What Is Apnea, Infantile?

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Intoduction

Apnea is defined by the cessation of respiratory airflow. The length of time necessary to be qualified as a true apneic event has changed dramatically over the last few decades: 2 minutes in 1956,  minute in 1959, 30 seconds in 1970, and 20 seconds or shorter if associated with bradycardia or cyanosis in 1978. The reduction of the duration in the definition of apnea reveals doctors’ desire to intervene early enough to avoid systemic consequences.

The 3 main categories of apnea are central, obstructive, and mixed. Central apnea is a result of inadequate medullary responsiveness and thus no or poor muscle coordination for breathing

Apnea is a term used to describe the temporary absence of spontaneous breathing. Infantile apnea occurs in children under the age of one year. Apnea may occur because of neurological impairment of the respiratory rhythm or obstruction of air flow through the air passages. The symptoms of infantile apnea include the stoppage of breathing during sleep, an abnormal bluish discoloration to the skin (cyanosis) and sometimes an unusually slow heartbeat (bradycardia). Infantile apnea may be related to some cases of sudden infant death syndrome. Episodes of apnea may decrease with age. However, several forms of adult sleep apnea also exist.

Infantile apnea is a rare disease that is characterized by cessation of breathing in an infant for at least 20 seconds or a shorter respiratory pause that is associated with a slow heart rate, bluish discolouration of the skin, extreme paleness and/or decreased muscle tone.[1] Infantile apnea occurs in children under the age of one and it is more common in premature infants.[2] Symptoms of infantile apnea occur most frequently during the rapid eye movement (REM) stage of sleep.[3] The nature and severity of breathing problems in patients can be detected in a sleep study called a polysomnography which measures the brain waves, heartbeat, body movements and breathing of a patient overnight.[3] Infantile apnea can be caused by developmental problems that result in an immature brainstem or it can be caused other medical conditions.[1][3][4] As children grow and develop, infantile apnea usually does not persist.[3] Infantile apnea may be related to some cases of sudden infant death syndrome (SIDS) however, the relationship between infantile apnea and SIDS is not known.[2]

Apnea in infants is the term used to describe episodes of cessation of breathing and may be due to many physiological and pathophysiological processes. Brief periods of apnea that occur in short cycles of 5 seconds to 10 seconds is not pathologic and is referred to as periodic breathing. Periodic breathing is seen predominantly during the age of two to four weeks and resolves by age six months.

Apnea is frequently seen in preterm infants but can occur at any age.

Apnea of prematurity is defined as sudden cessation of breathing that lasts for at least 20 seconds or is accompanied by bradycardia or oxygen desaturation (cyanosis) in an infant younger than 37 weeks’ gestational age.

Apnea of infancy is defined as “an unexplained episode of cessation of breathing for 20 seconds or longer, or a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked hypotonia.”

Apnea may be central, obstructive, or mixed.

Central apnea is due to the depressed respiratory center where there is a cessation of output from the central respiratory centers, and there is no respiratory effort.

Obstructive apnea occurs when there is an obstruction to the airway, and respiratory efforts are inadequate to maintain ventilation.

Mixed apnea (a period of central apnea, typically followed by airway obstruction) is the most frequent type among preterm infants.

 Symptoms

The symptoms of infantile apnea include the temporary cessation of breathing; an abnormal bluish discoloration of the skin, lips, and mouth (cyanosis), and/or an unusually slow heartbeat (bradycardia). Serious apnea is defined as the cessation of breathing during sleep for longer than 10 to 15 seconds.

Infantile sleep apnea may occur in several forms. The normal rate of respiration is regulated by groups of nerve cells in the brain. They control the rhythm of breathing in response to changing oxygen levels in the blood (respiratory drive). In central apnea, the respiratory drive is low and, during apneic episodes, there are no chest movements and no air passes through the mouth or nostrils. In this form of the disease, the brain does not send adequate signals to the diaphragm and lungs. Breathing stops and does not resume until the oxygen-starved brain sends impulses to the diaphragm and lungs.

In obstructive apnea (upper airway apnea), the airway is blocked and breathing may become difficult. Blockage may occur for a variety of reasons including collapse of the soft tissues of the throat. In this form of apnea, chest movements are present, but there is no air flow into the lungs. When breathing resumes, infants may make a loud “snorting noise” and become aroused from sleep. Obstructive apnea does not involve the cessation of breathing; rather, the affected infant struggles to breath and has increased respiratory effort.

Central apnea followed by or together with obstructive apnea is known as mixed apnea.

Some research indicates that in many cases the symptoms of infantile apnea may decrease with advancing age.

If your infant has OSA they may:

  • Have prolonged pauses in breathing that last 20 seconds or longer
  • Have patterns of repeated pauses in breathing that last less than 20 seconds
  • Have related problems such as low oxygen or a slow heartbeat
  • Have needed resuscitation or other urgent care

The following are the most common symptoms of obstructive sleep apnea. However, each child may experience symptoms differently. Symptoms may include:

  • Loud snoring or noisy breathing during sleep
  • Periods of not breathing. Although the chest wall is moving, no air or oxygen is moving through the nose and mouth into the lungs. The duration of these periods is variable and measured in seconds.
  • Mouth breathing. The passage to the nose may be completely blocked by enlarged tonsils and adenoids. May also speak with a nasal voice.
  • Restlessness during sleep. This occurs with or without periods of being awake.
  • Excessive daytime sleepiness or irritability. Because the quality of sleep is poor, the child may be sleepy, hard to wake from a nap, or irritable in the daytime.
  • Hyperactivity during the day. May also experience behavioral, school, or social problems.

The symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Always consult your child’s doctor for a diagnosis.

Some babies with sleep apnea stop breathing for 20 seconds or longer during sleep. Others stop breathing for shorter periods and become limp, turn pale or blue, or have a slowed heart rate as they sleep.

(Keep in mind that it’s normal for newborns and babies younger than 6 months to experience an irregular breathing pattern. This is called “periodic breathing” and typically starts with rapid breaths, then slower breaths, then a pause in breathing for five to 10 seconds. Then the pattern resumes with rapid breaths, and so on. Periodic breathing isn’t anything to worry about, and babies usually outgrow it by the time they’re about 6 months old.)

  • Observed cessation of breathing during sleep that may include:
  • Color change (Infant is pale or bluish)
  • Tone change – limpness
  • noisy breathing during sleep

Causes

The exact cause of infantile apnea is not known. It may occur as the result of a combination of environmental and developmental factors (multifactoral). In extremely rare cases, central infantile apnea may be familial and affect more family members than would otherwise be expected.

n children, the most common cause of obstructive sleep apnea is enlarged tonsils and adenoids in the upper airway. Infections may cause these glands to enlarge. Large adenoids may completely block the nasal passages and make breathing through the nose difficult or impossible.

There are many muscles in the head and neck that help to keep the airway open. When a person (child or adult) falls asleep, muscle tone tends to decrease, thus, allowing tissues to fold closer together. If the airway is partially closed (by enlarged glands) while awake, falling asleep may result in a completely closed passage.

Obesity may cause obstructive sleep apnea. While a common cause in adults, obesity is a less common reason for obstructive sleep apnea in children.

A rare cause of obstructive sleep apnea in children is a tumor or growth in the airway. Certain syndromes or birth defects, such as Down syndrome and Pierre-Robin syndrome, can also cause obstructive sleep apnea.

  • In babies, immaturity of the brain stem (which regulates breathing) or an airway obstruction is often responsible. Other possible causes include:
  • Bleeding in the brain
  • Exposure to drugs or poisons
  • Birth defect
  • Infection
  • Respiratory disease
  • Gastrointestinal problems (like reflux)
  • Imbalance in body chemistry (like incorrect amounts of calcium or glucose)
  • Problems with the heart or blood vessels

Risk Factors

Small preterm infants are most likely to have infant sleep apnea. It sometimes occurs in larger preterm or full-term infants. It is less common in infants under the age of six months.

During the first month after birth it occurs in 84 percent of infants who weigh less than 2.2 pounds. The risk decreases to 25 percent for infants who weigh less than 5.5 pounds. It is rare in full-term newborns.

In preterm infants, infant sleep apnea tends to appear between the second and seventh day of life. It is rare on the first day of life. Its presence at birth is usually a sign of another illness.

A variety of medical conditions can cause infant sleep apnea or make it worse. These problems include:

  • Acid reflux
  • Anemia
  • Anesthesia
  • Drugs
  • Infection
  • Lung disease
  • Metabolic disorders
  • Neurological problems
  • Seizures
  • Small upper airway

Any baby can have sleep apnea, but it’s much more common in babies who were born prematurely. In babies born before 37 weeks of pregnancy, it’s called apnea of prematurity. In babies born at 37 weeks or later, it’s called apnea of infancy.

The more premature a baby is, the more likely he is to suffer from apnea.

Children with Down syndrome and other congenital conditions that affect the upper airway also have a higher incidence of sleep apnea. More than half of children with Down syndrome develop OSA.

Diagnosis

Your child’s doctor should be consulted if noisy breathing during sleep or snoring becomes noticeable. Your child may be referred to an ear, nose, and throat (ENT) specialist (otolaryngologist) for further evaluation.

In addition to a complete medical history and physical examination, diagnostic procedures for obstructive sleep apnea may include:

  • Sleep history. A report from parents or caretaker.
  • Evaluation of the upper airway
  • Sleep study (also called polysomnography). The best test available for diagnosing obstructive sleep apnea. The test requires a high level of collaboration on the part of the child and may not be possible in younger and/or uncooperative children. Two types of tests are available. In the first type, the child will sleep in a specialized sleep laboratory. In the second type, the child has on similar monitors but sleeps in his or her own bed. During the sleep study a variety of testing occurs to evaluate the following:
  • Brain activity
  • Electrical activity of the heart
  • Oxygen content in the blood
  • Chest and abdominal wall movement
  • Muscle activity
  • Amount of air flowing through the nose and mouth

During the sleep study, episodes of apnea and hypopnea will be recorded:

  • Complete airway obstruction.
  • The partial airway obstruction combined with a significant decrease in the oxygen content of the blood.

Based on the laboratory test, sleep apnea is generally considered significant in children if more than 10 apnea episodes occur per night, or one or more occur per hour. Some experts define the problem as significant if a combination of one or more episodes of apnea and/or hypopnea occur per hour of sleep.

Symptoms of obstructive sleep apnea may resemble other conditions or medical problems. Consult your child’s doctor for more information.

If your baby’s doctor suspects that your baby has sleep apnea, she’ll do a physical exam and various tests, including a measurement of the amount of oxygen in his blood and monitoring of his breathing and heart rate. She may also take an X-ray.

Your doctor may refer you to a sleep specialist, a pediatric pulmonologist (lung specialist), or an apnea specialist for more testing.

The test that’s commonly used to diagnose sleep apnea is called a polysomnogram. This is a painless procedure done in a sleep lab under observation by trained technicians. It monitors your baby’s brain waves, eye movements, breathing, and oxygen level in his blood as well as the snoring and gasping sounds he makes during sleep.

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