Is periodic breathing normal in infants?

Periodic Breathing in Infants

Periodic breathing is a normal respiratory pattern in infants, particularly during the first few months of life. 1

Definition and Normal Patterns

• Periodic breathing is defined as ≥3 episodes of central apnea lasting >3 seconds separated by no more than 20 seconds of normal breathing 1
• This breathing pattern is most common in:
  • Preterm infants, especially those 30-33 weeks gestational age 2
  • Full-term infants during the first 6 months of life 3
  • More prevalent during REM (active) sleep than during NREM (quiet) sleep 4

Prevalence and Age-Related Changes

• The percentage of infants exhibiting periodic breathing decreases significantly with age:
  • 78% of infants at 0-2 weeks of age
  • 29% of infants at 39-52 weeks of age 3
• For infants who do demonstrate periodic breathing, the typical pattern involves:
  • Less than 6% of total sleep time in infants <35 weeks gestational age 2
  • Less than 1% of sleep time in healthy full-term infants 3
• The time spent with paradoxical inward rib cage movement during REM sleep (which can be associated with periodic breathing) decreases with age:
  • Present during nearly 100% of REM sleep time in newborns
  • Present during only 10% of REM sleep time by 3 years of age 1

Clinical Significance and Monitoring

• Normal full-term infants occasionally have respiratory pauses of 10-12 seconds 3
• Apneas >15 seconds are rare in healthy infants and should prompt further evaluation 4
• An acute increase in periodic breathing may reflect:
  • Illness (infection, necrotizing enterocolitis)
  • Physiological stressors (immunizations)
  • Medication changes (caffeine discontinuation) 2

When to Be Concerned

• Features that distinguish pathological from normal periodic breathing:
  • Apneas lasting >15 seconds 4
  • Obstructive or mixed apneas (rather than central apneas) 4
  • Association with bradycardia or oxygen desaturation 4
  • Sudden increase in periodic breathing (>2-fold over baseline) 2
  • Periodic breathing occupying >10% of sleep time 2

Pitfalls and Caveats

• The normal respiratory pattern and oxygenation status of infants in the 2-8 month at-risk age range for SIDS is still not fully understood 1
• Polysomnography studies generally have not been predictive of ALTE (now called BRUE) recurrence and do not identify infants at risk of SIDS 1
• Routine polysomnography in infants presenting with lower-risk BRUE is likely to have low diagnostic yield and unlikely to lead to changes in therapy 1
• There is considerable intersubject variability in rates of respiratory pauses, making it important to consider the overall clinical picture 4