Apnea is the term for brief pauses in breathing. In children, these events can be common, and very scary for parents. It's important to know common causes of apnea in children, so parents and practitioners know when to be concerned, and when not to be. Pauses in breathing, cyanosis (turning blue), unresponsiveness, are all signs to look out for and can determine the severity of the issue. Here are possible causes of apnea in children and neonates.
Apnea of Prematurity
Children born before 37 weeks are considered premature. Premature infants are at high risk for breathing disorders because the lungs are one of the last organs to finish developing. In fact, even after birth, lung maturation continues until about the age 25. Children born before 20 weeks have very low rates of survival because of the lack of lung development. Children born before 28 weeks also are at high risk of death due to the lack of maturity for survival.
Surfactant is a substance on the lungs that provides lubrication and reduces surface tension. Without it, the lungs are at high risk for collapsing, making air exchange impossible. Surfactant is not produced until 28 weeks, making lung collapse a common event in children born before or around that time.
Aside from that, children born before 36 weeks have an underdeveloped respiratory center. This means that the brain does not send consistent signals to the lungs to breathe. Obstruction could also be an issue as they do not have proper muscle control, which can block the airway.
All of these are causes for apnea of prematurity, and babies born early are at risk of having respiratory issues. If you have a premature child, these are some of the reasons they may stop breathing. Most premature children are kept in the hospital until they demonstrate they can breathe on their own and have no other major concerns.
Periodic Breathing
Periodic breathing is a normal variation in the breathing patterns of newborns, both premature and full term. This is due the lack of maturity of their respiratory drive and inability to fully sense the amount of CO2 in their body. Therefore, they pause in breathing until the levels of CO2 rise, which triggers their breathing again. Once the levels drop, they may pause in breathing again, repeating the cycle.
These pauses should not last more than 10 seconds at a time, and breathing returns to normal without any stimulation or intervention. When breathing returns, it may be rapid and shallow, before starting the cycle all over again. This is nothing to be concerned about unless your child is demonstrating concerning respiratory distress.
Central Apnea
Central apnea is similar to apnea of prematurity in the sense that there are pauses in breathing due to the immaturity of the respiratory center in the brain. This means the brain will sometimes "forget" to signal to the lungs to breathe. Central apnea is different in the sense that it can affect both premature and full-term babies.
Sometimes, this is an indication that something is wrong, and the part of the brain responsible for breathing is being compressed or interfered with in some manner. Examples of this include Arnold-Chiari malformation and Cheyne-Stokes Breathing Patterns.
If your child pauses in breathing during sleep for more than 10 seconds, you may want to present the symptoms to your child's doctor so they can ensure there is no cranial or cerebral malformation. Treatment for this is mechanical ventilation of a BIPAP so it's important to alert your doctors as soon as possible so they can intervene quickly.
Obstructive sleep apnea
Obstructive sleep apnea, OSA, is the most common cause of apnea in children and adults. OSA is caused by a blockage of the airway, which leads to snoring and pauses in breathing throughout the night. For children, this obstruction can be a swallowed item, excess tissue, loss of muscle tone in the pharynx, or crowded anatomy.
Risk factors for children include obesity, large tonsils, and genetic disorders such as Pierre Robin sequence, Down Syndrome, or cerebral palsy.
OSA can cause hypoxia, heart disease, and other health problems, so it is important to recognize it and get treatment right away. Common symptoms include restless or poor sleep, behavioral problems, irritability or fussiness, mouth breathing, snoring or choking while sleeping, and obvious signs of sleep deprivation.
BRUE
BRUE, or brief resolved unexplained event, is a less than 1 minute, self-resolved episode with: cyanosis or pallor, absent or irregular breathing, change in tone, or altered level of responsiveness in an infant less than 1 year old.
It is a strange event because there is no identifiable cause and children recover without any issue. There are variable levels for risk of a serious adverse event for infants who experience a BRUE.
Low risk infants over 2 months of age, born at term who experience a single, brief (<1 minute), self-limited (no intervention necessary) BRUE. No additional testing is recommended, except for potentially an electroencephalogram (EEG) and pertussis (whooping cough) screening.
The evaluation and intervention for high-risk infants with BRUE are still being determined. High risk would include prematurity, high likelihood of an underlying cause, and unresponsiveness accompanied with another alarming feature. Knowing the basics of infant CPR and contacting your physician right away are excellent management plans for parents.
SIDS
Sudden infant death syndrome, or SIDS, is different from BRUE because there is no benign resolution. The child dies for no identifiable reason, normally in their sleep. It is a diagnosis of exclusion, so it will not be determined as the cause of death until the autopsy rules out any other potential cause.
Children under a year old are at high risk for SIDS. This is due to their decreased muscle tone, poor strength, and inconsistency of their regulatory centers.
Risk factors for SIDS include stomach sleeping, smoking, soft bedding or pillows, and bed sharing. To reduce the risk for SIDS, infants should be placed on their backs in a separate bed with a flat surface. They do not need blankets, pillows, stuffed animals, or anything else other than a fitted sheet. Children are not strong enough to move items off their face, so they can suffocate if an adult, pillow, blanket, or other soft item covers their face.
All they need is to sleep in a onesie for them to be warm. Although expensive, monitors that track their vitals throughout the night can be helpful in preventing infant death.
Karen J. Marcdante MD, Robert M. Kliegman MD, Abigail M. Schuh MD, MMHPE. Nelson Essentials of Pediatrics, Chapter 134, 533-536