Brain, Vol. 123, No. 3, 654-655,
March 2000
© 2000 Oxford University Press
Book reviews |
ATLAS OF SLEEP MEDICINE IN INFANTS AND CHILDREN.
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Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, London, UK University Children's Hospital, Queen Fabiola, Brussels, Belgium
The importance of sleep and its disorders is increasingly recognized, with a growing demand for more precise diagnosis, since sleep-related problems can be extremely disruptive within the family. There is a consensus that polysomnography is the technique of choice which yields clinically useful information in this context. Major technological improvements and greater availability of recording equipment have contributed to the relatively recent development of sleep medicine.
Children tend to present with a different set of problems from adults and, as ever, interpretation is made more complex by maturational factors. In the introduction to this atlas, the authors make the point that sleep medicine has been born out of four disciplines—neurology, pulmonary medicine, psychiatry and psychology—and that very few practitioners have been paediatricians. The authors have therefore set out to present standards for recording procedures, illustrate important findings and highlight common pitfalls in paediatric sleep medicine, based on their extensive experience.
The quality of any atlas depends on its illustrations. In this book, they are clear and presented in landscape form, with a good degree of consistency in the display of data. The authors have chosen not to present ideal recordings, providing the reader with realistic examples, for instance often showing contamination of channels by other biological signals. It is, however, not always clear whether the legends are describing everything in the associated figures or making more general points.
The book is divided into five sections. The introductory text to each is very brief and might have been extended, but contains appropriate selections of seminal references, both historical and current. Following the Foreword and brief Introduction, the first section deals with recommended recording techniques. The recommendations are fairly pragmatic, and while variations in the practice of different centres are mentioned in passing, there is no discussion of their appropriateness. However, some of the technical issues are mentioned in the figure legends. For instance, the use of thermistry rather than capnography in the assessment of hypopnoea is illustrated and discussed. The authors raise the vexed question of the appropriate number of EEG channels to be recorded in order to detect a probable or possible epileptic process as the basis of the sleep disorder. The implicit message that the choice of EEG recording montage is based upon the fundamental clinical skills of adequate history taking and examination might have been emphasized more clearly. The issues of automated sleep staging and event recognition are not addressed.
The next section is devoted to home monitoring, which is being used more widely. While this approach seems attractive in the context of the current focus on `ambulatory paediatrics', the authors emphasize its inherent limitations and difficulties.
The third section, devoted to artefacts, is one of the most important in the book, and is likely to be consulted frequently by those trying to interpret their own recordings. The authors rightly highlight the importance of the skilled technician in recognizing, annotating and, where possible, improving the quality of the recording. One common problem with many digital systems is that saturation of the signal results in an apparently abnormal rhythmic activity, and it might have been helpful to illustrate this.
The normal polysomnogram is illustrated in the following section. With regard to premature babies, more illustrations would have been particularly welcome, demonstrating the different stages of development and, indeed, of sleep states. The authors have perhaps overdone their efforts to present a brief simplified overview of early sleep maturation. For example, they mention only tracé alternant as a feature of quiet sleep in the infant approaching term. The importance of a book of this type is in pointing out prominent maturational features in children's recordings which may appear unusual or even abnormal to an interpreter who is unfamiliar with them. It is therefore surprising that, for example, the marked changes that sleep spindles undergo in the first year of life are not alluded to. Some of these features are recognizable in the illustrations, but the attention of the novice might have been drawn to them. However, the authors do place appropriate emphasis on the importance of behavioural observations.
Abnormalities are dealt with in the final sections, the first being on `disorders'. The illustrations are clear, although not all neurologists would agree with the categorization of some of the phenomena as abnormal. An indication of the particular definitions that the authors were using would have been helpful here. The relation between obstructive sleep apnoea and sudden infant death syndrome is not discussed.
There are some useful illustrations of hypnograms together with all-night data showing events. The chapter on the parasomias contains a representative selection of those seen in childhood, and is one of the more successful sections of the book.
The final part of the book is concerned with sleep in children with neurological conditions. The introduction to this section is somewhat longer, and gains thereby in clarity and in conveying a sense of perspective. In a future edition, perhaps a more balanced range of conditions might be illustrated. For example, conditions such as Rett's syndrome or narcolepsy, although rare, pose a sufficiently common diagnostic challenge to warrant inclusion in an atlas of paediatric sleep medicine. There is a welcome emphasis on the importance of using video in documenting clinical behaviour correlated with epileptiform abnormalities. However, the usefulness of this book would have been significantly enhanced if polysomnographic aspects of a much wider range of epileptic disorders had been included.
Given that this is a book which will be consulted repeatedly, it is regrettable that pages of the review copy began to fall out from the first time the book was opened. Perhaps production copies will be more robust.
The authors have clearly expended considerable effort in putting this atlas together, with over 120 illustrations that are generally of high quality. However, the scope of paediatric sleep disorders is so wide that this volume cannot be considered comprehensive. Nonetheless, it provides a welcome introduction to polysomnography in children and it should find a niche in departments recording sleeping children.
Notes
By Stephen H. Sheldon, Susan Riter and Detrojan Armonk. 1999. Pp. 288. New York: Futura Publishing Company, Inc. Price $150. ISBN 0-87993-423-9.
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