title: Long-term effects of caffeine therapy for apnea of prematurity on sleep at school age. Cycled Light Exposure Reduces Fussing and Crying in Very Preterm Infants Prevalence and risk factors for sleep-disordered breathing in 8- to 11-year-old children: association with race and prematurity. Observational study found that even small variations in light can wake up very preterm infants in a neonatal intensive care unit Neurophysiologic Assessment of Neonatal Sleep Organization: Preliminary Results of a Randomized, Controlled Trial of Skin Contact With Preterm Infants Children with a history of prematurity presenting with snoring and sleep-disordered breathing: a cross-sectional study. Effects of nesting and swaddling on the sleep duration of premature infants hospitalized in neonatal intensive care units Perinatal Risk Factors Associated with the Obstructive Sleep Apnea Syndrome in School-Aged Children Born Preterm. Effect of Prone and Supine Position on Sleep, Apneas, and Arousal in Preterm Infants Modulation of motor activity patterns and sleep states in low-risk prematurely born infants reaching normal term: a comparison with full-term newborns. Theophylline affects sleep-wake state development in premature infants. Behavioral Observation Differentiates the Effects of an Intervention to Promote Sleep in Premature Infants: A Pilot Study Sleep behaviour in preterm children from birth to age 10 years: A longitudinal study Biobehavioral Responses of Preterm Infants to Conventional and Swaddled Tub Baths: A Randomized Crossover Trial Randomized controlled trial to compare sleep and wake in preterm infants less than 32weeks of gestation receiving two different modes of non-invasive respiratory support. The effectiveness of earmuffs on the physiologic and behavioral stability in preterm infants. Neurodevelopmental outcomes following late and moderate prematurity: a population-based cohort study Neonatal Sleep Predicts Attention Orienting and Distractibility ROBINS-1: A tool for asssessing risk of bias in non-randomised studies of interventions.
abstract: RATIONALE Apnea of prematurity is a common condition that is usually treated with caffeine , an adenosine receptor blocker that has powerful influences on the central nervous system . However , little is known about the long-term effects of caffeine on sleep in the developing brain . OBJECTIVES We hypothesized that neonatal caffeine use result ed in long-term abnormalities in sleep architecture and breathing during sleep . METHODS A total of 201 ex-preterm children aged 5 - 12 years who participated as neonates in a double-blind , r and omized , controlled clinical trial of caffeine versus placebo underwent actigraphy , polysomnography , and  parental sleep question naires . Co primary outcomes were total sleep time on actigraphy and apnea-hypopnea index on polysomnography . MEASUREMENTS AND MAIN RESULTS There were no significant differences in primary outcomes between the caffeine group and the placebo ( adjusted mean difference of -6.7 [ 95 % confidence interval ( CI ) = -15.3 to 2.0 min ] ; P = 0.13 for actigraphic total sleep time ; and adjusted rate ratio [ caffeine/placebo ] for apnea-hypopnea index of 0.89 [ 95 % CI = 0.55 - 1.43 ] ; P = 0.63 ) . Polysomnographic total recording time and total sleep time were longer in the caffeine group , but there was no difference in sleep efficiency between groups . The percentage of children with obstructive sleep apnea ( 8.2 % of caffeine group versus 11.0 % of placebo ; P = 0.22 ) or elevated periodic limb movements of sleep ( 17.5 % in caffeine group versus 11 % in placebo group ) was high , but did not differ significantly between groups . CONCLUSIONS Therapeutic neonatal caffeine administration has no long-term effects on sleep duration or sleep apnea during childhood . Ex-preterm infants , regardless of caffeine status , are at risk for obstructive sleep apnea and periodic limb movements in later childhood OBJECTIVE : To examine whether cycled lighting ( CL ) conditions during neonatal care in very preterm infants ( < 32 weeks ’ gestational age [ GA ] ) decrease crying and fussing behavior , improve the consolidation of sleep , and influence activity behavior at 5 and 11 weeks ’ postterm corrected age ( CA ) compared with preterm infants cared for in dim lighting ( DL ) conditions . METHODS : Thirty-seven preterm infants were r and omly assigned to  CL  ( 7 am–7 pm lights on , 7 pm–7 am lights off [ n = 17 ; mean GA : 30.6 ± 0.95 weeks ; 9 girls ] ) or DL ( lights off whenever the child is asleep [ n = 20 ; GA : 29.5 ± 2.1 weeks ; 8 girls ] ) conditions . Sleeping , crying , and activity behavior was recorded by using parental diaries and actigraphy at 5 and 11 weeks ’ CA . RESULTS : A significant reduction of fussing ( 59.4 minutes/24 hours [ ±25.8 minutes ] ) and crying ( 31.2 minutes/24 hours [ ±14.4 minutes ] ) behavior and a trend to higher motor activity during daytime was found in CL-exposed infants at 5 and 11 weeks ’ CA compared with infants cared for in DL conditions . No significant difference between groups was observed for sleep behavior at 5 and 11 weeks ’ CA . Infants in CL conditions showed a trend to improved daily weight gain ( average : 3.6 g/d ) during neonatal care compared with DL conditions . CONCLUSIONS : CL conditions in neonatal care have beneficial effects on infant ’s fussing and crying behavior and growth in the first weeks of life . This study supports the introduction of CL care in clinical neonatal practice OBJECTIVES To evaluate the extent to which sleep-disordered breathing ( SDB ) varies with putative demographic and medical risk factors and to estimate the prevalence of undiagnosed SDB . STUDY DESIGN Prospect i ve , cross-sectional study in a population -based cohort of 850 children ( 41 % black , 46 % preterm ) , 8 to 11 years of age . Participants ' caretakers completed question naires about health and sleep . Children underwent overnight in-home cardiorespiratory recordings of airflow , respiratory effort , oximetry , and electrocardiography . SDB was identified by respiratory disturbance indices commonly applied in clinical practice . Risk factors were estimated by logistic regression . Prevalence was derived from cohort-specific estimates with birth weights from US live births data . RESULTS Using the most inclusive definition , SDB was detected in 40 ( 4.7 % ) participants , with prevalence varying widely across population subsets . Depending on the definition used , SDB was 4 to 6 times more likely in black children compared with white children and almost 3 to 5 times more likely in former preterm compared with term children . The estimated population prevalence of SDB was 2.2 % ( 95 % CI , 1.2 % , 3.2 % ) . CONCLUSIONS SDB is a relatively common condition in 8- to 11-year-old children . Potentially vulnerable subgroups , black children , and former preterm infants , are at increased risk This prospect i ve observational study evaluated the behavioural responses of very preterm infants to spontaneous light variations BACKGROUND . Sleep is important to brain organization , but few strategies to promote sleep among premature infants have been tested . Behaviorally based measures of sleep have shown increased quiet sleep ( QS ) and decreased active sleep ( AS ) during skin-to-skin contact ( SSC ) with the mother , but these results have not been confirmed with objective electroencephalographic/polysomnographic measures of sleep organization . Important differences exist between behavioral and electroencephalographic/polysomnographic definitions of sleep state . METHODS . Data for the first 28 relatively healthy , preterm subjects of an ongoing r and omized trial of one 2- to 3-hour session of SSC or incubator care between feedings are reported here . Infants were positioned prone , inclined , and nested in an incubator during the 2- to 3-hour pretest period , were fed , and then went into the test period of SSC or incubator care . Infants were left largely undisturbed throughout testing . A mixed-model regression analysis compared the test-pretest differences in outcome measures within and between groups . RESULTS . Results showed that arousals were significantly lower in the SSC group , compared with the control group , for the entire study period and for test-pretest matched segments of QS and AS . Rapid eye movement was significantly lower for the SSC group for the study period and AS segments . Indeterminate sleep was significantly lower for the SSC group when confounding environmental variables were included in the regression analysis . When 4 subjects who experienced excessive ambient light levels during SSC were removed from analysis , QS increased during SSC . CONCLUSIONS . The patterns demonstrated by the SSC group are analogous to more-mature sleep organization . SSC may be used as an intervention to improve sleep organization in this population of preterm infants OBJECTIVES /HYPOTHESIS To report on the prevalence of premature ( PM ) birth in a consecutive series of children treated for snoring and sleep-disordered breathing ( S/SDB ) , the parameters specific to their management and variables predictive of disease severity . STUDY DESIGN A retrospective study was undertaken at a tertiary pediatric hospital . METHODS Children with history of PM and presenting with S/SDB were identified from a prospect ively kept surgical data base . We set out to determine the prevalence of PM among the patients presenting with S/SDB who required airway evaluations and surgery .  Pulse oximetry is overnight recordable oxygen saturation and heart rate tracing that provides information about hypoxemia during sleep . This was performed on all children preoperatively . The pulse oximetry findings were used to plan for perioperative monitoring and care . A multivariable analysis was used to identify factors predictive of abnormal pulse oximetry studies . We evaluated the associated diagnoses , surgical procedures required , and response to treatment in these selected children . RESULTS Fifty-seven out of 1,038 patients were PM ( 33 males ; mean age , 62.09 ± 34.91 months ; range , 4 - 190 months ) . The mean gestational age was 30.3 ± 4.0 weeks . The prevalence rate of PM among patients treated surgically for SDB is 5.5 % ( 95 % CI 5.2 - 5.8 ) at our center . Comorbid pulmonary and gastrointestinal disorders were encountered on 23 ( 40 % ) and 17 ( 29.8 % ) occasions , respectively , and were the most commonly encountered comorbid diagnostic categories . Large airway abnormalities were encountered in 11 ( 19.3 % ) children , and the most common were subglottic stenosis ( four ) and laryngeal paralysis ( four ) . Comorbid respiratory disease was negatively predictive of abnormal pulse oximetry ( coefficient -0.35 , P<.05 ) . Postoperative respiratory outcomes correlated with abnormal pulse oximetry ( coefficient 0.3 ; P<.05 ) . CONCLUSIONS Our findings suggest children with PM presenting to pediatric otolaryngology require a comprehensive evaluation for S/SDB . A significant proportion of children with S/SDB and a history of PM frequently had pulmonary and gastrointestinal comorbidities in our cohort . One-half required admission postoperatively , and these were predictable based on preoperative pulse oximetry . Respiratory comorbidity was negatively predictive of severity of SDB . Inversely , children with untreated pulmonary comorbidities are more likely to have postoperative complications Background : In neonatal intensive care unit ( NICU ) , neonatal sleep is disrupted due to different factors . Due to the critical role of sleep in premature infants′ brain development , this study aim ed to investigate the effect of nesting and swaddling on the sleep duration of premature infants hospitalized in NICUs . Material s and Methods : In a crossover clinical trial , 42 preterm infants who met the inclusion criteria were enrolled . They were r and omly assigned to two groups of nest-swaddle and swaddle-nest .  Sleep status was evaluated by observation and use of Prechtl′s criteria . Then , duration s of total sleep time ( TST ) and quiet sleep time ( QST ) were recorded . Data were analyzed using repeated measure analysis of variance ( ANOVA ) . Results : Mean values of TST and QST during nesting and also swaddling periods were significantly higher than in the control period in both groups ( P < 0.001 ) . Mean values of TST and QST in the swaddling period were higher than in the nesting period in both groups , However , these differences were not significant ( P = 0.245 ) . Conclusions : Both swaddling and nesting could significantly increase the duration of TST and QST , compared to the control . There were no significant differences between the effects of these interventions on TST and QST . Therefore , using any of these methods is suggested to improve infants′  quality of sleep in NICU , with respect to the ward policies STUDY OBJECTIVES The obstructive sleep apnea syndrome ( OSAS ) is more prevalent in ex-preterm children compared to the general pediatric population . However , it is unknown whether OSAS in ex-preterm children is associated with specific perinatal risk factors . This multicenter cohort study aim ed to determine perinatal factors associated with OSAS at school age . METHODS 197 ex-preterm ( 500 - 1,250 g ) children aged 5 - 12 y who participated as neonates in a double-blind , r and omized clinical trial of caffeine versus placebo ( Caffeine for Apnea of Prematurity ) underwent comprehensive ambulatory polysomnography .  A negative binomial regression model was used to identify perinatal risk factors associated with OSAS . RESULTS 19 children had OSAS ( 9.6 % ) . Chorioamnionitis and multiple gestation were positively associated with OSAS with P values of 0.014 and 0.03 , respectively . Maternal white race ( P = 0.047 ) and maternal age ( P = 0.002 ) were negatively associated with OSAS . Other risk factors , such as birth weight , Apgar score at 5 min , antenatal corticosteroids , delivery route , and sex were not significant . CONCLUSIONS OSAS is very frequent , and is associated with chorioamnionitis and multiple gestation in ex-preterm children . Those born to older white mothers appear to be protected . We speculate that the former may be due to systemic inflammation and the latter to a higher socio-economic status . COMMENTARY A commentary on this article appears in this issue on page 721 OBJECTIVE . Prematurely born compared with term born infants are at increased risk of sudden infant death syndrome , particularly if slept prone . The purpose of this work was to test the hypothesis that preterm infants with or without bronchopulmonary dysplasia being prepared for neonatal unit discharge would sleep longer and have less arousals and more central apneas in the prone position . METHODS . This was a prospect i ve observational study in a tertiary NICU . Twenty-four infants ( 14 with bronchopulmonary dysplasia ) with a median gestational age of 27 weeks were studied at a median postconceptional age of 37 weeks .  Video polysomnographic recordings of 2-channel electroencephalogram , 2-channel electro-oculogram , nasal airflow , chest and abdominal wall movements , limb movements , electrocardiogram , and oxygen saturation  were made in the supine and prone positions , each position maintained for 3 hours . The duration of sleep , sleep efficiency ( total sleep time/total recording time ) , and number and type of apneas , arousals , and awakenings were recorded . RESULTS . Overall , in the prone position , infants slept longer , had greater sleep efficiency ( 89.5 % vs 72.5 % ) , and had more central apneas ( median : 5.6 vs 2.2 ) , but fewer obstructive apneas ( 0.5 vs 0.9 ) . The infants had more awakenings ( 9.7 vs 3.5 ) and arousals per hour ( 13.6 vs 9.0 ) when supine . There were similar findings in the bronchopulmonary dysplasia infants . CONCLUSIONS . Very prematurely born infants studied before neonatal unit discharge sleep more efficiently with fewer arousals and more central apneas in the prone position , emphasizing the importance of recommending supine sleeping after neonatal unit discharge for prematurely born infants To evaluate the influence of prematurity and postnatal age on the relationship between motor activity ( MA ) and sleep states , forty clinical ly and neurologically normal infants were recorded polygraphically and grouped according to their gestational ( GA , prematures : < 36 weeks , full-term : 37 - 41 weeks ) and conceptional ( CA , 37 - 38 and 39 - 41 weeks ) ages . Sleep states ( active : AS , and quiet : QS ) were defined by the concordance of EEG and rapid eye movement criteria . Movements of both upper ( UL ) and lower ( LL ) limbs were independently recorded . In all groups the amount of MA in both UL and LL clearly predominated in AS compared with QS ( p < 0.02 ) . Contrariwise , both the longest period without movement and the no-movement 20-sec epochs were significantly higher in QS than in AS ( p < 0.005 ) . In AS , age-related modifications and modulation of MA amount throughout the state were similar for PRT and FT groups : a ) in both groups a significant decrease of MA with advancing CA was observed ( p < 0.05 ) ; b ) MA throughout the state was r and omly distributed regardless of CA . In QS , however , PRT were distinguishable from FT by the absence of : a ) a significant decrease of MA amount with advancing CA , together with a reduced increase of both the longest period without movements and the no-movement 20-sec epochs ; b ) prevalence of MA in LL compared with UL ; c ) modulation of the distribution of MA throughout the state This study investigated the prolonged effects on state behavior of theophylline administered to infants for apnea of prematurity . There were three groups : Four premature infants who had received theophylline in the preterm period , five premature infants who had not received theophylline , and twenty-eight normal fullterm infants . The Theophylline infants had been off the drug for at least one month prior to the beginning of the study . Sleep-wake states were observed in the home for seven-hour periods when all infants were the same corrected ages : two , three , four and five weeks post-term . Data from the portion of the day that the infants were alone were analysed for this study . The state organization of the Theophylline group differed significantly from those of the other groups . They exhibited more non-alert waking activity , more alert , more drowse or transition , and less active sleep than did the Non-Theophylline and Fullterm infants . The state distributions of the latter two groups did not differ . On the basis of similarities between the results of this study and of a previous animal study , it was concluded that theophylline altered the normal development of state organization in premature infants . These effects persisted long after the drug had cleared the body Purpose : Sleep and ongoing cycling of sleep states are required for neurosensory processing , learning , and brain plasticity . Many aspects of neonatal intensive care environments such as h and ling for routine and invasive procedures , bright lighting , and noise can create stress , disrupt behavior , and interfere with sleep in prematurely born infants . The study empirically investigated whether a 30-minute observation of infant sleep states and behavior could differentiate an intervention to promote sleep in premature infants with feeding difficulties relative to conventional care ( st and ard positioning , st and ard crib mattress [ SP ] ) . We included an intervention to determine the ability of the method to discriminate treatments and generate a benchmark for future improvements . The intervention , a conformational positioner ( CP ) , is contoured around the infant to provide customized containment and boundaries . To more fully verify the 30-minute observational sleep results , st and ard polysomnography was conducted simultaneously and sleep outcomes for the 2 modalities were compared . Subjects : In a r and omized crossover clinical trial , 25 infants , 31.5 ± 0.6 weeks ' gestational age and 38.4 ± 0.6 weeks at the study , with gastrointestinal conditions or general feeding difficulties used each intervention during an overnight neonatal intensive care unit sleep study . Methods : Infant sleep states and behaviors were observed during two 30-minute periods — that is , on the positioner and mattress — using the naturalistic observation of newborn behavior . Two certified developmental care nurses assessed sleep state , self-regulatory , and stress behaviors during 2-minute intervals and summed over 30 minutes . Sleep characteristics  from st and ard polysomnography  were measured at the time of behavior observations . Results : Infants on CP spent significantly less time in alert , active awake , or crying states by observation compared with SP . Surgical subjects spent more time awake , active awake , or crying and displayed a higher number of behavior state changes than the nonsurgical infants . The percentage of time in observed deep sleep and quiet sleep was correlated with both percentage sleep efficiency ( r = 0.78 ) and fewer state shifts per hour ( r = −0.65 ) from electroencephalogram ( EEG ) . Sleep efficiency by EEG was greater on CP versus SP . Conclusions : The CP enabled sleep compared with the st and ard mattress ( SP ) over 30-minute observation periods . Sleep status from behavioral observation was verified by st and ard EEG-based sleep techniques . Behavioral observation of sleep states may be a useful strategy for measuring the effectiveness of strategies to facilitate sleep in premature infants . Surgical subjects may benefit from additional interventions to promote sleep Aim : To study clinical ly relevant aspects of sleep behaviour in preterm children in comparison to term children . Methods : Longitudinal sleep behaviour data were collected prospect ively by structured interviews in 130 preterm and 75 control term children from birth to age 10 y. Results : No significant differences in sleep duration ( time in bed per 24 h ) , bedsharing , night wakings , bedtime resistance and sleep‐onset difficulties were found between preterm and term children Bathing is a routine care procedure that exposes preterm infants to prolonged h and ling , which could cause stress and potentially disrupt infants ' biobehavioral responses . The aim of this double-blind r and omized crossover trial was to compare the preterm infant 's body temperature , heart rate ( HR ) , peripheral capillary oxygen saturation ( SpO2 ) , salivary cortisol levels , and sleep-wake states during and after swaddled and conventional tub baths .  Forty-three infants born at 32 to 36 weeks postmenstrual age , weighing 2225 g or less , were enrolled in the study . Infants were videotaped before and after each type of baths . The time interval between baths ranged from 24 to 72 hours to allow a washout period . Physiological , hormonal , and behavioral responses were collected at baseline and during recovery from baths . No significant differences in the mean body temperature , HR , SpO2 , salivary cortisol levels , and sleep-wake states between the bath types were observed in the baseline or recovery responses during the first 20 minutes after bath . Regardless of bath type , salivary cortisol levels showed a nonstatistical significant increase AIM To determine whether respiratory support via heated humidified high flow nasal cannulae ( HHHFNC ) results in infants < 32weeks gestation spending a greater proportion of time in sleep compared to those receiving nasal continuous positive airway pressure ( NCPAP ) . METHODS A subgroup of infants enrolled in a r and omized controlled trial to compare HHHFNC or NCPAP post-extubation had sleep and wake activity measured by actigraphy for 72hours post-extubation . Activity diaries were completed contemporaneously to record episodes of infant h and ling . Actigraphy data were downloaded with known periods of h and ling excluded from the analysis . RESULTS 28 infants with mean gestation of 28.3weeks ( SD 2 ) and birth weight 1074 g ( SD 371 ) were studied . Infants receiving HHHFNC  spent a lesser proportion of time in sleep 59.8 % ( SD 18.5 ) than those on NCPAP 82.2 % ( SD 23.8 ) p=0.004 . Infants receiving HHHFNC had a lower sleep efficiency and higher mean activity score than those on NCPAP ( p=0.003 , p=0.002 , respectively ) . CONCLUSION Infants receiving HHHFNC  had a higher mean activity score and spent less time in sleep than those allocated NCPAP . Further study of sleep wake activity in preterm infants receiving respiratory support is required as this may impact on neurodevelopmental outcomes BACKGROUND The use of earmuffs can protect preterm infants against negative effects of high noise levels in the neonatal intensive care unit . This study was aim ed at assessing the effectiveness of the earmuffs on the physiologic and behavioral responses in preterm infants . METHODS A crossed over controlled trial was conducted at Aliasghar Hospital ( Tehran , Iran ) in 2014 . Thirty-six preterm infants cared in closed incubators , 18 cases wore a pair of silicon earmuffs in the first day and the others were worn it at the second day . During 2 consecutive days , all subjects were observed as their own controls ( without earmuffs ) . Physiologic ( body temperature , heart rate , respiratory rate , systolic , diastolic pressures , arterial Oxygen Saturation ) and behavioral responses ( according to the And erson behavioral state scoring system ) were assessed every 2 h for 8 h long during daytime for two consecutive days . RESULTS The application of earmuffs could decrease the rate of the heart and respiratory while could increase the amount of oxygen saturation ( p < 0.05 ) . The results also showed that the preterm infants  with  earmuffs had lower ABSS score and a better light sleep compared to those without earmuffs ( 2.38 ± 0.47 versus 4.8 ± 0.97 , p < 0.05 ) . CONCLUSION The results indicated that using the earmuffs reduces the level of noise in NICUs following by improving the preterm neonates ' physiological stability and behavioral states of ABSS Objective There is a paucity of data relating to neurodevelopmental outcomes in infants born late and moderately preterm ( LMPT ; 32 + 0–36 + 6 weeks ) . This paper present the results of a prospect i ve , population -based study of 2-year outcomes following LMPT birth . Design 1130 LMPT and 1255 term-born children were recruited at birth . At 2 years corrected age , parents completed a question naire to assess neurosensory ( vision , hearing , motor ) impairments  and the Parent Report of Children 's Abilities-Revised to identify cognitive impairment . Relative risks for adverse outcomes were adjusted for sex , socio-economic status and small for gestational age , and weighted to account for over-sampling of term-born multiples . Risk factors for cognitive impairment were explored using multivariable analyses . Results Parents of 638 ( 57 % ) LMPT infants and 765 ( 62 % ) controls completed question naires . Among LMPT infants , 1.6 % had neurosensory impairment compared with 0.3 % of controls ( RR 4.89 , 95 % CI 1.07 to 22.25 ) . Cognitive impairments were the most common adverse outcome : LMPT 6.3 % ; controls 2.4 % ( RR 2.09 , 95 % CI 1.19 to 3.64 ) . LMPT infants were at twice the risk for neurodevelopmental disability ( RR 2.19 , 95 % CI 1.27 to 3.75 ) . Independent risk factors for cognitive impairment in LMPT infants were male sex , socio-economic disadvantage , non-white ethnicity , preeclampsia and not receiving breast milk at discharge . Conclusions Compared with term-born peers , LMPT infants are at double the risk for neurodevelopmental disability at 2 years of age , with the majority of impairments observed in the cognitive domain . Male sex , socio-economic disadvantage and preeclampsia are independent predictors of low cognitive scores following LMPT birth Objective : Children with sleep disorders tend to experience attention problems , yet little is known about the relationship between sleep and attention in early development . This prospect i ve follow-up study investigated the longitudinal relationships between neonatal sleep , attention , and distraction in infants born preterm . Method : We used actigraphy and sleep-wake diaries in the neonatal intensive care unit ( NICU , N = 65 ) , attention orienting in a visual-recognition-memory task ( VRM ) at age 4 months , and structured observation of attention and distractibility at age 18 months . Results : Infants with poorer neonatal sleep ( n = 31 ) exhibited longer first gaze duration s in the VRM at 4 months and longer distraction episodes at 18 months relative to neonatal controls who slept well ( p < .01 ) . Hierarchical regression models support relations between neonatal sleep and gaze behavior at 4 months and distractibility at 18 months ; moreover , alterations in orienting attention at 4 months predicted the likelihood of being distracted during the second year of life . Conclusion : Findings underscore the importance of early sleep-wake and attention regulation in the development of distraction in infants born preterm Compared to r and omized controlled trials , non-r and omized studies of interventions might be biased in additional domains . As most previous tools for assessing risk of bias are not sufficient , a Cochrane working group has developed a new risk of bias tool called ROBINS-I ( Risk of bias in non-r and omized studies of interventions )
target: Compared to full term , premature infants exhibit significant differences in sleep structure , which mainly include differences in electroencephalographic spectral values , in total sleep time and in arousal threshold .
  Furthermore , prematurity seems to be a risk factor of sleep breathing disorders in childhood and adolescence .
  Conclusions The alterations in sleep patterns are an outcome of prematurity ( immaturity of nervous system ) as well as of postnatal factors and comorbidities .
  Sleep problems in this population of infants seems to be a missing piece of the puzzle of impaired neurodevelopment .
background: Background Sleep undergoes changes from birth to adulthood , while sleep disorders are associated with various cognitive deficiencies in childhood .
  In parallel , prematurity is known to predispose to poor neurodevelopmental outcomes .
  Our aim is to provide literature data about factors influencing sleep in the premature infants and sleep outcomes in this population .