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Diagnosing sleep-disordered breathing in children with suspected sleep-disordered breathing Sleep questionnaires, combined sleep questionnaires and ‘protocol-driven’ clinical assessments, sleep video recordings and sleep audio recordings Children without comorbidities Recommendations The Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire (SRBD-PSQ), with a cut-off of ≥0.33, or Obstructive Sleep Apnoea-18 item questionnaire (OSA-18), with a cut-off of ≥0.60, can be considered for diagnosing moderate-to-severe SDB in children of at least 2 years of age with no comorbidities. While pulse oximetry is non-discriminatory at all ages, particular caution is required in using oximetry to diagnose OSA in children under 2 years of age as children in this age group are predisposed to central sleep apnoea (CSA) (as a result of developmental immaturity) and oxygen desaturations cannot discriminate between obstructive and central events. If hypoventilation is suspected, please refer to the ‘Pulse oximetry and carbon dioxide (CO2) monitoring’ recommendations and GPPs below. The American Academy of Sleep Medicine (AASM) recommends scoring hypoventilation during sleep when >25% of the total sleep time, as measured by either the arterial PCO2 or surrogate (transcutaneous or end tidal which is more relevant in paediatrics), is spent with a PCO2 >50 mm Hg/6.7 kPa.3 Home monitoring (pulse oximetry or CRSS) Recommendation Home CRSS can be considered for diagnosing SDB in children without comorbidities where the patients and/or carers are deemed appropriate for implementing a home sleep study.

The search strategy is available for review in Online supplement appendix 12 of the full guideline.1 Critical appraisal and GRADE analysis of the evidence After an initial screening to determine relevance to the clinical questions, each paper was assessed to determine if it addressed: Following data extraction from the ‘accepted’ papers, evidence profiles were generated for each of the clinical questions and the quality of the evidence was assessed using the GRADE principles.5 Where GRADE analysis was not possible, but the evidence was deemed important enough to be included in the guideline, the evidence has been listed as (Ungraded), denoting that inclusion was reached by consensus of the Guideline Development Group (GDG). A definition of the GRADE scores is shown in table 1.Table 1 GRADE score definitions GRADE Definition High High confidence that the true effect is close to the estimated effect Moderate Moderate confidence that the true effect is close to the estimated effect Low Low confidence that the true effect is close to the estimated effect Very low Very low confidence that the true effect is close to the estimated effect Ungraded GRADE analysis not possible, but evidence deemed important GRADE, Grading of Recommendations, Assessment, Development and Evaluation. GRADE specifies two categories of strength for a recommendation as shown in table 2.Table 2 Explanation of the terminology used in BTS recommendations Strength Benefits and risks Implications Strong Recommended, so ‘offer’ Benefits appear to outweigh the risks (or vice versa) for the majority of the target group Most service users would want to, or should receive this intervention Conditional Suggested, so ‘consider’ Risks and benefits are more closely balanced, or there is more uncertainty in likely service users’ values and preferences Service users should be supported to arrive at a decision based on their values and preferences BTS, British Thoracic Society.

[...]development of suitable training must involve clinicians who are knowledgeable and experienced in the clinical fields of emergency paediatrics and paediatric intensive care, in direct practice in low-resource countries, and in delivering high-quality clinical education.3 BMP was chairman of the Advanced Paediatric Life Support (APLS) Working Party during 1993-2006 and is a trustee of the Advanced Life Support Group.

However, in more mature infants with conditions such as bronchiolitis, congenital diaphragmatic hernia, and phrenic nerve palsy, we believe that CNEP can be a valuable means for nurses and even parents to provide non-invasive respiratory support.

The North Staffordshire Hospital Trust, Staffordshire Social Services and Staffordshire Police prepared a protocol on protection from child abuse. The guidelines were passed by the Staffordshire Area Child Protection Committee on Jan. 12, 1994. A summary of the protocol is presented.

In a recent article in this journal our unit was accused of a number of errors of judgment in applying covert video surveillance (CVS) to infants and children suspected of life-threatening abuse. The article implied, that on moving from the Royal Brompton Hospital in London to North Staffordshire Hospital, we failed to present our work to the Research Ethics Committee (REC). We did send our protocol to the REC though we did not consider that, after a total of 16 patients had been documented as being the subject of life-threatening abuse, this was research. The REC in Staffordshire agreed with us. We were also accused of undertaking work that should be pursued by the Police. We agree with this. However, unlike the Metropolitan Police the Staffordshire Police would not undertake CVS. We fail to agree that 'working together' with parents is necessarily practical or safe when trying to protect children from life-threatening abuse of this kind.

Covert video surveillance (CVS) can provide definitive evidence of child abuse. CVS can ensure that an abused child can be protected through child care proceedings under the provisions of the Children's Act of 1989. Prosecution of the abuser should not discourage pediatricians from identifying the abuse. The difficulties in diagnosing this form of child abuse necessitate the use of CVS as a tool in gathering evidence.

OBJECTIVE--To determine the mechanisms and thereby appropriate management for apparent life threatening events treated with cardiopulmonary resuscitation in infants and young children. DESIGN--Prospective clinical and physiological study. SETTING--Royal Brompton Hospital or in patients' homes, or both. SUBJECTS--157 Patients referred at median age 2.8 months (range 1 week to 96 months), 111 (71%) had recurrent events, 44 were born preterm, 19 were siblings of infants who had died suddenly and unexpectedly, and 18 were over 12 months old. INTERVENTIONS--Multichannel physiological recordings, including oxygenation, in hospital (n = 150) and at home (n = 61). Additional recordings with electroencephalogram, video, or other respiratory measures were used to confirm diagnoses. Management involved monitoring of oxygen at home, additional inspired oxygen, anticonvulsant treatment, or child protection procedures. MAIN OUTCOME MEASURES--Abnormalities on recordings compared to published normal data and their correlation with clinical events; sudden death. RESULTS--53 of 150 patients had abnormalities of oxygenation on hospital recordings, 28 of whom had an accompanying clinical event. Home recordings produced physiological data from 34 of 61 patients during subsequent clinical events. Final diagnoses were reached in 77 patients: deliberate suffocation by a parent (18), hypoxaemia induced by epileptic seizure (10), fabricated history and data (Munchausen syndrome by proxy; seven), acute hypoxaemia of probable respiratory origin (40), and changes in peripheral perfusion and skin colour without hypoxaemia (two). Four patients died: three suddenly and unexpectedly (none on home oxygen monitors) and one from pneumonia. CONCLUSIONS: Identification of mechanisms is essential to the appropriate management of infants with apparent life threatening events.