Premature Baby

Premature Baby-Apnea

Once a baby is born, he or she needs to breathe continuously to get oxygen. In a preemies baby, the part of the central nervous system (brain and spinal cord) that controls breathing is not yet mature enough to allow nonstop breathing. This causes large bursts of breath followed by periods of shallow breathing or stopped breathing. The medical term for this condition is apnea of prematurity, or AOP.

Apnea of prematurity is fairly common in a premature baby . Doctors usually diagnose the condition before the mother and baby are discharged from the hospital, and the apnea usually goes away on its own as the infant matures. Once apnea of prematurity goes away, it does not come back. But there's no doubt about it - it's frightening while it's happening.

What Is Apnea of Prematurity?

Apnea is a medical term that means a premature baby has stopped breathing. Most experts define apnea of prematurity as a condition in which premature babies stop breathing for 15 to 20 seconds during sleep.

Generally, babies who are born at less than 35 weeks' gestation have periods when they stop breathing or their heart rates drop. (The medical name for a slowed heart rate is bradycardia). These breathing abnormalities may begin after 2 days of life and last for up to 2 to 3 months after these premature babiesare born. The lower the infant's weight and level of prematurity at birth, the more likely it is that the infant will have AOP spells.

Although it's normal for all infants to have pauses in breathing and heart rates, those with AOP have drops in heart rate below 80 beats per minute, which causes them to become pale or bluish. They may also appear limp, and their breathing may be noisy. They then either start breathing again by themselves or require help to resume breathing.

AOP may happen once a day or many times a day. Doctors will closely evaluate your infant to make sure the apnea isn't due to another condition, such as infection or internal bleeding.

Apnea of prematurity should not be confused with periodic breathing, which is also common in premature babies. Periodic breathing is marked by a pause in breathing that lasts just a few seconds and is followed by several rapid and shallow breaths. Periodic breathing is not accompanied by a change in facial color (such as blueness around the mouth) or a drop in heart rate. A baby who has periodic breathing resumes regular breathing on his or her own.

Although it can be frightening, periodic breathing typically causes no other problems in newborns.

How Is Apnea of Prematurity Treated?

Most of the time, premature babies(especially those less than 34 weeks' gestation at birth) will receive medical care for apnea of prematurity in the hospital's neonatal intensive care unit (NICU). When they are first born, many of these premature babies must get help breathing from a ventilator because their lungs are too immature to allow them to breathe on their own.

During mechanical ventilation, a tube is placed into the premature baby's trachea (windpipe) and breaths of air are blown through the tube into the premature baby's lungs. These breaths are given at a set pressure. The ventilator is also programmed to give a certain number of breaths per minute, and the premature baby's breathing, heart rate, and oxygen levels are continuously monitored.

Sometimes babies with apnea of prematurity are given medications to help mature their lungs and allow the preemies to come off mechanical ventilation within a few weeks and breathe on their own.

When infants are disconnected from a mechanical ventilator, often they require a form of assisted breathing called nasal continuous positive airway pressure (CPAP). A nasal CPAP device consists of a large tube with tiny prongs that fit into the premature baby's nose, which is hooked to a machine that provides oxygenated air into the baby's air passages and lungs. The pressure from the CPAP machine helps keep a premature baby's lungs open so he or she can breathe. However, the machine does not provide breaths for the baby, so the baby breathes on his or her own.

Once preemies are off a mechanical ventilator and breathing on their own - with or without nasal CPAP - they are monitored continuously for any evidence of apnea. The cardiorespiratory monitor (also known as an apnea and bradycardia, or A/B, monitor) also tracks the infant's heart rate. An alarm on the monitor sounds if there's no breath for a set number of seconds. When the monitor sounds, a nurse immediately checks the baby for signs of distress. False alarms are not uncommon.

If a baby doesn't begin to breathe again within 15 seconds, a nurse will rub the baby's back, arms, or legs to stimulate the breathing. Most of the time, babies with apnea of prematurity spells will begin breathing again on their own with this kind of stimulation.

However, if the nurse handles the baby, and the baby still hasn't begun breathing on his or her own and the baby becomes pale or bluish in color, oxygen may be administered with a handheld bag and mask. The nurse or doctor will place the mask over the infant's face and use the bag to slowly pump a few breaths into the baby's lungs. Usually only a few breaths are needed before the baby begins to breathe again on his or her own.

If a baby begins to have many such apnea spells, medication is sometimes given intravenously or by mouth to stimulate the part of the brain that controls breathing. This often reduces the apnea spells.

When Your Baby Is on a Home Apnea Monitor

Although apnea spells are usually resolved by the time most premature babies go home, a few will continue to have apnea spells. In these cases, if the doctor thinks it's necessary, the premature baby will be discharged from the NICU with an apnea monitor.

An apnea monitor consists of two main parts: a belt with sensory wires that your child wears around his or her chest and a monitoring unit with an alarm. The sensors measure the premature baby's chest movement and breathing rate while the monitor continuously records these rates. Before the baby leaves the hospital, the NICU staff will thoroughly review the monitor with you and give you detailed instructions on how and when to use it, as well as how to respond to an alarm. Parents and caregivers will also be trained in infant CPR, even though it's unlikely they'll ever have to use it.

If the baby isn't breathing when you check him or her or your baby's face seems pale or bluish, follow the instructions given to you by the NICU staff. Usually, your response will involve some gentle stimulation techniques and, if these don't work, starting CPR and calling 911. Remember, never shake your baby to wake him or her.

It can be very stressful to have a baby at home on an apnea monitor. Some parents find themselves watching the monitor, afraid even to take a shower or run to the mailbox. This usually becomes easier with time. If you're feeling this way, it may help to share your feelings with the NICU staff. They may be able to reassure you and even put you in touch with other parents of preemies who have gone through the same thing.

Your child's doctor will determine how long your baby wears the monitor, so be sure to talk to him or her if you have any questions or concerns.

Caring for Your Child

Apnea of prematurity usually resolves on its own with time. For most premature babies, this means AOP stops around 44 weeks of postconceptional age. Postconceptional age is defined as the gestational age (how many weeks of pregnancy at the time of birth) plus the postnatal age (weeks of age since birth). In rare cases, AOP continues for a few weeks longer.

Healthy infants who have had AOP usually do not go on to have more health or developmental problems than other babies. The apnea of prematurity does not cause brain damage. If a healthy baby is apnea free for a week, he or she will probably never have apnea again.

Although sudden infant death syndrome (SIDS) does occur more often in premature infants, no relationship between AOP and SIDS has ever been proven.

Aside from AOP, there may be other complications with your premature baby that may limit the time and interaction that you can have with your child. Nevertheless, you can bond with your baby in the NICU. It's a good idea to talk to the NICU staff about what type of interaction would be best for your baby, whether it's holding, feeding, caressing, or just speaking softly. The NICU staff is not only trained to care for premature babies, but also to reassure and support the parents of preemies.

Reviewed by: Michael L. Spear, MD

                      Clinical Director, NICU
                      Medical Director, Infant Apnea Team
                      Division of Neonatology
                      Alfred I. duPont Hospital for Children
                      Wilmington, DE
                      Clinical Professor of Pediatrics
                      Jefferson Medical College
                      Philadelphia, PA



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