Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Comment
  • Published:

Apnea of prematurity: when is the right time to stimulate?

Pediatric Research (2024)Cite this article

Apnea of prematurity (AOP) remains one of the common diagnoses in neonatal intensive care units, especially with the increased survival of extremely premature infants. Multiple definitions exist for AOP, depending on the medical society. It has been defined by the American Academy of Pediatrics Committee of the Fetus and Newborn as the presence of respiratory pauses for more than 20 s or shorter pauses associated with cyanosis or desaturations or bradycardia less than 100 bpm in infants less than 37 weeks gestational age.1 The control of breathing is a complex process, which includes interaction between multiple peripheral and central receptors, neurons, and the respiratory center in the bulbo-pontine region, which is responsible for rhythmogenesis. AOP is the best single indicator of the immaturity of this process.2 An increasing number of apnea days has previously been shown to be associated with worse clinical outcomes, including abnormal neurodevelopment, which might be related to intermittent hypoxic episodes and bradycardia during those events.

Methylxanthines and non-invasive respiratory support have been the mainstays of the management of AOP. Caffeine citrate is the only Food and Drug Administration-approved medication for the treatment of AOP. However, despite these interventions, the severity of AOP can progress to needing invasive mechanical ventilation and its untoward consequences. In most cases, sensory tactile stimulation, in addition to supplemental oxygen, terminates the episode. The mechanism by which tactile stimulation stimulates respiration is unclear, but it is postulated that it does so by producing non-specific excitatory neuronal impulses that result in respiratory stimulation together with activating the reticular formation of the brain stem, leading to arousal.3 In addition, limb motion has been shown to increase respiratory rates even during sleep through proprioceptive afferents, which coordinate respiratory generation and locomotion.4 Moreover, the effect of mechanical stimulation on the respiratory centers depends on the nerves that are stimulated. Various sensory receptors are present throughout the skin, each type responding to a different degree of stimulus, indicating that the location and degree of tactile stimulus can lead to a different response.5,6

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

References

  1. Eichenwald, E. C. Apnea of prematurity. Pediatrics https://doi.org/10.1542/peds.2015-3757 (2016).

  2. Erickson, G., Dobson, N. R. & Hunt, C. E. Immature control of breathing and apnea of prematurity: the known and unknown. J. Perinatol. 41, 2111–2123 (2021).

    Article  PubMed  PubMed Central  Google Scholar 

  3. Trippenbach, T. & Flanders, D. Interaction between somatic and vagal afferent inputs in control of ventilation in 2-week-old rabbits. Respir. Physiol. 116, 25–33 (1999).

    Article  CAS  PubMed  Google Scholar 

  4. Iwamoto, E. et al. The neural influence on the occurrence of locomotor-respiratory coordination. Respir. Physiol. Neurobiol. 173, 23–28 (2010).

    Article  PubMed  Google Scholar 

  5. Abdel Mageed, A. S. A., Olama, K. A., Abdel Rahman, S. A. & El-Gazzar, H. E. The effect of sensory stimulation on apnea of prematurity. J. Taibah Univ. Med. Sci. 17, 311–319 (2022).

    PubMed  Google Scholar 

  6. Mortimer, B. J., Zets, G. A. & Cholewiak, R. W. Vibrotactile transduction and transducers. J. Acoust. Soc. Am. 121, 2970–2977 (2007).

    Article  PubMed  Google Scholar 

  7. Cramer, S. J. E. et al. The effect of vibrotactile stimulation on hypoxia-induced irregular breathing and apnea in preterm rabbits. Pediatr. Res. https://doi.org/10.1038/s41390-024-03061-2 (2024).

  8. Bou Jawde, S., Scheuermann, A., Bartolák-Suki, E. & Suki, B. The effect of mechanical or electrical stimulation on apnea length in mice. Biomed. Eng. Lett. 8, 329–335 (2018).

    Article  PubMed  PubMed Central  Google Scholar 

  9. Pergolizzi, J. et al. Treating apnea of prematurity. Cureus 14, e21783 (2022).

    PubMed  PubMed Central  Google Scholar 

  10. Joshi, R., Mortel, H. V., Feijs, L., Andriessen, P. & Pul, C. V. The heuristics of nurse responsiveness to critical patient monitor and ventilator alarms in a private room neonatal intensive care unit. PLoS ONE 12, e0184567 (2017).

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Section of Neonatology, Department of Pediatrics, Children’s Mercy Hospital, Kansas, MO, USA

    Ahmed El-Saie

  2. Division of Neonatology, Department of Pediatrics, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA

    Binoy Shivanna

Authors
  1. Ahmed El-Saie
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Binoy Shivanna
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Binoy Shivanna.

Ethics declarations

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

El-Saie, A., Shivanna, B. Apnea of prematurity: when is the right time to stimulate?. Pediatr Res (2024). https://doi.org/10.1038/s41390-024-03173-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1038/s41390-024-03173-9

Search

Advanced search

Quick links