After they're born, babies must breathe continuously to get oxygen. In a premature 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 is apnea of prematurity, or AOP.
About apnea of prematurity
Apnea of prematurity is fairly common in preemies. 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 no doubt about it — it's frightening while it's happening.
Apnea is a medical term that means a baby has stopped breathing. Most experts define apnea of prematurity as a condition in which premature infants 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 the birth. The lower the infant's weight and level of prematurity at birth, the more likely he or she will have AOP.
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 should not be confused with periodic breathing, which is also common in premature newborns. 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.
Treatment
Most of the time, premature infants (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 born, many of these premature infants must get help breathing because their lungs are too immature to allow them to breathe on their own.
The following devices help with breathing:
Ventilator. During mechanical ventilation, a tube is placed into the baby's trachea (windpipe) and breaths of air are blown through the tube into the 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 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.
Continuous positive airway pressure (CPAP). When infants are disconnected from a mechanical ventilator, they often 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 baby's nose, which is hooked to a machine that provides oxygenated air into the air passages and lungs. The pressure from the CPAP machine helps keep a preemie'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.
Monitoring breathing
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 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 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 unassisted and 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 lungs. Usually only a few breaths are needed before the baby begins to breathe again on his or her own.
AOP can 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. If a baby begins to have many apnea spells, medication might be 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 preemies go home, a few will continue to have them. In these cases, if the doctor thinks it's necessary, the baby will be discharged from the NICU with an apnea monitor.
An apnea monitor has two main parts: a belt with sensory wires that a baby wears around the chest and a monitoring unit with an alarm. The sensors measure the baby's chest movement and breathing rate while the monitor continuously records these rates.
Before your 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 your baby isn't breathing or his or her 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 can 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 doctor will determine how long your baby wears the monitor, so be sure to ask if you have any questions or concerns.
Caring for your baby
Apnea of prematurity usually resolves on its own with time. For most preemies, 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. A healthy baby who is apnea free for a week will probably never have AOP again.
Although sudden infant death syndrome (SIDS) does occur more often in premature infants, no relationship between AOP and SIDS has ever been proved.
Aside from AOP, other complications with your premature baby may limit the time and interaction that you can have with your child. Nevertheless, you can bond with your baby in the NICU. 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 their parents.