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Despite the fact that infants spend more time asleep than awake, an understanding of the importance and effects of sleep on the pathophysiology of illness in infancy is a relatively recent development, and is commonly overlooked in paediatric training. In this review we describe some of the characteristics of sleep in infancy, with particular reference to normal developmental physiology and its relevance to the signs, symptoms and pathophysiology of illness in this age group.

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Objective: There has been a rise in the prenatal detection of right sided aortic arch (RAA). When associated with a left-sided arterial duct (LD), this forms a vascular ring encircling the trachea. Infants may have symptoms or signs suggestive of tracheoesophageal compression but many are asymptomatic. The objective of this study was to investigate the relationship between symptoms and severity of tracheobronchial compression assessed by bronchoscopy. Methods: Retrospective review of all cases of prenatally diagnosed RAA-LD in the absence of associated congenital heart disease at Evelina London Children's Hospital and Kings College Hospital over a 4-year period between April 2015−2019. Clinical records, fetal echocardiograms, and free-breathing flexible bronchoscopy (FB) data were reviewed.Results: One hundred and twelve cases of isolated RAA-LD were identified of whom 82 cases (73%) underwent FB. FB was performed median age of 11 months (range 1−36 months), no complications occurred. Aberrant left subclavian artery (ALSA) was present in 86% (96/112) and mirror image branching (MIB) in 13% (15/112). 34/112 (30%) reported symptoms during follow-up. 36/77 (47%) with ALSA who underwent FB showed moderate-severe compression mostly at distal tracheal and carinal level of whom 38% had parent-reported symptoms. Moderate-severe compression was seen in 3/5 (60%) with MIB mostly at mid tracheal level; 3 were symptomatic but only 2 had tracheal compression. In total 36% (18/50) of investigated asymptomatic patients showed moderate-severe compression. Respiratory symptoms were poorly predictive of moderate-severe tracheal compression (positive predictive value 66%, negative predictive value 64%). Conclusion:The absence of symptoms did not exclude significant tracheal compression. The anatomical effect of the vascular ring is under appreciated when symptoms alone are used as a marker of tracheal compression.