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In March 2014, the American Academy of Sleep Medicine (AASM) Board of Directors requested the Scoring Manual Editorial Board develop rules, terminology, and technical specifications for scoring sleep/wake states in full-term infants from birth to 2 mo of age, cognizant of the 1971 Anders, Emde, and Parmelee Manual for Scoring Sleep in Newborns. On July 1, 2015, the AASM published rules for scoring sleep in infants, ages 0–2 mo. This evidence-based review summarizes the background information provided to the Scoring Manual Editorial Board to write these rules. The Anders Manual only provided criteria for coding physiological and behavioral state characteristics in polysomnograms (PSG) of infants, leaving specific sleep scoring criteria to the individual investigator. Other infant scoring criteria have been published, none widely accepted or used.
The AASM Scoring Manual infant scoring criteria incorporate modern concepts, digital PSG recording techniques, practicalities, and compromises. Important tenets are: (1) sleep/wake should be scored in 30-sec epochs as either wakefulness (W), rapid eye movement, REM (R), nonrapid eye movement, NREM (N) and transitional (T) sleep; (2) an electroencephalographic (EEG) montage that permits adequate display of young infant EEG is: F3-M2, F4-M1, C3-M2, C4-M1, O1-M2, O2-M1; additionally, recording C3-Cz, Cz-C4 help detect early and asynchronous sleep spindles; (3) sleep onsets are more often R sleep until 2–3 mo postterm; (4) drowsiness is best characterized by visual observation (supplemented by later video review); (5) wide open eyes is the most crucial determinant of W; (6) regularity (or irregularity) of respiration is the single most useful PSG characteristic for scoring sleep stages at this age; (7) trace alternant (TA) is the only relatively distinctive EEG pattern, characteristic of N sleep, and usually disappears by 1 mo postterm replaced by high voltage slow (HVS); (8) sleep spindles first appear 44–48 w conceptional age (CA) and when present prompt scoring N; (9) score EEG activity in an epoch as "continuous" or "discontinuous" for inter-scorer reliability; (10) score R if four or more of the following conditions are present, including irregular respiration and rapid eye movement(s): (a) low chin EMG (for the majority of the epoch); (b) eyes closed with at least one rapid eye movement (concurrent with low chin tone); (c) irregular respiration; (d) mouthing, sucking, twitches, or brief head movements; and (e) EEG exhibits a continuous pattern without sleep spindles; (11) because rapid eye movements may not be seen on every page, epochs following an epoch of definite R in the absence of rapid eye movements may be scored if the EEG is continuous without TA or sleep spindles, chin muscle tone low for the majority of the epoch; and there is no intervening arousal; (12) Score N if four or more of the following conditions are present, including regular respiration, for the majority of the epoch: (a) eyes are closed with no eye movements; (b) chin EMG tone present; (c) regular respiration; and (d) EEG patterns of either TA, HVS, or sleep spindles are present; and (13) score T sleep if an epoch contains two or more discordant PSG state characteristics (either three NREM and two REM characteristics or two NREM and three REM characteristics).
These criteria for ages 0–2 mo represent far more than baby steps. Like all the other AASM Manual rules and specifications none are fixed in stone, all open for debate, discussion and revision with the fundamental goal to provide standards for comparison of methods and results.
A commentary on this article appears in this issue on page 291.
Grigg-Damberger MM. The visual scoring of sleep in infants 0 to 2 months of age. J Clin Sleep Med 2016;12(3):429–445.
At increasingly younger ages, children are being referred to sleep specialists, technologists, laboratories, and centers in the United States. Criteria for scoring sleep in children developed by the American Academy of Sleep Medicine (AASM) are for children 2 mo of age or older.1 Members of the AASM requested rules and recommendations for scoring sleep in neonates and infants. In March 2014, the AASM Board of Directors requested the Scoring Manual Editorial Board develop rules, terminology, and technical specifications for scoring sleep/wake states in full-term infants from birth to 2 mo of age,2 cognizant of the 1971 Anders, Emde, and Parmelee Manual for Scoring Sleep in Newborns (Anders Manual).3 Rules for scoring respiratory events or arousals in infants this age were not devised, reflecting a belief that the current rules for scoring these would suffice for now. On July 1, 2015, the AASM published rules for scoring sleep/wake states in infants 0–2 mo of age.2 This review summarizes the background information provided to the Scoring Manual Editorial Board to write these rules.
Knowing an infant's conceptional age (CA) is crucial for interpreting the normalcy, immaturity, or abnormality on an electroencephalogram (EEG) or polysomnogram (PSG) because the brain and the EEG continue to develop and mature at a similar rate independent of whether the infant is in utero or post-delivery. Except when stressed, or in situations involving encephalopathy, seizures, or medication-related factors, the PSG in infants 6 mo or younger reflects the developmental age of the brain.4–6 The PSG of a normal low-risk premature infant born at 32 w gestational age (GA) whose chronological or legal age is 8 w should resemble that of a normal infant of 40 w GA born 2 days earlier.
CA is the GA at birth plus the number of weeks postpartum.7 GA is the time elapsed between the first day of the mother's last menstrual period and the day of delivery expressed in completed weeks. If the pregnancy was achieved using assisted reproductive technology, GA is calculated by adding 2 w to the CA. Chronological age (or postnatal or legal age) is the time elapsed since birth (and can be expressed in days, months, or years). The American Academy of Pediatrics recommends postmenstrual age (PMA) be used instead of CA, but CA is used here (and in the scoring criteria) because the evidence cited uses CA.7 At birth, an infant is classified as being born premature (< 37 w gestation), full-term (37–42 w); or postterm (born after 42 w). A neonate is a child during the first 28 days after birth; an infant is a child between 1–12 mo of age.7
To write this review, the author did a literature search using PubMed and searching for terms: infant or neonatal or fetal AND sleep OR polysomnography. The author additionally searched for development and sleep, sleep spindles, eye movements and sleep, and infant. More than 3,000 abstracts and papers were found. The author reviewed the abstracts of these, and then identified relevant papers. From references contained in some of these, the author found other papers that were then reviewed. The author wrote a preliminary version of this review, which was submitted to the Scoring Manual Editorial Board to assist them in writing the rules. Illustrative figures of PSG epochs were provided from the author's sleep laboratory demonstrating wakefulness (W), rapid eye movement (REM, R), nonrapid eye movement (NREM, N) and transitional sleep (T), and different EEG patterns seen in these states.
The author later suggested preliminary scoring rules and technical recommendations to the Scoring Manual Editorial Board for their consideration. The Scoring Manual Board reviewed these and wrote the rules and recommendations, submitting these to the AASM Board of Directors for revision and approval. The author reviewed the final rules and recommendations and revised this paper, summarizing these. The Scoring Manual Board requested only rules for scoring sleep/wake states in from 0–2 mo of age. Rules for scoring respiratory events or arousals were not requested, nor were rules for scoring sleep/wake states in premature infants.
The earliest studies of sleep and waking in infants were based on observations of caregivers watching bedside.8–10 The first observations of cyclic fluctuating levels of arousal and motor behavior in humans were studied in infants, not adults. The discovery of REM sleep was made possible by Aserinsky and Kleitman,11 who decided to simultaneously record eye movements (electro-oculography, EOG) and EEG in infants because they thought eye movements were a better marker of state changes than EEG. To their surprise, clusters of REMs were observed when infants fell asleep. In 1955, they published their findings that infants when sleeping exhibited regularly recurring periods of eye motility and other concomitant motor behaviors.12 This discovery soon led to the recognition of REM sleep and its association with dreaming in adults by Dement and Kleitman in 1957.13
Beginning in the late 1950s, neonatal electroencephalographers14–17 and infant sleep researchers18–24 systematically studied the EEG, PSG and behaviors of sleep and wake in full-term infants. Dreyfus-Brisac et al.,14 Dreyfus-Brisbac and Monod,15 Monod and Pajot,16 and Parmalee et al.17,25 identified REM and NREM sleep states, respectively, terming them active sleep (AS) and quiet sleep (QS). Infants during QS/NREM were "very quiet" with regular respiration and heart rates, preserved chin electromyography (EMG) activity, and no or rare vertical eye movements. Whereas, during AS/REM sleep, REMs, small movements of the limbs or face, irregular respiration and heart rates, and no chin muscle activity were noted. They identified and named four different EEG patterns seen in term infants when sleeping: tracé alternant (TA), high voltage slow (HVS), activité moyenne (mixed, M), and low voltage irregular (LVI)15,26–28 (Figure 1). They recognized that normal infants had many periods (or epochs) of sleep that were not easily categorized as a particular sleep state because of discordant features between the physiological markers of sleep/wake states (EEG, EOG, chin EMG, respiration, and body movements).16,26,29 These were variously called transitional, indeterminate, or intermediate sleep.
Thirty-second epochs of each of the four sleep EEG patterns seen in infants between ages 0–2 mo: (A) mixed (M) EEG pattern characterized by both high voltage slow (HVS) and low voltage polyrhythmic components intermingled with little periodicity; (B) high voltage slow (HVS) EEG pattern characterized by continuous synchronous symmetrical predominantly high voltage (100–150 μV) 1–3 Hz delta activity, which often has an occipital or central predominance; (C) trace alternant (TA) pattern characterized by ≥ 3 alternating runs of bilaterally symmetrical synchronous high voltage (50–150 μV) bursts of 1–3 Hz delta activity lasting 5–6 sec (range, 3–8 sec) alternating with periods of lower amplitude (25–50 μV) 4–7 Hz theta activity (range, 4–12 sec); and (D) low voltage irregular (LVI) EEG pattern characterized by continuous low voltage mixed-frequency activity with delta and predominantly theta activity. The only EEG pattern distinctive of a particular sleep/wake state is trace alternant (TA) which when present suggests NREM sleep. The other three EEG patterns can be observed in more than one sleep/wake state. The (M pattern can be seen in W or R, rarely N; LVI in either R or W; and HVS most often in N, rarely R. The EEG pattern of R sleep before a period of R is often M, and LVI after a period of N (respectively termed AS1 and AS2).
Electroencephalogram (EEG) patterns of sleep in infants 0–2 mo of age.
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By the 1960s, neonatal electroencephalographers had delineated how the characteristic EEG patterns of AS and QS evolve in premature infants with increasing CA based on hundreds of neonatal EEG studies.17,30,31 These studies found that the behavioral correlates (and cycles) of REM sleep are seen as early as 25–30 w CA when the EEG was still undifferentiated.32,33 Recognizable EEG patterns of REM and NREM sleep first appeared at 32–34 w CA.31 In 1968, Parmelee et al.17 published a seminal catalog of EEG patterns observed in infants at each CA. With the catalog, the authors were able to predict an infant's CA within 2 w in 85% of infant EEGs scored blindly.17 In 2010, Andre et al.32 published a comprehensive and well-illustrated glossary of the EEG features and neonatal behavioral states at different CA, which incorporates digitized EEG tracings and cites available evidence for the patterns of both normal and pathological neonatal EEGs, a worthy tool when reading PSGs in children this age.
During the same period, infant sleep researchers Prechtl18,20,34,35 and Anders et al.21–24 developed scales for "staging" sleep in infants solely based on behavioral observations (Table 1). They argued that particular combinations of behaviors more reliably identified sleep/wake states and even normalcy of development than EEG. Although this approach continues to be used by Anders and his colleagues, the two schools merged into one to develop the Anders Manual for scoring sleep in newborn infants published in 1971.3
Anders and Chalemian methodology for scoring sleep in infants solely based on behavioral observations.
In 1969, the Association for the Psychophysiological Study of Sleep (APSS, the earlier name of the Sleep Research Society) chartered an ad hoc committee to develop a guide for scoring sleep in infants.3 This committee (chaired by Anders, Emde, and Parmelee) developed consensus-derived terminology, criteria for coding sleep/wake states, and a manual containing illustrative examples for scoring sleep in healthy normal full-term infants. The authors of A Manual for Standardized Terminology, Techniques, and Criteria for Scoring of States of Sleep and Wakefulness in Newborn Infants emphasized it was meant only to provide criteria for coding physiological and behavioral parameters in PSGs of healthy full-term infants, leaving "specific criteria for scoring states…to the investigator."3
Anders et al.3 reported they "had considerable difficulty reaching a consensus on the criteria for scoring states" in part because of debates about recognizing or ignoring indeterminate or transitional sleep with discordant features for the particular sleep state. Committee members used to scoring sleep primarily in adults "were inclined to ignore indeterminate sleep" while infant sleep researchers did not. By hard-won consensus, the Committee agreed to score either 20- or 30-sec epochs from lights out to lights on as either wakefulness (W), quiet (Q), active (A), or indeterminate (I) sleep. Anders et al.3 presumed that QS and AS, respectively, were antecedents of NREM and REM sleep.
Contained within the Anders Manual are important observations that continue to serve when scoring sleep/wake in newborns. Transitions from W to sleep are particularly difficult to score in neonates because (1) sleep onset is most often REM sleep; (2) there is no dominant posterior rhythm in wakefulness to drop out; (3) the EEG backgrounds of W and REM sleep are quite similar, both "continuous" mixed frequencies; and (4) short periods of drowsiness often alternate with REM sleep. Epochs of indeterminate or transitional sleep are most often observed at sleep onset, upon arousal, and especially in transitions from REM to NREM sleep. The EEG pattern of TA is only seen in NREM sleep, LVI in REM sleep, but HVS and M can be seen in either NREM or REM sleep. Regularity (or irregularity) of respiration is the single PSG characteristic most useful for scoring sleep states in infants. They defined regular respiration (characteristic of NREM sleep) as a period in which the respiratory rate varies by < 20 breaths per minute; irregular respiration > 20 breaths per minute.3,16 They thought regularity of respiration could usually be determined by visual inspection.3 If more precise measurement was needed, they advised measuring the longest and shortest respiratory cycles in an epoch, and extrapolating the respiratory rates of each of these for 1 min.
Since the publication of the Anders manual in 1971,3 several groups have published criteria for scoring sleep in PSG of newborns and young infants, but none have been widely accepted or used.36–38 All said these were based on the Anders Manual criteria. In 1987, Hoppenbrouwers et al.36 published criteria for scoring sleep/wake in infants between birth and 6 mo of age using 60-sec epochs and recognizing four states: wakefulness (AW), active sleep (AS), quiet sleep (QS), indeterminate sleep (IS). In 1997, Crowell et al.39 developed detailed PSG recording and sleep/wake scoring criteria for the Collaborative Home Infant Monitoring Evaluation (CHIME) study (a prospective multicenter collaborative home infant monitoring study of 415 healthy infants ages 34–64 w CA). These criteria use C4-A1 as the primary EEG derivation and C3-A2 as a "back-up channel" in case the first malfunctioned. A particular EEG pattern was scored if it occupied > 50% of a 30-sec epoch. Wakefulness they thought was most easily scored when the infant's eyes were open, crying, or being fed. Transitional (T) sleep was scored if a 30-sec epoch contained too many discordant state markers (e.g., three NREM + two REM state characteristics or two NREM + three REM state characteristics). They recommended ignoring respiratory pauses lasting > 3 sec and small movements when assessing regularity or irregularity of respiration in a given epoch. Table 2 summarizes the definitions of sleep EEG patterns in different infant sleep scoring criteria.
Definitions of sleep electroencephalogram patterns in different infant sleep scoring criteria.
In general, the technical specifications for recording PSG in infants 0–2 mo of age are much the same as those recommended by the AASM Manual for scoring children 2 mo to 18 y of age. However, a few important differences should be mentioned. Infant EEG is often of much higher voltage requiring sensitivity settings of 10–15 μV/mm (but an initial gain of 7 μV/mm is appropriate).32 It is important to record EEG over the mid-line (Cz, vertex) because sleep spindles appear here first, and wise to display left and right central EEG derivations because sleep spindles are more often asynchronous at this age. An EEG montage that permits adequate display of young infant EEG is: F3-M2, F4-M1, C3-M2, C4-M1, O1-M2, O2-M1, adding C3-Cz, Cz-C4 to optimize detection of asynchronous sleep spindles. Figure 2 shows a PSG montage the author's laboratory uses to record infants 0–2 mo of age. Lead I electrocardiographic electrodes are placed on the right and left arms which permits simultaneous recording of electrocardiographic as well as arm movements. Recording video to correlate behaviors with other PSG features is crucial for recognizing sleep/ wake states, especially W. However, even more important are real time observations and detailed documentation of behaviors by the sleep technologist during collection to confirm if a restless baby is in W, R, or T.
Eye channels (left eye [E1], right eye [E2]) are referenced to the midline frontopolar electrode (FPz). Electroencephalogram (EEG montage is left frontal-right mastoid (F3-M2), right frontal-left mastoid (F4-M1), left central-right mastoid (C3-M2), right central-left mastoid (C4-M1), left occipital-right mastoid (O1-M2), right occipital-left mastoid (O2-M1), left central-midline central (C3-CZ), and midline central-right central (CZ-C4). This EEG montage allows easy recognition of low voltage 12–14 Hz sleep spindles, which may be seen as early as 43 w, usually present by 45–48 w CA. Other PSG signals recorded include: EKG, chin electromyogram (EMG), left and right anterior tibialis (L Leg, R Leg) muscles, snore microphone, nasal pressure (NP), thermal sensor, respiratory inductance plethysmography (RIP) thoracic, RIP abdomen, RIP SUM, pulse oxygen saturation (SpO2), R-R interval, pulse waveform, endtidal carbon dioxide (EtCO2), capnogram, and transcutaneous carbon dioxide (tcCO2).
Polysomnographic (PSG) montage for recording infants 0–2 mo of age.
Sleep is the penultimate behavioral state of the fetus, neonate, and young infant. The ontogenetic development of sleep follows orderly reproducible patterns.40–44 The behavioral correlates of REM sleep are seen as early as 28–30 w CA when the EEG was still undifferentiated; recognizable EEG patterns of REM and NREM sleep first appear at 32–34 w CA.32,33,45,46 Piaget47 and Piers and Piaget48 thought play was the major "work" of children, but for infants it is sleep. Newborn full-term infants typically spend 16–18 h per day sleeping. 70–80% of sleep time is spent in REM sleep in preterm infants and 50% in term infants, falling to 30% by 6 mo of age, and adult levels of 20–25% by 5 y of age.49 The greater time spent sleeping in infants and early childhood is thought to reflect the crucial role sleep plays in fostering optimal brain development, cognition, and behavior. The time course of REM sleep development (and decline) in humans corresponds well with critical periods of brain maturation.68 Why do infants spend so much time in REM sleep? Roffwarg and Dement50 and Marks et al.51 were first to speculate greater time spent in REM sleep could provide sensory experiences in the absence of external stimuli in utero. Sleep in premature infants in utero is not a passive state of rest, waiting for birth, but a time in which neuronal networks underlying vision, olfaction, somatosensory, and motor pathways are being devised. Infants twitch far more when sleeping than adults, even more so when they are premature. Premature infants from 24–35 w CA are constantly moving and twitching, far more than those born closer to term.
In utero muscle twitches (often tens of thousands per day) are neither random nor purposeless. Evidence from studies in human infants and infant animal models show feedback from a twitching limb guides organization of spinal sensorimotor circuits and trigger 1-sec bursts of electrical activity in appropriate regions of the developing somatosensory cortex. These bursts of electrical activity are triggered by proprioceptive feedback from the twitching limb.40,52 These bursts of EEG activity are none other than the quintessential EEG signature of premature infants, delta brushes. Scalp EEG recorded delta brushes reflect bursts of 8–25 Hz electrical activity within the cortex which is most prominent and prevalent during the third trimester of gestation. Myoclonic twitching during sleep in early development are thought to: (1) sculpt nascent neuronal circuits in the cerebral cortex; (2) guide the formation, rearrangement, and elimination of synapses; and (3) construct sensory maps for auditory, motor, touch, and noxious topographic regions of the brain and the infant connectome.53 Blumberg et al. (2014) argue that myoclonic twitches during REM sleep in infants represent a form of motor exploration which help human infants and other mammals explore limb biomechanics, build motor synergies, and lay a foundation for complex, automatic, and goal-directed movements when awake.44,45
Until approximately 44 w CA, sleep cycles repeat in a polyphasic pattern across the 24-h day interrupted approximately every 3–4 h by waking for care and feeding.54 Sleep onset is more often REM sleep in infants until 2–3 mo of age (Figure 3). Sleep cycles in healthy infants at term typically last a mean of 50–60 min (range, 30–70 min).55 At 43–48 w CA, sleep cycles average 60 min, wake periods are primarily to feed, the first half of the night sleep is more restless, and artifact more likely to obscure sleep scoring particularly in REM sleep. Sleep at this age is more restless in the first half of the night.55 Wakefulness usually accounts for only 8–10% of a 24-h day in infants up to 48 w CA.54
Sleep onsets more often are REM sleep in healthy infants until 2–3 mo postterm. Note sleep onset (purple arrow) is REM sleep (black bars). Note more than half the sleep time is spent in REM sleep, typical for infants this age.
Hypnogram showing rapid eye movement (REM) sleep onset in an infant.
Within a given REM-NREM-REM sleep cycle, REM sleep lasts 10–45 (mean 25) min, NREM sleep 20 min, and T sleep 10 min.16,54 The EEG pattern seen in the first REM sleep of a REM-NREM-REM sleep cycle after W is typically Mixed and comprises 25–30% of the cycle (Figure 4A). Of note, NREM sleep following a first period of REM sleep often begins with a brief period of HVS for 3–5% of the cycle (Figure 4B), then a longer period of TA (Figure 4C) for 25%. The sleep cycle then ends with another period of REM sleep but typically with LVI (Figure 4D) and for 25% of the cycle. 10–15% of epochs of sleep within the REM-NREM-REM ultradian sleep cycle are best scored as T sleep (Figure 5); these most often occurring at sleep onset, stage shifts (especially W to REM sleep (less often REM to NREM sleep) and following arousals or awakenings. A recently published study recording comprehensive home PSG on 84 healthy normal infants 44–48 w CA scored using infant sleep scoring they had adapted using AASM 2012 sleep scoring criteria.66 They reported mean time in bed was 719 ± 82 min, total sleep time (TST) 477 ± 59 min, and percentages of TST in REM sleep 37 ± 7%, NREM sleep 42 ± 5%, and T sleep 22 ± 6%. Using current AASM Manual scoring criteria, awakenings averaged 8.5 ± 2.1/h, arousals 19.3 ± 3.7/h of sleep, mean apneahypopnea indexes (AHI) 13.7 ± 14.1/h, obstructive AHI 0.0 ± 0.0/h, and 3% desaturation indexes of 20.9 ± 16.9/h.
(A) 30-sec epoch of rapid eye movement (REM) sleep with mixed (M) electroencephalogram (EEG) pattern, REMs and low chin electromyogram (EMG) tone typically seen following a period of wakefulness; (B) 30-sec epoch of NREM sleep with high voltage slow (HVS) EEG pattern, no eye movements, preserved chin EMG, and regular respiration, which often precedes longer period of trace alternant (TA) in infants at 38–42 w conceptual age (CA); (C) 30-sec epoch of nonrapid eye movement (NREM) sleep with trace alternant (TA) EEG pattern, no eye movements, regular respiration; and (D) 30-sec epoch of REM sleep with a low voltage irregular (LVI) EEG pattern, rapid eye movements (REMs), irregular respiration, and low chin EMG tone.
Representative examples of polysomnographic patterns of sleep in infants 0–2 mo of age.
The discontinuous EEG pattern of trace alternant, absence of eye movements and the regular heart rate suggest stage N, but irregular respiration and body movements are more consistent with REM sleep (stage R). The AASM Scoring rules for scoring sleep in infants recommend scoring stage T if 3 NREM + 2 REM characteristics or 2 REM and 3 NREM characteristics are discordant. See Figure 2 for explanation of the various channels displayed in the montage.
A 30-second epoch of sleep best scored as transitional sleep (T).
Sleep studies in infants 0–2 mo of age are most often done to evaluate for sleep disordered breathing (SDB).56–58 Several authors recently summarized current information on normal values for SDB in PSG done neonates and young infants.59–64,65 They found that: (1) apneas are common in normal infants this age; (2) the majority of apneas observed are central in type (70–80%) and typically last ≥ 3 but < 10 sec; (3) central apneas are commonly seen in REM sleep, after a sigh breath or a body movement, and during transition from wakefulness to sleep; (4) apneas lasting > 10 seconds are usually mixed apneas; and (5) periodic breathing is common typically averaging < 5% of sleep time for infants 1 and 3 months of age. Based on these studies (albeit limited), Ng et al.66 proposed an upper limit of normal central apnea index (CAI) was 45 central apneas per hour of sleep for 1-mo-olds and 30/h for 2-mo-olds. Ng et al. emphasized that obstructive apneas are uncommon in healthy neonates and young infants and suggested the upper limits of normal for both obstructive and mixed apneas are indexes of < 1.0/h of sleep. More normative data is needed.
The medical literature suggests the most crucial determinant of W (Figure 6) in a normal healthy term infant is open eyes (although transient eye closures often occur especially when crying). Characteristic features of W in infants 0–2 mo of age are: (1) open eyes (which sometimes pursue visual targets); (2) elevated chin EMG tone; (3) elevated limb EMG tone; (4) rapid and irregular heart rates; (5) rapid and irregular respiratory patterns; (6) spontaneous movements; (7) crying; and (8) a continuous synchronous symmetric irregular mixed frequency EEG with superimposed frequent movement artifacts.54,68
The technologist noted eyes open, moving head and crying. The EEG is continuous mixed EEG frequencies, rapid eye movements are present, chin muscle tone is high, respiration irregular and rapid, and movement and muscle artifact mar the tracing. See Figure 2 for explanation of the various channels displayed in the montage.
A 30-second epoch of sleep best scored as wakefulness (W).
Infants this age have a variety of eye movements when awake, including eye blinks, conjugate 0.5–2 Hz vertical eye movements, and conjugate irregular sharply peaked rapid eye movements with an initial deflection of < 500 msec.43 Lambda waves have been observed as early as 2 w following birth in calm awake newborns looking at a visual target.69 These are characterized by sharply contoured waveforms over the occipital regions lasting 250–350 msec.69 Sucking and puckering mouth movements and/or dysconjugate eye movements are common in newborn infants when awake and are not to be mistaken for seizures.
The EEG background in infants 37–48 w CA is continuous and can include mixtures of either: (1) irregular theta and delta activity with amplitudes up to 100 μV maximal over the occipital regions; (2) diffuse irregular alpha and beta activity with amplitudes up to 30 μV; or (3) rhythmic theta activity with amplitudes up to 50 μV, and often maximal over the central regions.
W at 46 w CA is characterized by mixed frequency EEG activity, artifacts from body movements, eye movements, bursts of muscle activity in the chin and anterior tibialis EMG, irregular respiration, and pronounced heart rate variability. The EEG background awake at this age consists of a symmetrical continuous mixture of mixed EEG frequencies (Figure 6).
Of note, the AASM Manual recommends scoring a 30-sec epoch as W if either a, b, or c is present for the majority of the 30-sec epoch: (a) eyes are wide open (for the majority of the epoch); (b) vocalization (whimpering, crying, etc.) or actively feeding; and (c) all of the following conditions are met: (1) eyes are open intermittently; (2) rapid eye movements or scanning eye movements; (3) sustained chin EMG tone with bursts of muscle activity; (4) irregular respiration, and (5) the EEG shows low voltage irregular (LVI) or mixed (M) patterns.
Recognizing sleep onset in infants 0–2 mo of age is especially difficult. Sleep onsets are typically REM sleep (often preceded by a few epochs of sleep best scored as T). Sustained eye closure is the best physiological marker of drowsiness in an infant this age. Other behaviors suggestive of drowsiness are absence of focused attention, relative immobility, and intermittent opening and closing of eyes. If an infant's eyes remain closed for greater than 3 min, the infant is considered asleep.
By 44–48 w CA, more sleep onsets may be NREM sleep.70,71 REM sleep latencies at this age may be short (< 8 min) or longer (> 16 min). The EEG background in wake/sleep transitions may show increases in the amplitudes of theta and delta activity especially over the frontal regions. Isolated generalized myoclonic jerks can be seen as an infant wakes from sleep, not to be mistaken for seizures.
Characteristic features of NREM (N, Quiet) sleep at 38–42 w CA include: (1) no body movements; (2) no eye movements; (3) regular respiration; (4) regular heart rate; (5) some chin EMG activity; and/or (6) EEG pattern of either TA or HVS activity.26,29,72 The AASM Manual recommends scoring stage N if four or more the following are present, including regular respiration for the majority of the 30-sec epoch: (a) eyes closed with no eye movements; (b) chin EMG tone present; (c) regular respiration (postsigh respiratory pauses may occur); (d) TA, HVS, or sleep spindles present; and (e) reduced movement relative to wake.
Regularity of respiration during NREM/quiet sleep is reliably present in infants 40 w CA.26,73 However, chin EMG activity may be inappropriately absent or low in 15–20% of the N sleep time in infants 40 w CA.29 Similar percentages of absent chin EMG tone during N sleep are also seen 6-mo-old infants26,74,75 and even in adults.76 Two PSG markers best identify N sleep in infants 37–44 w CA: the discontinuous EEG pattern of TA and regularity of respiration.
It is worthwhile to appreciate the distinctive features of the TA pattern: bilaterally symmetrical and synchronous high voltage (50–150 μV) bursts of 1–3 Hz delta activity which typically last 5–6 sec (range, 3–8 sec) alternating with lower amplitude (25–50 μV) 4–7 Hz theta activity inter-burst intervals (IBIs) of similar duration (Figure 4C).32 Intermixed alpha and beta activity and isolated sharp waves in the theta range up to 100 μV are observed in the bursts of TA. Temporal asynchrony of the EEG background for several minutes can be seen during transition from REM to NREM sleep, and is of no pathological significance.
The other EEG pattern of N sleep is HVS (Figure 4A) characterized by continuous symmetrical and synchronous high voltage (50–150 μV) 1–3 Hz delta which often has an occipital or central predominance. Between 37–42 w CA, HVS accounts for only 3–8% of the N sleep time. HVS at this age occurs as a brief period following a REM sleep onset associated with the mixed (AS1) EEG pattern. HVS precedes a longer period of TA within the same NREM period. Between 42–44 w CA, the IBIs of TA shorten to 1–2 sec and the amplitude difference between bursts and IBIs lessens, making it harder to recognize and score. TA usually disappears by 44 w CA (up to 46 w) replaced by HVS.
Sleep spindles first appear as early as 3–9 w postterm in both infants born preterm (30–33 weeks) and term.70,77 Sleep spindles in infants 43–48 w CA typically first appear over the midline central (Cz, vertex), and shift from side to side over left and right central regions (C3 and C4). Multiple different studies have confirmed that sleep spindles are usually present by 12 w term,78,79 43–48 w CA,80 and 2 mo term.81–84 Studies using quantitative frequency analysis found they usually first appear 4–9 w term.85,86 Three longitudinal studies using EEG, PSG, or most recently magnetoencephalography (MEG) have confirmed that sleep spindles are usually present by 2 mo term.82–84
Electroencephalographers are taught to recognize two types of REM sleep EEG patterns (called AS1 and AS2). Both are continuous. AS1 typically occurs following W and AS2 following a period of NREM sleep. AS2 consists of primarily irregular synchronous low voltage (25–50 μV) 4–7 Hz theta activity intermixed with occasional similarly low voltage 1–3 Hz delta activity and called low voltage irregular (LVI, Figure 4D). AS1 contains generous amounts of intermixed high amplitude (> 100 μV) 2–4 Hz delta activity intermixed with lower voltage theta activity, is termed mixed (M, Figure 4A). Rarely, HVS may be seen during R sleep.32
As mentioned earlier, the most reliable physiological marker to distinguish N from R sleep in infants is the regularity or irregularity of respiration. REM sleep is characteristically associated with irregularities in respiration including differences in rate, depth, and minute ventilation with brief periods of relative bradypnea or tachypnea.43,87 REMs occur singly or in clusters during R. Irregular respiration and heart rate especially during phasic periods of REM when rapid eye movements are more prevalent.29 Chin EMG tone is most often low or absent during R, but may not be atonic (state dissociation reflecting immaturity of skeletal muscle atonia development). Last, an extraordinary panoply of motor behaviors accompany R at this age, including: sucking; facial grimaces; clonic jaw jerks; fine limb muscle twitches; chin, body and limb tremors; intermittent stretching; and large athetoid limb movements.88
Depending on how strictly criteria for NREM or REM sleep are defined, 10–15% or 20–40% of 30-sec epochs of sleep in infants at term could be scored as T sleep.89 Epochs best scored as T sleep are observed in transitions to sleep, especially transitions from W to R (less often R to N) and following arousals. Earlier infant scoring criteria have tried to reduce the percentages of T sleep scored by permitting scoring if only one, or better yet, two PSG correlates within an epoch are discordant for the sleep state.24,90 The percentage of sleep time spent in T sleep decreases with increasing infant maturation. Figure 5 shows an example of T sleep.
The AASM published the rules for staging sleep in infants, ages 0–2 mo, with the hope these would become widely used, thereby permitting comparisons among sleep laboratories, test results, and research. These were based on the Anders Manual coding criteria but rightly incorporated modern concepts, digital PSG recording techniques, more recent knowledge, realities, practicalities, and compromises. Table 3 compares earlier infant sleep scoring criteria. Table 4 summarizes the AASM Scoring Manual definitions for the four sleep EEG patterns (TA, HVS, M, and LVI) and Table 5 the sleep/wake state scoring characteristics. Table 6 shows the development of the EEG features of sleep and wakefulness from infancy through adolescence.
Earlier infant sleep/wake scoring criteria.
American Academy of Sleep Medicine Scoring Manual definitions of electroencephalogram patterns of sleep and wake in infants 0–2 months.
Summary of American Academy of Sleep Medicine Manual sleep/wake state characteristics for scoring sleep in infants 0–2 months of age.
Development of electroencephalogram features of sleep and wakefulness: infants to adolescents.
Sleep/wake should be scored in 30-sec epochs as either W, NREM, REM, or T sleep. Scoring sleep at this age begins by assessing whether in each 30-sec epoch: (1) eyes are open or closed; (2) the EEG background is continuous or discontinuous; (3) chin tone present, decreasing, or absent; (4) REMs are present or absent; and (5) respiration is irregular or regular. The most crucial behavioral determinant for scoring stage W is eyes wide open (with or without crying) because many of the distinctive EEG features of W are not seen until 2 mo postterm. Knowing whether the eyes are open or closed depends upon careful observations and notations made by the technologist when recording the PSG, supplemented by video review.
Regularity or irregularity of respiration is the most important PSG characteristic when scoring sleep/wake states in infants this age. Respiration is scored as regular if the variability between the slowest and fastest breaths is less than 20 breaths/min (and typical of N sleep); irregular if > 20 breaths/ min (seen in W, R, or T). However, regularity (or lack of it) is often judged solely by visual inspection. Respiratory events or pauses ≥ 3 sec are not used to determine respiratory irregularity. Preservation of chin EMG tone is often but not always present in N sleep at this age, present in only 80–85% of epochs of N sleep; its presence useful, its absence not.
Only one relatively distinctive EEG pattern in infants 0–2 mo of age is discontinuous TA; all the rest are continuous with varying combinations and frequencies in either W, N, R, or T. Given this, simply identifying EEG activity within a PSG epoch as "continuous" or "discontinuous" might suffice when scoring sleep in infants this age, especially because other PSG characteristics are better markers at this age. Sleep spindles may be seen as early as 43 w CA; if present, they warrant scoring an epoch as N (not N2 at this age). Simultaneous recording and scoring of left, right, and midline central EEG derivations (C3, C4, and CZ) provide the greatest likelihood of these often low amplitude rudimentary and asynchronous waveforms.
Given these tenets, W is scored in an epoch if either are present: (1) eyes are open intermittently; (2) vocalization (whimpering, crying, etc.) or actively feeding observed; or (3) all of the following are met: (a) eyes are open intermittently; (b) REMs or scanning eye movements; (c) sustained chin EMG tone with bursts of muscle activity; (d) irregular respiration; and (e) an EEG of either continuous LVI or M. The AASM Scoring Manual advises that: W is most reliably scored by behaviors observed because many of the distinctive EEG features of W are not seen until after 2 mo postterm. The EEG background may include: (a) irregular theta and delta activity (to 100 μV) maximal in O1, O2; (b) diffuse irregular alpha and beta activity (to 30 μV); (c) rhythmic theta activity (to 50 μV) often maximal in C3, Cz, C4; or (d) artifacts from body movements, and eye movements.
Sleep onsets are more often R sleep until 2–3 mo postterm. Drowsiness is best characterized at this age by visual observation (supplemented by video recordings) during which the infant appears relatively immobile, lacks focused attention, and may exhibit brief intermittent opening and closing of eyes. By consensus, the Committee decided if a healthy infant's eyes remain closed for ≥ 3 min, it was reasonable to consider the infant asleep.
NREM sleep is scored if four or more of the following conditions are present, including regular respiration, for the majority of the epoch: (1) eyes are closed with no eye movements; (2) chin EMG tone present; (3) regular respiration (postsigh respiratory pauses may occur); and (4) EEG patterns of either TA, HVS, or sleep spindles are present. The AASM Scoring Manual emphasizes that EMG in stage N is variable; it is generally lower than W and higher than in stage R. So, if chin EMG activity is present (higher than stage R) this favors scoring the epoch as NREM. However, stage N can still be scored with low EMG tone provided more than four other criteria for stage N including regular respiration are met.
REM sleep is scored in epochs with four or more of the following criteria present, including irregular respiration and REM(s): (1) low chin EMG (for the majority of the epoch); (2) eyes closed with at least one REM (concurrent with low chin tone); (3) irregular respiration; (4) mouthing, sucking, twitches, or brief head movements; and (5) EEG exhibits a continuous pattern without sleep spindles. In infants younger than 3 mo, the first epoch of sleep is commonly REM sleep. Given the difficulty in determining sleep onset, an epoch of definite stage R is required to begin scoring REM sleep. Because REMs may not be seen on every page, epochs following an epoch of definite REM sleep in the absence of REMs may be scored if all of the following conditions are present: (a) EEG shows low or medium voltage mixed frequencies without TA or sleep spindles; (b) chin muscle tone is low for the majority of the epoch; and (c) there is no intervening arousal using the same rules for scoring arousal in children and adults. Epochs of REM sleep containing REM sleep without atonia are not unusual in infants.
The AASM Scoring Editorial Board thought recognizing and scoring T sleep was needed because it is common in developing infants (accounting for 10–40% of epochs of sleep depending upon how stage T is defined) and a marker of development and maturation.89 They chose to call indeterminate sleep T because it most often occurs in transitions from W to R, before awakening, and at sleep onset. They further recommended scoring a 30-sec epoch as T if it contains either three NREM and two REM characteristics or two NREM and three REM characteristics. However, an epoch can be scored as stage N, stage R, or stage W if only one PSG characteristic is discordant for the sleep state.
Sleep specialists and technologists with little experience in scoring sleep and wakefulness in infants 0–2 mo of age are challenged by: (1) many epochs of sleep are better identified by regularity or irregularity of respiration and other behavioral correlates than the EEG background; (2) EEG transients, which are sharply contoured but not epileptic in nature, especially prominent in NREM sleep in infants 38–42 w CA; and (3) tendency for infants when stressed, sick, or born premature to exhibit EEG patterns that would classify them as younger than their CA (termed dysmature).
EEG of full-term newborns contains a variety of distinctive EEG transients that are often sharply contoured, easily mistaken by the inexperienced as epileptiform in appearance. Frontal sharp transients (FSTs) are isolated or repeated bursts of unilateral or bilateral 50–200 μV biphasic waves each lasting 0.5–0.75 sec over the frontal regions in infants, especially between 35–44 w CA, which are often more frequent and of higher amplitude during N sleep (especially at onset), but can be seen in W or R (especially AS1) sleep. FSTs disappear by 49 w CA. Sharp transients are also observed in infants 0–2 mo of age over the central and temporal regions. These are more likely to be considered abnormal if: excessively frequent for CA; appear in short runs; are consistently unilateral, occur frequently during the IBI of TA; and/or persist during R or W.
Delta brushes, an EEG transient most abundant in premature infants, are still seen at term, but usually in rare numbers mostly during N sleep and then usually localized to the occipital regions. At 38 w CA, the number of delta brushes observed in 30 min of N sleep are 60–125, only 6–8 in 30 min of R sleep. By 40 w, delta brushes average 0–24 in 30 min of N sleep, 0–6 in NREM. Delta brushes are normally only seen in N sleep in healthy infants 42 weeks then averaging 0–12 in 30 minutes of recording. Slow anterior dysrhythmia (short bursts of regular or irregular 50–100 μV 1–3 Hz delta waves are another EEG transient observed between 38–41 w CA, especially in AS1-REM sleep.
Poor-quality sleep in premature and term infants has lasting effects on later cognitive functioning.91–93 Sleep architecture of infants born premature may lag behind that of infants of a similar CA born at term with longer sleep cycles, more TA, less REM sleep, fewer and shorter duration arousals, fewer body movements, and less REMs.6 How well sleep architecture is organized in a neonatal EEG or PSG may predict long-term cognitive outcomes.91–94 Less REM sleep time in 81 infants born 32–36 w CA was associated with poorer developmental outcomes on the Bayley II at 6 mo.91 Whereas premature infants who had longer periods of sustained sleep, more time spent in REM sleep, and more periods of REM sleep with REMs had better cognitive outcomes. Another prospective study of 65 infants born premature found those who slept poorly as neonates exhibited poorer attention and greater distractibility at 4 and 18 mo than those who slept well.92 Another study of 143 infants born mean age 32 w CA that particular sleep/wake transitions predicted neurobehavior, emotional and cognitive growth at age 5 y.93 Sleep/wake transitions from NREM to wake were associated with greater neonatal neuromaturation, less negative emotionality, and better verbal, symbolic, and executive competences at age 5 y. Whereas, short episodes of REM and NREM sleep or REM sleep to wakefulness with cry were associated with poorer outcomes. Such findings have prompted interventions to improve premature sleep in neonatal intensive care units including environmental noise reduction, ear muffs when sleeping, lights on from 07:00–19:00 (and off the rest of the time) and nonpharmacological treatments for pain.95–99
Very few studies have been published evaluating reliability of individuals scoring sleep studies in infants. Crowell et al.39 calculated inter-reliabilities and intra-reliabilities for sleep parameters and sleep stages for three senior investigators and four sleep technologists scoring 408 randomly selected 30-sec epochs from overnight home PSG recorded in 15 CHIME home PSG records.39 They found the kappa statistics (Κ) for agreement in scoring among the investigators were 0.56 for EEG, 0.51 EOG, 0.54 body movements, and 0.67 respiration. After intensive training, Κ agreement for the technologists was 0.76 for EEG, 0.62 EOG, 0.68 body movements, and 0.73 for respiration. Crowell et al. found that intensive uniform training and careful attention to specification of scoring criteria improved inter-scorer reliability.
Stefanski et al.100 reported an overall inter-scorer agreement of 87% for scoring sleep EEG patterns in 23 infants using a scoring system they developed and validated.100 The greatest inter-scorer disagreement occurred when scoring premature infants. Hoppenbrouwers35 analyzed scoring agreement in their work and others.70,101 The following conditions were found: (1) infant scoring criteria that required three or four of five criteria to score N sleep significantly altered the percentage of N scored; (2) scoring agreements were "uniformly low" (50%) when scoring indeterminate sleep; (3) correctly scoring N sleep in infants 1–2 mo of age was especially challenging because TA had disappeared and sleep spindles were usually absent; and (4) using behavioral observations including respiration may have helped reduce inter-scorer disagreement when faced with distinguishing the M EEG background of REM sleep from HVS of NREM sleep at this age.
Satomaa et al.67 scored comprehensive home PSGs in 84 healthy 1-mo-old infants using sleep scoring criteria they adapted from the 2012 AASM criteria.67 Infants ranged in age from 44–48 w CA. Inter-scorer agreement between two independent scorers was 80.6% and a kappa score of 0.73 indicating substantial agreement. Scoring agreement was > 80% for REM, NREM, and W, but only 46% for T sleep. The most common mismatch between sleep stages were: T/REM (26.5%), Tl/ NREM (16.1%), and T/W (8.9%). W/REM, REM/NREM, and W/NREM mismatches accounted for only 10%, 5%, and 2% of all mismatches, respectively.
Time and again when AASM scoring rules are written, pragmatism wins. Rules are developed (and later revised) to be as simple as possible. Some pediatric sleep specialists and researchers lament the AASM Manual lumping stages 3 and 4 sleep into NREM 3, saying the "richness and complexity" of slow wave activity is lost. However, inter-scoring reliability is far better when stages 3 and 4 are combined, and so reason overruled wish. The Scoring Manual Editorial Board's bold decision the EEG in infant PSG be scored as continuous or discontinuous (rather than LVI, HVS, M) reflects recognition that TA is the only neonatal EEG pattern that can be reliably recognized even by experts.
These criteria for scoring sleep/wake states between ages 0–2 mo represents far more than baby steps. These rules, like all the other AASM Scoring Manual rules, are not fixed in stone, and are open for debate, discussion, and revision. Future studies are needed to: (1) evaluate inter-scorer and intra-scoring reliability of these sleep staging rules for ages 0–2 mo; (2) confirm or refute that scoring simply as continuous or discontinuous will suffice; (3) confirm whether these rules can be used in infants when stressed, sick or born premature; and (4) develop normative data for these by comparing results between patients, laboratories, and research.
This was not an industry supported study. The author has indicated no financial conflicts of interest.
left auricular electrode
right auricular electrode
American Academy of Sleep Medicine
apnea-hypopnea index (mean number of apneas and hypopneas per hour of sleep)
Association for the Psychophysiological Study of Sleep
active (REM) sleep
REM sleep EEG pattern following wakefulness
REM sleep EEG pattern following a period of NREM sleep
conceptional age
central apnea index
left central electrode
right central electrode
Collaborative Home Infant Monitoring Evaluation study
vertex electrode
left frontal electrode
right frontal electrode
frontal sharp transients
gestational age
high voltage slow
interburst intervals
indeterminate (transitional) sleep
low voltage irregular EEG pattern
kappa statistics
left mastoid electrode
right mastoid electrode
mixed EEG pattern
nonrapid eye movement sleep
left occipital electrode
right occipital electrode
post menstrual age
quiet (NREM) sleep
rapid eye movement sleep
rapid eye movements
sleep disordered breathing
transitional sleep
trace alternant
total sleep time
I would like to acknowledge my dear husband, Stanley Damberger, who edited the manuscript, and Dr. Mark Scher who was a member of the advisory committee. The literature searches, evidence review, rationale and writing of this entire document was solely done by the author and submitted to the AASM Scoring Manual Editorial Board.
Berry RB, Brooks R, Gamaldo CE, Harding SM, Lloyd RM, Marcus CL, Vaughn BV, authors; for the American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, Version 2.0.3. www.aasmnet.org. Darien, IL: American Academy of Sleep Medicine, 2014.
Berry RB, Brooks R, Gamaldo CE, Harding SM, Lloyd RM, Marcus CL, Vaughn BV, authors; for the American Academy of Sleep Medicine. The AASM manual for the scoring of sleep and associated events: rules, terminology and technical specifications, Version 2.2. www.aasmnet.org. Darien, IL: American Academy of Sleep Medicine, 2015.
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De Weerd AW, Despland PA, Plouin P, authors. Neonatal EEG. Electroencephalogr Clin Neurophysiol. 1999;Suppl 52:149–57.
Kahn A, Dan B, Groswasser J, Franco P, Sottiaux M, authors. Normal sleep architecture in infants and children. J Clin Neurophysiol. 1996;13:184–97. [PubMed]
Curzi-Dascalova L, Gaudebout C, Dreyfus-Brisac C, authors. Respiratory frequencies of sleeping infants during the first months of life: correlations between values in different sleep states. Early Hum Dev. 1981;5:39–54. [PubMed]
Eliet-Flescher J, Dreyfus-Brisac C, authors. [The sleep of the full-term newborn and premature infant. II. Electroencephalogram and chin muscle activity during maturation]. Biol Neonat. 1966;10:316–39. [PubMed]
Schloon H, O'Brien MJ, Scholten CA, Prechtl HF, authors. Muscle activity and postural behaviour in newborn infants. A polymyographic study. Neuropadiatrie. 1976;7:384–415. [PubMed]
Salzaulo P, author. L'atonie msculaire pendant le sommeil chez l'homme. Riv Psicol. 1968;62:201–20.
Ellingson RJ, Peters JF, authors. Development of EEG and daytime sleep patterns in low risk premature infants during the first year of life: longitudinal observations. Electroencephalogr Clin Neurophysiol. 1980;50:165–71. [PubMed]
Metcalf DR, author. The effect of extrauterine experience on the ontogenesis of EEG sleep spindles. Psychosom Med. 1969;31:393–9. [PubMed]
Metcalf DR, author. EEG sleep spindle ontogenesis. Neuropadiatrie. 1970;1:428–33. [PubMed]
Curzi-Dascalova L, author. [Waking and sleeping E.E.G. in normal babies before 6 months of age (author's transl)]. Rev Electroencephalogr Neurophysiol Clin. 1977;7:316–26. [PubMed]
Lenard HG, author. The development of sleep spindles in the EEG during the first two years of life. Neuropadiatrie. 1970;1:264–76. [PubMed]
Louis J, Zhang J, Revol M, et al., authors. Ontogenesis of nocturnal organization of sleep spindles: a longitudinal study during the first six months of life. Electroencephalogr Clin Neurophysiol. 1992;83:289–96. [PubMed]
Jenni OG, Borbely AA, Achermann P, authors. Development of the nocturnal sleep electroencephalogram in human infants. Am J Physiol Regul Integr Comp Physiol. 2004;286:R528–38. [PubMed]
Iglowstein I, Jenni OG, Molinari L, Largo RH, authors. Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics. 2003;111:302–7. [PubMed]
Sterman MB, McGinty DJ, Harper RM, Hoppenbrouwers T, Hodgman JE, authors. Developmental comparison of sleep EEG power spectral patterns in infants at low and high risk for sudden death. Electroencephalogr Clin Neurophysiol. 1982;53:166–81. [PubMed]
Schulte FJ, Bell EF, authors. Bioelectric brain development. An atlas of EEG power spectra in infants and young children. Neuropadiatrie. 1973;4:30–45. [PubMed]
Kirjavainen T, Cooper D, Polo O, Sullivan CE, authors. Respiratory and body movements as indicators of sleep stage and wakefulness in infants and young children. J Sleep Res. 1996;5:186–94. [PubMed]
Roffwarg H, Dement W, Fisher C, authors. Preliminary observations of the sleep-wake pattern in neonates, infants, children, and adults. In: Harms E, editor. Preliminary observations of the sleep-wake pattern in neonates, infants, children, and adults. New York City, NY: Macmillan, 1964:60–72.
de Weerd AW, van den Bossche RA, authors. The development of sleep during the first months of life. Sleep Med Rev. 2003;7:179–91. [PubMed]
Parmelee AH Jr, Wenner WH, Akiyama Y, Schultz M, Stern E, authors. Sleep states in premature infants. Dev Med Child Neurol. 1967;9:70–7. [PubMed]
Arditi-Babchuk H, Feldman R, Eidelman AI, authors. Rapid eye movement (REM) in premature neonates and developmental outcome at 6 months. Infant Behav Dev. 2009;32:27–32. [PubMed]
Geva R, Yaron H, Kuint J, authors. Neonatal sleep predicts attention orienting and distractibility. J Atten Disord. 2016;20:138–50. [PubMed]
Weisman O, Magori-Cohen R, Louzoun Y, Eidelman AI, Feldman R, authors. Sleep-wake transitions in premature neonates predict early development. Pediatrics. 2011;128:706–14. [PubMed]
Nunes ML, Khan RL, Gomes Filho I, Booij L, da Costa JC, authors. Maturational changes of neonatal electroencephalogram: a comparison between intra uterine and extra uterine development. Clin Neurophysiol. 2014;125:1121–8. [PubMed]
Hwang SS, O'Sullivan A, Fitzgerald E, Melvin P, Gorman T, Fiascone JM, authors. Implementation of safe sleep practices in the neonatal intensive care unit. J Perinatol. 2015;35:862–6. [PubMed]
Almadhoob A, Ohlsson A, authors. Sound reduction management in the neonatal intensive care unit for preterm or very low birth weight infants. Cochrane Database Syst Rev. 2015;1:CD010333. [PubMed]
Voos KC, Terreros A, Larimore P, Leick-Rude MK, Park N, authors. Implementing safe sleep practices in a neonatal intensive care unit. J Matern Fetal Neonatal Med. 2015;28:1637–40. [PubMed]
Szymczak SE, Shellhaas RA, authors. Impact of NICU design on environmental noise. J Neonatal Nurs. 2014;20:77–81. [PubMed Central][PubMed]
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Stefanski M, Schulze K, Bateman D, et al., authors. A scoring system for states of sleep and wakefulness in term and preterm infants. Pediatr Res. 1984;18:58–62. [PubMed]
Emde RN, Walker S, authors. Longitudinal study of infant sleep: results of 14 subjects studied at monthly intervals. Psychophysiology. 1976;13:456–61. [PubMed]
Anders TF, Chalemian RJ, authors. The effects of circumcision on sleep-wake states in human neonates. Psychosom Med. 1974;36:174–9. [PubMed]
Wolff PH, author. The causes, controls, and organization of behavior in the neonate. Psychol Issues. 1966;5:1–105. [PubMed]


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Amber Parrish
13950 Highland Church RD, Fayetteville
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Beautiful home with 3 bedrooms 2.5 baths in the perfect location! Minutes away from Wilson Park, the University of Arkansas, the Historic district, and so…More Details
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Beautiful 3 or 4 bedroom/game room home on 3 acres!! Spacious living w/vaulted ceilings, wood floors in living and hall, huge eat-in updated kitchen, private…More Details
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BEAUTIFUL 4 bdrm, 2.5 bath tucked away in a great community. This house includes a bonus room that could be used as a 5th bedroom!…More Details
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subset: commoncrawl


text:
Is it possible to connect a single Dropbox Mac app with two or more Dropbox accounts?
Assume I have corporate and private account. How can I use a single dropbox app for them?
Stack Exchange network consists of 175 Q&A communities including Stack Overflow, the largest, most trusted online community for developers to learn, share their knowledge, and build their careers.Visit Stack Exchange
Is it possible to connect a single Dropbox Mac app with two or more Dropbox accounts?
Assume I have corporate and private account. How can I use a single dropbox app for them?
You can't do it out of one copy of the app, but it seems that you can duplicate the app. You can see (somewhat complicated) instructions here:
I haven't done this personally, but this looks like it should work.
I do this with one copy of Dropbox. For my secondary account, I run an automator script on login that sets:
HOME=$HOME/Desktop/SECONDARY-DROPBOX /Applications/Dropbox.app/Contents/MacOS/Dropbox &
I end up with two dropbox icons in the menu bar. I configure one to be alternate black/white icon so I can distinguish visibly between the two.
My (less complicated?) fix to this was...
I have two Mac accounts:
Robert, Corp a/c Bob, Personal a/c
Dropbox installed on both Accounts synching to
From a Terminal window in the Bob account
bob$>su Robert -c /Applications/Dropbox.app/Contents/MacOS/Dropbox
You'll be prompted for password for Robert
Dropbox will run something like
Open a new terminal shell 'Cmd-T' and then run Dropbox for Bob
bob$> /Applications/Dropbox.app/Contents/MacOS/Dropbox
I'm running Dropbox v2.8.2 on Mountain Lion
Thanks to Mark for his answer to this Can I start an application as another user without actually switching users?
You can simply do that using multiple OS X accounts, running the same copy of Dropbox in each of them.


text: Slovak Republic Swan, Part Deux May 20, 2006 0 Comment Share this:ShareEmailPrintTweet Bratislava Slovak Republic Slovakia Swan zwaan Previous PostSolitude Next PostIntricate Stained Glass Leave A Comment Cancel reply Comment Name * Email * Website Notify me of follow-up comments by email. Notify me of new posts by email. This site uses Akismet to reduce spam. Learn how your comment data is processed.


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Gotta Love Pet Shaming!
The Taser Photoshoot
This is so cool! I love it and had to share it. I know it doesn't really sound happy of fun but trust me!
This is so creative and different I hope you enjoy!
The Taser Photoshoot: Portraits of People's Faces When Hit With A Stun Gun
Each person was tased by their friend or significant other which created an interesting dynamic in itself. The emotions on both sides of the taser were extremely entertaining to watch. The person getting tased was almost always nervous and jittery with either a sense of fear or anxiety. The participants doing the tasing had a different demeanor altogether. Most of them were excited to cause pain to their friend and only showed remorse immediately after executing the shock. I wanted to record both of these reactions and you can see a second slow motion edit of both people's reactions in the video below:
Catnip -VS- Cannabis
**Hope this link stays up as this is so funny. If you can't see the video try googleing "City the Kitty finds the catnip bag"
Baby Ducks In A Sink... Awwww
They are just too cute and let's be honest we can always use a smile! :~)
To see all six parts in this got to the youtube channel.
I can't stop watching them! lol Too funny!
Finally all three of them! Awwww
Dancing Pony
Every time I see this I smile!
Fiery Hawk
I couldn't stop laughing!
As seen on Comic Relief's 'Horne and Corden Get Their Clips Out'.
Talking Guinea Pig Interview
I just watched this and had to add it now! I can't stop laughing!
Happy Fun!!!
These are some wonderful pics and other things to make you smile and laugh :~)
September 2016


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Q. What are your shipping services and time frames?
Ans. Available to Australian customers only, for now, and it will take 3 to 5 business days from despatch.
Q. How do I track my order?
Ans. Once your CosPlus parcel has been shipped, you will receive a shipping confirmation email entailing your tracking details. You can track your parcel using this link.
Q. Will my parcel be delivered to my address?
Ans. Yes of course! Your parcel will be delivered to the address provided at the time of purchase.


text:
Looking for the perfect Christmas gift? See our favourites here!
Earrings : Verdandi : Rose Gold Plated
Regular price 34,95 EUR
- Dramatic rose gold-plated statement earrings
- Exudes strength and a distinctive beauty
- Measuring 5.5 cm in length
- Slender satin-finish bars form the shape of a beautiful ethereal arrow
DescriptionGlamorous satin-finish statement earrings. From the delicate rose gold-plated hoops hang multiple slender bars featuring a rustic line pattern. The various lengths of the bars form an ethereal arrow, symbolising the one-way direction of time. The inspiration for these beautiful earrings comes from the myth of the goddess Verdandi, who spins the threads of life for the present. These earrings allow modern goddesses to seize the moment and enjoy their own charismatic beauty and strength.
Details and measures
Gross Height55 mm
Gross Width3 mm
Gross Depth25 mm
MetalRose Gold Plated
Product ID131944033
About Pilgrim
Jewellery is our passion; it is all about dreams, style, heart and soul. We take pride in keeping the brand authentic – staying true to who we are and where we came from. Pilgrim is still about going out and seeking new things, new ways and new adventures. It is not only the destination that matters, but also how we get there. We are a living brand in constant motion and development.
It has been an amazing journey, and Pilgrim has become a recognised international brand, with a Scandi-cool approach to design. We have grown into the fashion and jewellery scene, and the journey is far from over – we are here to stay!
Just as in the beginning, it is all about love for people and jewellery – made by hand and heart.


text:
Lakhs witness Lord Jagannaths Bahuda Yatra
Wrapping up their nine-day annual sojourn to their aunt`s abode, Lord Jagannath, elder brother Lord Balabhadra and their sister Devi Subhadra set off for their return journey to the 12th century shrine on three majestic wooden chariots.
Several special rituals were performed before the deities journeyed out of the Gundicha temple to the three colourfully decorated chariots for the return journey as sound of "Jai Jagannath" rent the air in the seashore town.
The three deities were taken to the chariots in an elaborate royal ritual called `Pahandi` to the beating of gongs, cymbals and blowing of Conch shells as devotees and sevayats jostled to have a closer look and to touch them.
Lord Jagannath was ensconed in the largest of the chariots, 45-feet high `Nandighosh` which has 16 huge wooden wheels. The chariot of Balabhadra was the 14-wheeled 44 feet high `Taladhwaja` and that of Subhadra known as `Darpadalan` with 12 wheels and standing 43 feet high.
The Gajapati King of Puri Divya Singha Deb arrived from his palace for the `Chhera Pahanra` ritual. He offered prayers to the deity and then swept the platforms with a golden broom and sprinkled flowers and fragrant water.
The giant chariots were pulled by devotees amid gaiety and devotion on "bada danda", the grand avenue up to the lion`s gate in front of Sri Jagannath temple where they would be stationed till Wednesday.
The deities would be decorated with "suna besha", golden attire, tomorrow on the chariots, which is expected to attract a large number of devotees.


text:
Julian Roux-Stevens
Technical co-founder at Rentonomy.com
Startupbootcamp Commerce Amsterdam || Media Amsterdam Mentor
Bridging the gap between business and technology, Julian is a highly motivated technical entrepreneur with nearly 20 years of online product development and coding experience resulting in a fantastic track record launching Internet startups. He brings with him extensive experience delivering complex IT solutions and services, as well as setting strategic direction across a range of industry sectors including property, finance and the public sector.
Having recently moved to Amsterdam from London, Julian continues to work with London's fastest growing rental property start-up rentonomy.com – a B2C and B2B portal built on cloud-based open source technologies. He now lives in the heart of Amsterdam with his young family and when not working he finds himself either on a rugby field, in a museum or in one of the town's fine wine bars.
Key areas of expertise include: Technical Development, eCommerce, APIs, Rapid Application Development and cloud solutions.
As a Startupbootcamp mentor he works to share his considerable technical experience with aspiring startups to help them achieve success.


text:
The way we find music has changed dramatically over the last couple of years.
It used to be most people discovered new music from the radio, which meant a small number of people had control over what the rest of us listened to.
Record companies spent hundreds of thousands of dollars to get their artists played on stations across the country.
Editor's note: this is a guest post by Michael Fleming from Songs That I Like, a cool new blog that reviews music.
As a DIY musician, it's important to pay attention to where people discover music. Because these are the places where you should be streaming and selling your music.
The Old-Fashioned Ways To Find Music
For those of us that craved something different, there was really only two options.
The first was word of mouth from friends and those whose music taste we trusted. The other was to comb through the record stores and try to discover new bands on our own.
The second option was similar to searching Blockbuster for a movie to watch, but at the same time a completely different experience.
There aren't many movies that will stay with you for a lifetime, but finding a new band can be a life-changing experience.
A New Way To Find Music: Online
However, these days, high-speed internet and cheaper recording options give listeners more bands and more ways to consume than ever before.
Although this is exciting, music fans are still trying to navigate this new scene to find fun new bands.
This post is for those that are still craving new music in a world with no Tower Records to go to on a Saturday afternoon.
When it comes to online music streaming services, Spotify has shown itself to be the best.
With any tech company it really comes down to algorithms, and Spotify has been great at curating new artists for me.
And there are a couple of features on Spotify you should make sure to explore.
Spotify's Discover Feature
The first feature is the "Discover" feature.
This playlist includes artists that Spotify thinks you will like based on your listening history and new releases from bands that Spotify knows you love.
I appreciate that the bands Spotify will often recommend have only a few thousand streams, and it isn't only reserved for major label acts.
Spotify's Related Artist Feature
The second place to explore in Spotify is the "Related Artists" section of my favorite bands.
Spotify will give twenty other bands it thinks you might like based off one band's profile.
It allows you to go through an entire Tower Records aisle of music in a matter of minutes.
RELATED: Submit your music to the Good Music Spotify playlist
Every Noise At Once
If you want to explore more genres than you could even imagine, then Every Noise At Once is the place to head.
It's a fairly simple music streaming site that lists genres ranging from Icelandic hip-hop to outlaw country.
You click on a genre of music, and a thirty-second sample of a band in that genre will begin to play.
If you like what you hear, you click the double arrow next to the genre listing, and it will take you to another page with dozens of more artists in that genre.
On that page, you can click on any band and get to hear a thirty-second sample of their music.
And on and on. You get the point.
RELATED: Don't Limit Your Creativity
I like that everything is on one page, and the thirty-second samples are enough for me to gauge whether I want to hear more from a band.
Sometimes you can get stuck listening to the same kind of music repeatedly, and Every Noise can help you branch out.
Some radio stations have been able to make a name for themselves with online streaming and by putting studio performances up on YouTube.
In my opinion, none has been as successful as Seattle's KEXP.
I've spent countless hours on their YouTube page watching artists perform in their studios. The station brings in an eclectic group of artists and highlights songs and interviews.
RELATED: Try Amazon Music Unlimited for free
And KEXP recently received a $10 million endowment that will allow them to keep their doors open and showcase artists.
Talk about a winning endorsement.
RELATED: submit your music to KEXP


text:
This month on Challenge yourself a sketch challenge, my favorite!
I've used these small and old pictures of me, being 1 in 1956 ;)
The sketch is so nice! Have used paper form Kaisercraft, love that brand. You can make so much layouts and cards with one line. Hope you like it, bye.


text:
Is PAX Worth the Price?
Critical Intel wants to know if it's quite literally worth your money to go to big conventions.
I do like hitting up the big cons like PAX or Gen Con, but I hate the inflated hotel prices. Like you said, for the hotel and airfare I end up paying I could end up just about anywhere else I'd want to go. But of course, like Disney World, sometimes it's the one place you really want to go, so it's not about where else you could go.
I like attending PAX because it is PAX... taking an international vacation or going somewhere else wouldn't achieve that goal. I go to see internet friends, play some games with them, pick up new releases (Fantasy Flight Games debuts their the betas for their Star Wars games at the big cons), check out the expo hall (swag and hands-on pre-releases!), hit some panels, and of course the concerts.
But you're right, it ain't cheap.
The next convention on my horizon is Loncon in August, and considering that I live pretty close, it shouldn't be too big an expense. Still, between a £65 ticket (which, for five days, is admittedly great value) plus train fare of probably about £15/day, it's going to come to about £150 before I factor in food, drink and swag. Admittedly, that has nothing on PAX - I do want to go to PAX someday, but I'd rather not think about the price of flights from the UK - but when you're freelancing and not getting a regular income, it's still a lot of money.
Conventions are so much fun, and I love them, but they're a big expense even if you're close by.
Some day I wish to live in a city where the cost of living is low enough I can actually afford to go on vacation AT ALL.
Vacations? I vaguely remember something like that ten years ago. I don't like going near airports any more.
Riding a train down to Boston, staying in my father's apartment for the duration. Set.
I spit my tea when you went over the numbers, it looks like austerity hasn't touched the Rath household.
I can see why you go with your work but I couldn't justify spending that on myself with a wife and child. As you point out, there is so much else that money could be spent on
Any of the PAX ticket costs are actually pretty low by some comparisons. An earlier poster mentioned hotel prices which is what gets most people. This is due to not knowing scheduled days until it's nearly too late to find anything manageable.
There are alternatives. Especially to keep lodging prices down. I go to Prime every year and here's my suggestions:
Look for rentals vs hotels
Be prepared to walk or take transit (This is good for you anyway!). The more able you are to take public transit, the lower the lodging cost.
Despite lodging, buy portable, store bought food. This can be anything from chips to fruit. Cuts the cost of eating.
Try and buy those tickets early, but don't get gouged. Prices are only as high as the demand at any current time. The sooner they're available, the higher the price.


text:
Chi siamo
Chi siamo
The company was born from the high competencies and know-how of two research laboratories, the laboratory of Control and Automation from the Polytechnic of Bari and the laboratory of Operations Research from the University of Trieste.
AutoLogS srl is therefore based on the experiences of a high skilled team of engineers and mathematicians dedicated to develop and implement innovative decisional tools supported by ICT solutions.
The high level of experience is maturated in industrial context as well as in academic field in order to link these two approaches to have the maximum level of efficiency and competency for the AutoLogS clients.
The expertise has been developed and strengthened also in international projects with several partners all around Europe.


text:
All villas in Rimtalay village, Ko Yao Noi, Thailand
1 villa
View and book from over 1 villa from 11,162 AUD per night. Book with peace of mind with our Price Guarantee and local customer support.
This villa introduces guests a magical Southeast Asian experience and the best of Koh Yao Noi has to offer.
Add to shortlist
Per Night
FromAUD$ 11,162
Including tax & services feesView Details


text:
Book Rooms & Suites
Wellness rooms in Saaserhof the cozy hotel in the Saas Valley
You are looking for quiet rooms or family suite in Saas-Fee? Whether single room, budget room or superior double room: quiet comfort and convenience! These things are essential to a well-kept and relaxing holiday in the hotel room. All this offers the Saaserhof in Saas-Fee.
Choose individually furnished rooms, apartments or family rooms and enjoy your stay in Saaserhof. You may also expect a little more. Hospitality, helpfulness, friendliness - because your satisfaction is our passion. The rooms vary only in terms of size and decor, but not with respect to the hospitality that coming across at us.


text:
Call or text: 231-223-7788 Toll free: 1-800-513-8271
TASCAM DR-05 Stereo Handheld microSD Card Recorder
By: Ben Richey Date Added: 07/26/2011Quite a nice unit. I have used this in a live band situation where the 125 db peak came in handy. I played the recording back through the mixer during a break and everyone was quite impressed. Works well for quick and easy lesson/studio recordings and dump right into the computer for fast emailing of files.


text:
You are hereHome › NLS Annotated Bibliography ›
Search Results
Resulting in 1 citation.
Johnson, Katherine A.
Tyler, Kimberly A.
Adolescent Sexual Onset: An Intergenerational Analysis
Journal of Youth and Adolescence 36,7 (October 2007): 939-949.
Also: http://www.springerlink.com/content/p86412573k14132m/
Cohort(s): NLSY97
Publisher: Kluwer Academic Publishers
Keyword(s): Adolescent Behavior; Adolescent Fertility; Age at First Intercourse; Intergenerational Patterns/Transmission; Sexual Activity; Sexual Behavior
Permission to reprint the abstract has not been received from the publisher.
Adolescents have begun to initiate sexual activity at increasingly early ages in the past few decades. Using a sample of 2,494 adolescents from the National Longitudinal Survey of Youth (NLSY97), structural and parental process variables were examined in the prediction of sexual onset. Results indicated that the age at which youth initiate sexual intercourse is related to the structural characteristics of their grandmothers and mothers, as well as puberty, gender, and race. There is support for partial mediation of the effects of these grandmother characteristics via mother characteristics and parental process. Results are discussed within the framework of the life course perspective and provide support for the importance of previous generations in the explanation of adolescent sexual behavior. Implications for families and adolescents are also addressed. [ABSTRACT FROM AUTHOR] Copyright of Journal of Youth & Adolescence is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts)
Bibliography CitationJohnson, Katherine A. and Kimberly A. Tyler. "Adolescent Sexual Onset: An Intergenerational Analysis ." Journal of Youth and Adolescence 36,7 (October 2007): 939-949.


text:
Demand for homes in expensive resort towns surged in the first three months of 2010, according to local tallies. Sales in the Hamptons on New York's Long Island more than doubled in the first quarter from a year earlier, reported Miller Samuel Inc., a New York property appraiser. In Aspen, Colorado, transactions rose 43 percent, said Tim Estin, a broker with Mason Morse Real Estate.
Iain Heydon traveled to Colorado's Rocky Mountains three times during the past year looking for a vacation home in Grand Lake, where waterfront properties list for as much as $3.95 million. After seeing more than a dozen houses, he has yet to make an offer."I'm watching to see what happens to the U.S. economy," said Heydon, 46, who lives near Basel, Switzerland. "The market for these homes may not have reached its bottom."Demand for U.S. luxury vacation properties may be fading along with prospects for faster economic growth, after an early 2010 rebound. The government last week reported slower growth in private-sector jobs and manufacturing and a decline in factory orders. While rates on jumbo mortgages used for many expensive homes have dropped, it's harder to qualify."There is a lot of concern about a double-dip recession that's keeping people on the sidelines, especially at the high end," said Mark Goldman, a mortgage broker with Cobalt Financial Corp. in San Diego.
By Kathleen M. Howley, July 8, 2010 Bloomberg
Link to article


text:
How to Set Up Account Create Your Own Domain or Website Email ID
Indonesia..ID domain name registration requires special documents and conditions depending on the domain extension you want to register. Agency To Domain Indonesian List. Are you in need of a domain from Indonesia, but you can't make a purchase manually or you don't seem to understand many procedures that will be done so this needs to be seen again what is needed but you don't need to be confused and all can be solved it's easy for both hosting and domain purchases, yes, you are ready to have it by contacting the service below. You will be connected to this service to purchase domains or hosting in Indonesia without having to worry .
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A This service also makes it easy to purchase domain hosting or that you can't do such as Indonesian domain verification or ID, of course, everything can be solved here. so also for the interest of buying hosting services or items that you want to buy in Indonesia, guarantee of all transactions.
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ANYTHING.ID & Hosting Clouds Full Power, is intended for Business Entities entities similar entities that are Indonesian legal entities and or Citizens of the Republic of Indonesia. Required documents are: Valid KTP of the Republic of Indonesia. If the Registrar is a business entity, then the requirements for domain registration require SIUP equivalent permits for registrants in the form of business entities / legal entities. If the Registrar is a State Executing Agency, then the registration of the Domain Name follows the Decree of the Minister in charge of Communication and Information. Especially for ANYTHING.ID domain, the character length of a .ID domain name is a minimum of 5 characters. As for other domains, at least 3 characters.


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Marina Queirolo
Marina manages Evergreen's initiatives related to food policy, public markets, and hubs. She works to change the status quo of city systems, like food, to make them more just, equitable, and sustainable. Marina developed Evergreen's Food and Public Market Action Plan and created a suite of programs that promote food literacy, community development, local entrepreneurship, and place making. Marina has been a member of the Toronto Food Policy Council since 2013, is chair of the Council's Public Food Market Working Group, and has almost 15 years working in food systems and city building. In 2017, Marina received the Canada 150 Outstanding neighbour award by MP Carolyn Bennet and recently joined the global Placemaking Leadership Council (PPS). Marina has a BA from the University of Buenos Aires.
Area of expertise
Food Systems
Public Markets
Community Engagement


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The charity called the pitch in June last year after Leo Burnett resigned the business.
Krow and Teneo Blue Rubicon will work on the strategic and creative direction for the RNLI's "Respect the water" campaign which raises awareness of the dangers around water.
The agencies pitched for the business together. RNLI's media planning and buying is handled by OMD UK.
Ross MacLeod, community safety marketing manager at the RNLI, said: "The agencies bring a wealth of behaviour change and marketing expertise, which we really believe will help us to save more lives at sea with this exciting campaign."