Academic journal article Pre- and Peri-natal Psychology Journal

Clinical Implications for Behavioral Assessment of Sleep/Wake States in Neonates: Augmenting Medical Diagnostic Evaluations

Academic journal article Pre- and Peri-natal Psychology Journal

Clinical Implications for Behavioral Assessment of Sleep/Wake States in Neonates: Augmenting Medical Diagnostic Evaluations

Article excerpt

ABSTRACT: The use of behaviorally defined sleep and wake states for detecting or predicting abnormal development in high risk newborn infants is addressed. One case of a relatively low risk 32-week gestation infant is used to illustrate that immediate subjective impressions by a trained observer may reveal information useful to the medical staff without having to wait for the lengthy computer analyses usually performed with this assessment technique. A second case illustrates a situation in which sleep/wake assessment by a trained observer assisted the medical team in confirming their diagnosis of massive brain damage and loss of function in an anencephalic newborn. The use of sleep variables in evaluating other behavioral and medical conditions in the young infant is also discussed.

The literature demonstrating the usefulness of sleep/wake patterns to predict or evaluate medical and behavioral problems in newborns has grown steadily over the past three decades. Such varied disorders as aplastic anemia, behavior disorders (possible Attention Deficit Disorder with Hyperactivity), developmental delays on standardized tests in infancy, Down's Syndrome, high bilirubin levels (liver problems), high riskness accompanied by clear signs of Central Nervous System (CNS) dysfunction, mental development at one year, prenatal exposure to drugs, prenatal exposure to maternal stress and seizure disorders have been predicted or immediately diagnosed as a result of sleep/ wake evaluation (Becker & Thoman, 1981; Dinges, Davis & Glass, 1980; Prechtl, Theorell & Blair, 1973; Thoman, Denenberg, Sievel, Zeidner & Becker, 1981). Perhaps the greatest volume of support for the predictive validity of neonatal sleep patterns concerns Sudden Infant Death Syndrome (Guilleminault, Ariagno, Souquet & Dement, 1976; Harper, Leake, Hoffman, Walter, Hoppenbrouwers, Hodgman & Sterman, 1981; Thoman et al., 1981).

While most of these studies used polygraphic means to determine states, a few added behavioral criteria and another group used solely behavioral criteria. Behavior-only sleep-wake assessment of infants shares some commonality in its definitions with the pioneering work of Wolff (1966). However, users of the behavioral technique have varied in amount of observation time (from one to several hours), length of epoch defining a state (from 10s to 3 or more minutes), the specific states used and their defining criteria, and the statistical variables analyzed (Prechtl, 1977). This has made cross-laboratory comparison difficult for research purposes but need not be a serious obstacle to making clinical inferences.

The infants described below were observed with a behavior-only method that has demonstrated predictive validity (Waite, DeSantis, Thoman & Denenberg, 1977), reliability (Thoman, Waite, DeSantis & Denenberg, 1979), and sensitivity to experimentally induced differences (DeSantis, Waite, Thoman & Denenberg, 1977) in animal models. The animal model version was deliberately chosen so that investigators could go back and forth between species in order to obtain both empirical and clinical information. It was modified for species-specific human behaviors before application to preterm and fullterm infants (DeSantis, in review) but otherwise is applicable to at least developing rabbits and rats as well as to infants.


The procedure for the two infants to be described involved one hour of observation immediately following a feeding (in the case of the anencephalic, the entire interfeeding interval was covered, or 3.5 hours).

States were defined based on a 10s epoch signalled to the observer through a tone delivered through an earpiece. The observation was entirely naturalistic, involving no intervention or disturbance to the infant (and thus making the procedure useful in a variety of settings).

Specific designations of waking used were Quiet Alert and Waking Active. …

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