of clinical value. The left lateral position is a suitable alternative to prone for the postural management of infants with symptomatic gastro-oesophageal reflux.

Developmental Care in Advanced Practice Neonatal Nursing Education

Neonatal nursing education for the future is being influenced by two forces: expanding knowledge of infant development and health care reform. In response to the former and in anticipation of the latter, the University of Colorado School of Nursing incorporated developmentally based, family-centered care concepts in its recent revision of the master's program in neonatal nursing.

Diurnal rhythms in cardiorespiratory function of the fetal baboon

Diurnal periodicities of cardiorespiratory function were monitored between 144 and 156 days of gestation (term = 175 days) in six chronically instrumented fetal baboons. For each fetus, 5-11 days of electrocardiographic and tracheal fluid pressure data were summarized as hourly means of fetal heart rate (FHR), standard deviation of FHR, breath-to-breath interval (B-Bi) and percent time spent in fetal breathing activity (PFB). Summaries were evaluated by cosinor analysis to determine the least squares fit to a 24-h cycle. For all fetuses, FHR had a significant (P < 0.001) diurnal rhythm with peak to nadir fluctuations of 17.4 beats/min around a 24-h mean of 163.2 beats/min. The time of the peak FHR was similar across animals occurring in the mid-day between 10:49 h and 14:45 h. For each fetus, standard deviation of FHR also had a significant (P < 0.01) diurnal periodicity with highest values at night between 20:15 h and 02:04 h. The times of the acrophase for these heart rate parameters were correlated (R = 0.88, P < 0.02) across fetuses. Significant (P < 0.001) 24-h rhythms were found in four of six fetuses for B-Bi and five of six for PFB. These PFB rhythms accounted for a fluctuation of 14.4% around a mean of 36.9 +/- 4.5%. In contrast to heart rate, the acrophases of fetal breathing parameters were distributed throughout the entire 24-h cycle and not significantly correlated across fetuses. It is concluded that diurnal rhythms of fetal heart rate, which are synchronized with light/dark conditions in the environment, are evidence for a passive response or entrainment of fetal systems to maternal circadian influences. Alternately, the absence of synchronization across fetuses in daily rhythms of fetal breathing activity provides evidence for a functioning fetal pacemaker, and not simply the imposition of maternal rhythms on her fetus. This differential in the cardiac and breathing activity of the developing primate indicates that pathways for entrainment of fetal pacemaker function are subject to important maturational influences during late gestation.

Development of circadian rhythmicity of temperature in full-term normal infants

Twelve full-term infants (7 girls and 5 boys) with normal neurological, behavioral and somatic development were followed at regular intervals during the first 5 months of life to appreciate the development of circadian rectal temperature rhythmicity. Activity and temperature (oral at birth, rectal thereafter) were monitored for a minimum of 60 hours on seven separate occasions: at birth, 3 weeks, 6 weeks, 8 weeks, 10 weeks, 16 weeks and 20 weeks of age. Activity was measured using an actigraph worn on the infant's wrist, and rectal temperature was measured using a rectal probe attached to a portable microprocessor (Vitalog TM). Data points were collected every 2 minutes. No fewer than ten infants were monitored at each session, and no infant missed more than one session. Missing recordings were due to equipment malfunctions, probe expulsions and minor health problems. Six infants out of 12 were successfully monitored at each of the first four sessions, from birth to 8 weeks of age inclusively, and two subjects were successfully monitored at all seven sessions. Periodic regression analysis was performed by least squares curve fit with secondary analysis of variance. Analysis of covariance was performed on repeated measures. There was no evidence of rectal temperature circadian rhythmicity at 3 weeks. Two infants demonstrated a circadian rhythmicity at 6 weeks, and all infants had a circadian rhythmicity at 10 weeks post-natal age. At the time of the first observance of circadian rhythmicity of rectal temperature, the mean delta in temperature from peak to trough was 0.6 +/- 0.3 degrees C. This delta was greater at the 16th week, with a mean value of 1.2 +/- 0.3 degrees C. The trough was seen during the first part of the long nocturnal inactivity period. Circadian rhythmicity of rectal temperature was always observed in the studied subjects before the establishment of a consolidated, long daytime wake period.

Perinatal development of human circadian rhythms

The early development of circadian rhythms in primates, including man, was reviewed. Continuous 24-h recordings were carried out for maternal and fetal circadian rhythms during gestation as well as in preterm infants. Several propositions were made based on these new findings: 1. The fetal biological clock is an endogenous clock capable of generating circadian rhythms and responding to maternal entraining signals long before the moment of birth. 2. Through the fetal biological clock, maternal circadian rhythms influence the fetal overt rhythms. 3. Maternal rhythms influence the fetus, and fetal rhythms feed back to the mother (via the placenta). Disruption of this fetal-maternal interaction during gestation leads to: a. disturbances of maternal and fetal circadian rhythms; b. disappearance of circadian rhythms at the time of birth; c. a gestational period which is either too short or too long (see also Honnebier and Swaab, 1973); d. delayed or impaired maturation of the circadian rhythms of the infant.

[Actimetry: simplified analysis of wake-sleep rhythms in the newborn. Preliminary results]

Actimetry in newborns is relevant if two actimeters are placed, one on each ankle. This study has been conducted on nine normal three days old newborns. It has shown an indisputable link between the lack of activity and the observed sleep during the night that was missing during the day. The longest period of wake was recorded during the day and the longest period of sleep or inactivity was during the night. This study has confirmed the existence of an ultradian rhythm of quiet sleep and wake. It is also possible that a beginning of a circadian rest-activity rhythm exists already in the neonatal period, that is still discussed in the literature.

Development of sleep-wakefulness rhythm in premature babies

The aims of this study were: (1) to investigate the evolution of the sleep pattern in preterm newborns during their first month of life; (2) to assess the influence of light-dark on the sleep pattern; and (3) to compare this pattern with that of full-term newborns. The population consisted of 60 healthy, preterm newborns and 63 full-term newborns, divided into four age groups, 1 week apart, throughout the first month of life. Preterm newborns were further divided into five groups according to conceptional (corrected) age. An observer took note every 30 min, for 24 h, of sleep or wakefulness in every case. The average sleeping time in preterm groups according to postnatal age remained unchanged during the first month of life: 17.57 h on day 1 and 17.15 h on day 28. When the preterm infants were re-grouped according to conceptional age, average daily sleep was 17.86 h at 32 weeks and 15.22 h at 37 weeks. The full-term newborns had an average daily sleep of 14.78 h on day 1 and 11.94 h on day 28, with a decrease throughout week 4 of life (p < 0.001). The decrease in daily sleeping time in the full-term groups, took place at the expense of the daylight span, where there was a decrease throughout the first month of life (p < 0.01). There were no differences in preterm newborns during the light and dark phases. A progressive synchronization of sleep to the light-dark was seen in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

The incidence of sleeping problems in preterm and fullterm infants discharged from neonatal special care units: an epidemiological longitudinal study

Anecdotal reports have suggested that sleeping problems are a frequent complaint from parents of preterm infants. This prospective epidemiological study examined the incidence and stability of sleeping problems of very preterm (< 32 weeks gestation at birth), preterm (32-36 weeks gestation) and fullterm infants, all admitted to special care baby units (SCBU) after birth, in comparison to healthy term infants over the first 5 years of life. Preterm infants were found to have fewer and shorter night-wakings at 5 months. No differences in sleeping behaviour compared with healthy term children were found at 20 and 56 months of age. Similar significant, and moderate, stability of nightwaking from one age to the next were found for exSCBU-graduates and healthy fullterm infants. Parental interventions such as staying with the child until sleep and taking the infant into bed af night were related to nightwaking problems and increased parental distress. It is concluded that prematurity, and thus neurological immaturity and special care experience are less important than caretaking behaviour in the development of sleeping problems in both preterm and fullterm infants.

Ultradian and diurnal cyclicity in the sleep states of newborn infants during the first two postnatal days

OBJECTIVE

The purpose of this study was to investigate both ultradian and diurnal cyclicity in the sleep states of newborn fullterm infants during the first 2 postnatal days.

METHODS

The sleep of 31 healthy newborn infants was recorded continuously throughout the first 2 postnatal days, starting immediately after birth, using an automated Motility Monitoring System (MMS). The MMS consists of a pressure sensitive mattress pad connected to an amplifier and a small 24-h analog recorder. A single channel of analog signals produced by the infant's respiration and body movements was recorded and then scored in 30-s epochs for Active Sleep. Quiet Sleep, Active-Quiet Transition, Sleep-Wake Transition, and Wake.

DATA ANALYSES

The 48 h of recording were divided into successive 12-h periods from 07:00 h to 19:00 h (day) and 19:00 h to 07:00 h (night), and all measures were derived for each day and night period. Both cross-sectional and repeated measures analyses were used because all babies were not represented in all day/night periods.

RESULTS

Day/night differences in state variables: On both days, there was greater Wakefulness, shorter Quiet Sleep Bout Lengths, shorter Mean Sleep Periods and shorter Longest Sleep Periods during the daytime. On day 1 only, there was less Quiet Sleep, shorter Quiet Sleep Bout Lengths and more Sleep-Wake Transition during the daytime. On day 2, repeated measures analyses revealed two additional day/night differences: less Quiet Sleep and more Sleep-Wake Transition during the daytime. Day/night differences in Quiet Sleep cyclicity: 28 sleep periods met the criteria for analysis of Quiet Sleep cyclicity, and only six of these occurred during the daytime. Seventeen of 28 analyzable sleep periods showed significant Quiet Sleep cyclicity. Only two of these occurred during the daytime.

CONCLUSIONS

Contrary to the prevailing view of developing sleep rhythms, the results of this study suggest that newborn infants exhibit both ultradian ad diurnal cyclicity in their sleep patterns from the earliest postnatal period.

Light therapy as treatment of dyschronosis in brain impaired children

Fourteen children aged 9 months-4 years with moderate to severe mental retardation and varying neurologic lesions were referred for severe and continuous nocturnal sleep disturbances and very abnormal day/night schedules. All children had previously been given hypnotic medications and behavioral treatments which had little or no effect on nocturnal sleep. The severity of the sleep disturbances significantly affected family life and was a major handicap to the children. All children were treated with light therapy (minimum 4000 lux). Five children responded to treatment and had normal sleep-wake cycles at the most recent post-treatment evaluation (2-5 years after the first treatment). Two of the patients' families were unable to follow the prescribed regimen. Treatment failed in 7 children. One of these seven children spontaneously improved 3 years later. In three of the failure children the neurologic problem progressively worsened, leading to death in one of them. Phototherapy is a treatment worth pursuing in children with very significant sleep/wake disruption which is unresponsive to behavioral or other treatments. It has few side-effects and may lead to normalization of the sleep-wake cycle. Recent improvement in the technology used to monitor the 24-h temperature rhythm over several days and the present commercial availability of "light boxes" should render these therapeutic trials easier than at the time of these initial investigations.

Perinatal development of human circadian rhythms: role of the foetal biological clock

The development of circadian rhythms and the neuronal mechanisms underlying their generation (particularly the suprachiasmatic nucleus of the hypothalamus) were reviewed. Based on perinatal animal studies and data from human foetuses and/or preterm infants it was concluded that human circadian rhythms are present as early as at 30 weeks of gestation. The significance of the mother and/or the environment regarding the entrainment of the "endogenous" foetal biological clock was emphasized.

Skin temperature and heart rate rhythms in infants of extreme prematurity

Nine preterm infants of 26 to 29 weeks' gestational age and 792 to 1200 g birth weight spent six to 17 weeks in our neonatal medical unit. Hourly recordings of skin temperature and heart rate were carried out. The first five to 15 weeks were spent in the intensive care ward, in continuous light, due to various medical conditions. After recovery they were moved to a nursery for one to nine weeks, with 12 hourly periods of light and darkness. Four infants developed circadian rhythms in temperature and three in heart rate in light-dark periods, the remainder failing to do so. Some infants take longer than others to develop circadian rhythms but the reasons for this are not clear. It is suggested that earlier exposure to a light-dark environment may synchronize the 'body clock' to a 24 hour period in more preterm infants.

Circadian rhythms and the suprachiasmatic nucleus in perinatal development, aging and Alzheimer's disease

Circadian rhythms are already present in the fetus. At a certain stage of pre-natal hypothalamic development (around 30 weeks of gestation) the fetus becomes responsive to maternal circadian signals. Moreover, recent studies showed that the fetal biological clock is able to generate circadian rhythms, as exemplified by the rhythms of body temperature and heart rate of pre-term babies in the absence of maternal or environmental entrainment factors. Pre-term babies that are deprived of maternal entrainment and kept under constant environmental conditions (e.g., continuous light) in the neonatal intensive care unit run the risk of developing a biological clock dysfunctioning. However, the fact should be acknowledged that at least in mice the development of the circadian pacemaker (i.e., SCN) does not depend on environmental influences (Davis and Menaker, 1981), although other data suggest that severe disruption of the maternal circadian rhythm indeed abolishes the circadian rhythm of the fetal SCN (Shibata and Moore, 1988). During aging and in particular in AD circadian rhythms are disturbed. These disturbances include phase advance and reduced period and amplitude, as well as an increased intradaily variability and a decreased interdaily stability of the rhythm. Among the factors underlying these changes the loss of SCN neurons seems to play a central role. Other contributory factors may be reduced amount of light, degenerative changes in the visual system and the level of activity and decreased melatonin.