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 first 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
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 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.
Outcomes for Premature Babies
In general, outcomes for premature babies are very good.
Before the development of Neonatal Intensive Care Units (NICUs), many
premature babies did not survive. The introduction of incubators, mechanical
ventilation, and other technologies and medical techniques, as well as a more
complete understanding of newborn baby physiology, have increased premature
baby survival dramatically. As a result, some premature babies who would have
died in the past now survive, but may have lifelong problems. Medical
professionals make this distinction using the words “morbidity” and
“mortality.”
Mortality and morbidity
Mortality is the rate of death or the number of premature
babies admitted to an NICU who do not survive compared to those who do. As
noted above, the mortality rate of premature babies has dramatically improved
over the last 20 years or so. The overwhelming majority of babies with access
to the modern technology and medical techniques available in the NICU now
survive. At the same time, there are limits to the medical technology and
techniques available in the NICU; some babies who are born too soon are too
small to either save at all or save without serious disability or morbidity.
Morbidity is the number of babies who survive but with
lasting complications, compared to the number who survive with no lasting
complications. In other words, the morbidity rate is the number of premature
babies who grow up with medical, developmental, or psychological problems
compared to those who grow up without any of these issues. Although many
premature babies go on to live normal, healthy lives, the success rate in
this regard is not as overwhelming as the dramatic improvement in mortality.
In fact, the two statistics are related: medicine has become very successful
at keeping premature babies alive, especially the extremely premature, who
tend to have more complications than other premature babies.
Mild, moderate, and extreme prematurity
In general, outcomes are related to:
- the gestational age, or the number of weeks a premature
baby spent in the womb
- the weight of the baby at birth
The spectrum of prematurity
Based on their gestational age and birth weight, premature
babies are placed into loosely defined categories of mild, moderate, and extreme
prematurity.
- Mild prematurity refers to babies who are born between
33 and 36 completed weeks gestational age and/or have a birth
weight between 1500 and 2500 g (between about 3 lbs 5 oz and 5
lbs 8 oz).
- Moderate prematurity refers to babies who are born
between 28 and 32 completed weeks gestational age with a birth weight
ranging between 1000 and 1500 g (between about 2 lbs 3 oz and 3 lbs 5
oz).
- Extreme prematurity refers to babies who are born before
28 completed weeks gestational age or who have a birth weight of less
than 1000 g (less than about 2 lbs 3 oz).
Mildly premature babies do better than moderately premature
babies, who in turn do better than extremely premature babies. This makes
intuitive sense: barring other complications not due to prematurity, the
longer a baby has spent in the womb, the more developed her organs are and
therefore the more prepared she is for the challenges of the outside world.
Statistics and the individual baby
As specific complications are addressed in this site, outcome
statistics specific to that condition are provided where appropriate.
However, mortality and morbidity statistics are based on group data and do
not take into account the individual baby. The body is very much an
interconnected system. The ways in which two or more complications affect
each other can have a huge impact on morbidity and mortality, making the
course and outcomes of illness difficult to predict.
Some, though few, extremely premature babies do
surprisingly well and go on to thrive as healthy children. Conversely, some
mildly premature babies who are expected to do well develop complications and
lifelong problems or do not survive at all.
This is not to say that statistics and outcome data should
be ignored; this information is extremely useful to physicians and other
medical professionals who are devoted to producing the best possible outcomes
for premature babies. Mortality and morbidity data can help medical staff
anticipate and predict problems that have not surfaced yet, allowing for
pre-emptive or preventive treatment that will benefit the baby.
Outcome statistics are not definitive. Rather, they are a
guide to be used by medical professionals, and parents and families. Given
all the possible combinations of complications premature babies may face,
making an actual outcome prediction can be complex, even impossible. At other
times, a particular complication or series of complications may make outcome prediction,
both good and poor, more simple. For this reason, staff at the NICU will
speak in terms of probabilities: for example, they may say that 75% of babies
with a specific condition will recover completely without lifelong
complications. Predicting an individual baby’s outcome cannot be done with
absolute certainty.
NEONATAL
Pertaining to the first four weeks of a baby’s life.
NICU
Neonatal intensive care unit (NICU). A ward in a hospital
designed, equipped, and staffed for the intensive care of newborn babies
MORTALITY
Death. The mortality rate is the number of deaths in a
certain population, region, or group.
WOMB
An organ, also called the uterus, where the fertilized
egg cell implants and grows into the fetus during pregnancy.
GESTATIONAL AGE
The age of a fetus or newborn baby, in weeks, measured
from the date of the mother's last menstrual period. The age of premature
infants is often stated this way.
EXTREME PREMATURITY
Degree of prematurity, or how premature a baby is
considered, is often defined in different ways by different hospitals,
researchers, and medical associations. Within this site, the degree of
prematurity is defined as follows: Mild prematurity refers to babies who
are born between 33 and 36 completed weeks gestational age with an
approximate birth weight range between 1500 and 2500 grams (between about 3
lbs 5 oz and 5 lbs 8 oz). Moderate prematurity refers to babies who are
born between 28 and 32 completed weeks gestational age with an approximate
birth weight range between 1000 and 1500 grams (between about 2 lbs 3 oz
and 3 lbs 5 oz). Extreme prematurity refers to babies who are born before
28 completed weeks gestational age with an approximate birth weight of less
than 1000 grams (less than about 2 lbs 3 oz).
MILD PREMATURITY
Degree of prematurity, or how premature a baby is
considered, is often defined in different ways by different hospitals,
researchers, and medical associations. Within this site, the degree of
prematurity is defined as follows: Mild prematurity refers to babies who
are born between 33 and 36 completed weeks gestational age with an
approximate birth weight range between 1500 and 2500 grams (between about 3
lbs 5 oz and 5 lbs 8 oz). Moderate prematurity refers to babies who are
born between 28 and 32 completed weeks gestational age with an approximate
birth weight range between 1000 and 1500 grams (between about 2 lbs 3 oz
and 3 lbs 5 oz). Extreme prematurity refers to babies who are born before
28 completed weeks gestational age with an approximate birth weight of less
than 1000 grams (less than about 2 lbs 3 oz).
MODERATE PREMATURITY
Degree of prematurity, or how premature a baby is
considered, is often defined in different ways by different hospitals,
researchers, and medical associations. Within this site, the degree of
prematurity is defined as follows: Mild prematurity refers to babies who
are born between 33 and 36 completed weeks gestational age with an
approximate birth weight range between 1500 and 2500 grams (between about 3
lbs 5 oz and 5 lbs 8 oz). Moderate prematurity refers to babies who are
born between 28 and 32 completed weeks gestational age with an approximate
birth weight range between 1000 and 1500 grams (between about 2 lbs 3 oz
and 3 lbs 5 oz). Extreme prematurity refers to babies who are born before
28 completed weeks gestational age with an approximate birth weight of less
than 1000 grams (less than about 2 lbs 3 oz).
PREVENTIVE
Designed to prevent or slow down a disease or condition.
COMPLICATION
A second condition or disease that develops as a result
of an initial disease, condition, treatment, or other cause.
Donation
Choose how you want to help kids.
2. Give by mail by filling out
this form and mailing it to:
Grace Preemies Foundation
2676 Islington Avenue
Toronto. Ontario. M9V 2X5
3. Give by phone by calling (416) 744 8952.
We also accept usable materials for babies and specifically preemies. Please
contact us for delivery/collection of these.
