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Infant Scoring: The Force Awakens

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In 2015, the American Academy of Sleep Medicine published much needed rules for the scoring of sleep in infants aged 0–2 months.1 These rules were based on the literature review, written suggestions and expert guidance of Dr. Madeleine Grigg-Damberger as well as input from Dr. Mark Scher. Before these guidelines were available, sleep specialists used the Anders, Emde, and Parmelee Manual for Scoring Sleep in Newborns that was published in 1971 and did not provide clear scoring criteria.2 Considering that the Anders manual was published before modern digital polysomnographic equipment became mainstream, an updated manual for the scientific and clinical pediatric sleep community was long overdue. These guidelines complete the AASM's mission to address sleep across the lifespan.

Little attention has been paid to infant polysomnography scoring, despite its importance. For example, several sleep-related diseases are present in newborns and young infants, such as craniofacial anomalies, that predispose to obstructive sleep apnea. The article by Grigg-Damberger3 provides a didactic summary of evidence-based articles upon which the new scoring criteria are based. Until recently, clinicians and researchers relied mostly on their judgment to categorize sleep studies as normal or abnormal. A uniform clear set of rules are especially important for future multicenter research studies where reproducibility of data is crucial.

A strength of the article by Grigg-Damberger3 is the definition of age based on conceptional age. This is particularly important as many preterm infants are referred to sleep laboratories for evaluation. Maternal and perinatal health have made impressive strides over the past few years and therefore, we should expect to study more and more preterm infants. As with anthropometrics, developmental evaluations and many other measurements, sleep evaluations need to be corrected for the infant's conceptional age. In addition, considering that there are few longitudinal studies in pediatric sleep, this can have important research implications.

Another strength is the discussion of sleep architecture and, specifically, the reclassification of active sleep as REM sleep, quiet sleep as NREM sleep, and indeterminate sleep as transitional sleep. The sleep community has been aware that active sleep corresponded to REM sleep and quiet sleep to NREM sleep, but these terms may have been confusing for general pediatricians, otolaryngologists and other referring specialists. A consistent nomenclature across the age spectrum has clinical and research advantages. From a clinical perspective, it will increase interscorer reliability and may allow sleep trainees to further understand developmental sleep architectural changes. From a research perspective, it will favor the longitudinal analysis of EEG data.

In summary, the article by Grigg-Damberger3 highlights valuable information reading the scoring of sleep in infants ages 0–2 months. In order to seize this momentum and show that the “infant force has fully awoken,” the sleep community now needs to use the updated scoring manual to better understand neonatal and infant sleep. Specific issues requiring further research include (but are not limited to) studying normative respiratory data in this young population, further understanding of the neurodevelopmental correlates of the sleep-related EEG changes, and longitudinal studies assessing high risk neonates (for example, otherwise-heathy preterm infants have been shown to have a high rate of obstructive sleep apnea and periodic limb movements at school-age).4,5


The authors have indicated no financial conflicts of interest.


Tapia IE, Marcus CL. Infant scoring: the force awakens. J Clin Sleep Med 2016;12(3):291–292.


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