Apnoeic Spells Research Articles

Opioid-free anaesthesia for cleft lip surgery in a child with apnoeic spells: Another reason to smile?

Opioid-free anaesthesia for cleft lip surgery in a child with apnoeic spells: Another reason to smile?

A critical analysis of the purported role of hypoxaemia in the comorbidity of obstructive sleep apnoea and epilepsy.

Obstructive sleep apnoea (OSA) is a globally prevalent sleep disorder of significant health concern and confounded with several comorbidities resulting in adverse effect(s) on quality of life in patients afflicted with it. Of particular interest is the enigmatic high comorbidity of OSA with epilepsy, the exact underlying pathophysiology of which remains elusive despite a multitude of research performed in the last four decades. Hypoxaemia, which is an important characteristic feature found in OSA during apnoeic spells, has been implicated in the high comorbidity of OSA with epilepsy, the basis of which rests upon hypoxaemia-mediated brain damage, subcortical release phenomenon, oxidative stress and neuroinflammatory reactions. However, several studies present contradictory evidences that potentially refute the hypoxaemia-based mechanism. Additionally, the role of hypercapnia thatgenerally accompanies hypoxaemia during apnoeic spells, cannot be overlooked and is known to be potentially protective against neuronal hyperexcitability. Thus, hypoxaemia theory implicated in the high comorbidity of OSA and epilepsy appears weak and refutable. This brief paper studies and critically analyses the role of hypoxaemia in conjunction with hypercapnia in the underlying pathophysiology of the comorbidity.

Evaluation of safety of magnesium of sulphate therapy in neonates with birth asphyxia

Background: Incidence of perinatal asphyxia is about 1 to 1.5% in most centres of world and is usually related to gestational age and birth weight. The incidence is higher in term infants of diabetic and toxaemic mothers. Intrauterine growth retardation, antepartum hemorrhage and breech presentation are also associated with an increased incidence of asphyxia. Methods: This is a prospective study carried out in Basveshwar & Sangmeshwar Teaching & General Hospitals from 1.12.2007 to 31.5.2009 on 80 terms, appropriate for gestational age babies. They all suffered severe birth asphyxia, of whom 40 formed control group & 40 formed study group. All were treated for birth asphyxia and its complications, except that the study group received injection of magnesium sulphate 250 mg/kg within half an hour of birth and subsequently 125 mg/kg at 24 & 48 hrs of life. Thereafter, they were monitored for effects on vital parameters and immediate outcome. Results: The mean cord blood serum magnesium level in control and study group was 0.85±0.12 and 0.83±0.10. The serum magnesium levels at 12, 24, 48 and 72 hours were 1.80±0.16, 1.82±0.16, 1.81±0.18, 1.82±0.17 in the study group, which were significantly higher than those in control group. The serum magnesium levels in study group ranged between 1.50 mmol/L & 2.20 mmol/L which are considered to be neuroprotective range. No significant alteration in vital parameters was seen following magnesium infusion. Evidence of HIE was seen more frequently in the control group with 26 (65%) babies showing HIE versus 22 (55%) in the study group. The incidence of HIE, neonatal seizures, & apnoeic spells were lesser in the study group compared to control group. Conclusions: Injection MgSO4 administered in a dose of 250 mg/kg & 125mg/kg as intravenous infusion is safe, Mg level obtained are in neuroprotective range & it causes better immediate outcome.

Is synchronised NIPPV more effective than NIPPV and NCPAP in treating apnoea of prematurity (AOP)? A randomised cross-over trial

BackgroundApnoea, desaturations and bradycardias are common problems in preterm infants which can be treated with nasal continuous positive airway pressure (NCPAP) and nasal intermittent positive pressure ventilation (NIPPV). It is...

519 Predictive Value of Clinical Signs in Late-Onset Sepsis (LOS) in Preterm Neonates

Background: Accurate diagnosis of LOS in preterm neonates is a major challenge because clinical signs are aspecific leading to unnecessary antibiotic treatment. Aims: To determine the predictive value of clinical signs for identifying LOS in preterm infants. Methods: In all patients 2 seconds, dys/tachypnea, increasing oxygen-need, tachycardia, thermal instability, hyper/hypothermia, feeding difficulties, increasing apnoeic spells, lethargy and irritability) and 4 risk factors (gestational age (GA), weight, sex, central venous catheter (CVC), mechanical ventilation, postnatal age) were prospectively assessed. LOS was defined as bloodculture-proven sepsis occurring after 3 days of age. Results: LOS was diagnosed in 28% of 180 episodes of suspected infection, occurring in 142 neonates (mean GA 30+3 ±2+2 weeks). Only 3 signs were significantly associated with LOS: deterioration of respiratory condition (OR 3,2;95%CI 1,6-6,3), capillary refill >2 seconds (OR 2,9;95%CI 1,5- 5,7) and lethargy (OR 4,4;95%CI 2,2-8,7). Multiple regression resulted in a model with these 3 signs and the presence of a CVC (AUC 0,828; 95%CI 0,764-0,892, p< 0,001). In the absence of these 4 factors, LOS was found in 2,3% (1/43). In case of one or more of the 4 factors sensitivity was 98%, specificity 32%, positive LR 1,45 and negative LR 0,06. Conclusion: Deterioration of respiratory condition, capillary refill, lethargy and the presence of a CVC are the most important clinical signs in predicting LOS in preterm infants. In the absence of all these signs probably antibiotics can be safely withheld.

Paroxysmal disorders in infancy and their risk factors in a population‐based cohort: the Generation R Study

To examine the incidence of paroxysmal epileptic and non-epileptic disorders and the associated prenatal and perinatal factors that might predict them in the first year of life in a population-based cohort. This study was embedded in the Generation R Study, a population-based prospective cohort study from early fetal life onwards. Information about the occurrence of paroxysmal events, defined as suddenly occurring episodes with an altered consciousness, altered behaviour, involuntary movements, altered muscle tone, and/or a changed breathing pattern, was collected by questionnaires at the ages of 2, 6, and 12 months. Information on possible prenatal and perinatal determinants was obtained by measurements and questionnaires during pregnancy and after birth. Information about paroxysmal events in the first year of life was available in 2860 participants (1410 males, 1450 females). We found an incidence of paroxysmal disorders of 8.9% (n=255) in the first year of life. Of these participants, 17 were diagnosed with febrile seizures and two with epilepsy. Non-epileptic events included physiological events, apnoeic spells, loss of consciousness by causes other than epileptic seizures or apnoeic spells, parasomnias, and other events. Preterm birth (p<0.001) and low Apgar score at 1 minute (p<0.05) were significantly associated with paroxysmal disorders in the first year of life. Continued maternal smoking during pregnancy and preterm birth were significantly associated with febrile seizures in the first year of life (p<0.05). Paroxysmal disorders are frequent in infancy. They are associated with preterm birth and a low Apgar score. Epileptic seizures only form a minority of the paroxysmal events in infancy. In this study, children whose mothers continued smoking during pregnancy had a higher reported incidence of febrile seizures in the first year of life. These findings may generate various hypotheses for further investigations.

Cold-induced sweating syndrome: CISS1 and CISS2: Manifestations from infancy to adulthood. Four new cases

Cold-induced sweating syndrome (CISS), a rare autosomal recessive disorder, is genetically heterogeneous. Deficiency of the CRLF1 and the CLCF1 gene functions results in CISS1 and CISS2, respectively. So far, only a single patient with CISS2 has been reported. Here we describe four new cases of CISS, two additional patients with CISS2 (confirming locus heterogeneity) and two patients with CISS1. Their case histories are given in detail to emphasize the striking similarity of their presentation, which makes a clinical differentiation impossible. All four cases had a uniform presentation in the neonatal period, much like Crisponi syndrome — inability to suckle and swallow due to facial and bulbar weakness; excessive startle and trismus-like facial contractions when crying or being handled; apnoeic spells; episodic unexplained fevers (up to 41°C) and associated seizures or even sudden death; erythematous skin rashes; and camptodactyly. Thus it is evident that Crisponi syndrome is the pediatric manifestation of both CISS1 and CISS2. Signs abate during infancy and most children have a normal psychomotor development. During the first decade all children develop scoliosis and abnormal sweating which is the most disabling symptom in adulthood. We report that cold-induced sweating can be effectively treated.Detailed clinical observations, correlated with the findings from basic science research, may serve to elucidate the role(s) of this important cytokine complex in embryonic and postnatal development.

Apnoeic spells following general anaesthesia in a patient with familial hemiplegic migraine

Hemiplegic migraine is an unusual variant of migraine, characterised by a temporary hemiparesis or hemiplegia associated with headache. We report a patient with hemiplegic migraine who developed atypical migraine with apnoeic spells, aphasia and hemiparesis following general anaesthesia. We review the clinical features of hemiplegic migraine and the considerations for its anaesthetic management.

Zentralnervöse Atemdepression als Komplikation der Behandlung des kongenitalen Glaukoms mit Brominidin-Augentropfen

We report the case of a premature newborn (gestational age 33 weeks) with congenital glaucoma. After a trabeculotomy high intraocular pressure persisted, leading to adjuvant treatment with timolol and--when the infant was 3 weeks old--with brimonidine. After the first application of topical brimonidine the infant developed such severe apnoeic spells that intubation and temporary ventilation were necessary. A review of the literature reveals that when used in young infants brimonidine eye drops can potentially have toxic effects on the central nervous system (e.g. respiratory depression). The use of topical brimonidine is therefore not advised in this age group.

New cervical approach for tracheopexy.

Deficiency of the tracheal cartilage is known to occur with oesophageal atresia resulting in abnormal compressibility. It does not require treatment unless symptomatic. Symptoms comprise apnoeic or cyanotic spells, often precipitated by feeds, and recurrent chest infections. When other causes such as stricture, recurrent fistula and gastro-oesophageal reflux have been excluded, the abnormality can be diagnosed radiologically and endoscopically. Previously tracheopexy through a lateral thoracic approach has been described. We describe three patients who had a successful tracheopexy through an anterior cervical approach, which is simpler, and a fourth in whom there was partial alleviation.

An unusual cause of stridor in childhood due to focal epileptic seizures

Respiratory disorders with stridor are a frequent cause of admission for children in an emergency department. Laryngospasm, as an isolated symptom of epilepsy, is a rare phenomenon [1, 3, 5]. Other respiratory symptoms of epilepsy, rarely seen in childhood, might be apnoeic spells [2, 4]. We report on a child with laryngospasm due to focal epileptic seizures.

Morbidity and mortality of low birth weight infants in the New Born Unit of Kenyatta National Hospital, Nairobi

Morbidity and mortality of low birth weight (LBW) infants at Kenyatta National Hospital (KNH) has previously been found to be high. Other centres have shown that even with lack of neonatal intensive care facilities, selective interventions can be implemented that improve neonatal survival rates. It is important to identify those factors at KNH that when selectively modified, will improve the quality of care hence survival rates. To quantify the morbidity and mortality of LBW infants in KNH. To audit the quality of care and identify factors that can be selectively modified to improve the quality of care and improve the currently low survival rates. Retrospective study utilising case notes. New born unit, Kenyatta National Hospital, Nairobi. All LBW infants admitted to the NBU at KNH from January to December 2000. Out of an expected 694 files, 533 (77%) were studied. The male to female ratio and LBW to VLBW ratio was 1:1 respectively. Small for gestational age (SGA) accounted for 11.6%. Overall mortality was 57.4% (574/1000 admissions) while mortality for SGA was 37%. Infants born out of KNH had significantly higher mortality (p=0.0047). Compared to Caeserian delivery, infants born via spontaneous vertex delivery had higher mortality (p=0.0087). The leading diagnoses on admission or death were respiratory distress(69%), apnoeic attacks (42%) suspected sepsis and jaundice (37% each), hypothermia(27%) and anaemia(17%). By time of death or discharge, 43% had no laboratory investigations done. While 37% had suspected sepsis, only 14% had blood culture done. Antibiotics were started in 460 (86%) of infants yet only 37% had diagnosis of suspected sepsis. Change of antibiotics was guided by culture and sensitivity reports in only 62(13.5%). Apnoeic spells were managed with rectal aminophyline in 156(29%) infants of whom 19(12%) survived. The terminal events for the dead infants included recurrent apnoeic spells. The only mode of nutrition was enteric feeding in 59% with breast milk, formula or pasteurized cows milk by nasogastric tube, breast feeding or cup feeding. Except for dextrose water, parenteral nutrition was not utilised. Of 63 infants dying with associated anaemia, 43(68%) were not transfused due to lack of reliable blood supply. Compared to previous studies, mortality of LBW infants in KNH- NBU has increased over the years. Improvement in supportive care as regards nutrition, temperature regulation, laboratory back up and respiratory support is recommended. There is a place for trial of kangaroo mother care and simple continous positive airways pressure administration methods. There is a need to ascertain the efficacy of the method of aminophyline administration.

Paediatric obstructive sleep apnoea: is a polysomnogram always necessary?

Obstructive sleep apnoea (OSA) is a common entity in children, most present with sleep disturbances such as snoring, choking during sleep, enuresis, restless sleep, or apnoeic spells. Other symptoms include poor school performance, hyperactivity, failure to thrive, heart failure and cor pulmonale. Most authors would concur that the polysomnogram (PSG) is the gold standard for the diagnosis of OSA, and that adenotonsillectomy is the surgical procedure of choice, with high curative rates and relatively low morbidity. Close post-operative monitoring of all children with OSA cannot be over-emphasized. The focus has been, traditionally, to anticipate post-operative airway and respiratory complications in this group of children. We present 73 children with clinical OSA and 36 children with proven OSA on PSG, with only one child having respiratory complications (mixed apnoea), and all with uneventful recovery. In view of our low complication rates, low post-operative morbidity, cost and facility factor, the need for a mandatory overnight PSG pre-operatively is questioned, and clinical criteria for performing a PSG preoperatively are suggested.

Endoscopic division of the ary-epiglottic folds in severe laryngomalacia

Objective: Laryngomalacia is the commonest cause of congenital stridor. The underlying anatomical abnormality associated with this condition is a prolapse of the supraglottic tissues into the laryngeal inlet during inspiration, and may involve the epiglottis, ary-epiglottic folds and the corniculate mounds of the arytenoids. However, it has been noted that the most consistent structural abnormality seen in these cases is the shortening of the ary-epiglottic folds and marked side to side curling of the epiglottis. We describe the follow-up and outcome of 33 cases treated by the simple division of the ary-epiglottic folds. Method: All case notes were reviewed with respect to indications of operation, age of operation, endoscopic findings, operative technique, complications and follow-up until resolution of symptoms. Results: Surgical outcomes could only be ascertained in only 32 patients. Twenty-two cases (68.7%) showed complete resolution of stridor and associated complications of laryngomalacia. In the remaining ten cases who could be followed up (31.2%), seven patients (21.8%) showed partial resolution with no further surgery required, two patients (6.2%) required additional excision of redundant mucosa as second procedure, one patient (3%) with associated cleft lip/palate and tracheomalacia had to undergo a tracheostomy. There was improvement in feeding after surgery in all the 12 patients (100%) who had had pre-operative feeding difficulties. All the four patients with cyanosis pre-operatively were cured, but one of the two patients with apnoeic episodes pre-operatively continued to have apnoeic spells despite resolution of their laryngomalacia. Conclusion: Simple endoscopic excision of the ary-epiglottic folds is a quick, reliable, highly effective procedure with very few complications. We recommend its use as the first line option in the management of severe laryngomalacia, with more extensive methods reserved for the very occasional case of primary failure.

Oral-facial-digital syndrome type IX in a patient with Dandy-Walker malformation.

We report a girl with oral, facial, and digital anomalies including multiple alveolar frenula, lobulated tongue with nodules, a posterior cleft palate, hypertelorism, a prominent forehead with a large anterior...

Olfaction and human neonatal behaviour: clinical implications

About 1–2% of the human genome is allocated to production of receptors for the olfactory epithelium–a hint as to the possible importance of this chemical sense, which includes two anatomically distinct systems: the main olfactory system with sensory cells located in the upper part of the nasal cavity, and the vomeronasal organ with sensory cells on the nasal septum. In adults, individual odours may influence mate preferences and a growing body of evidence indicates that naturally occurring odours play an important role in the mediation of the infant's behaviour. Even foetal olfactory learning seems to occur and breast odours from the mother exert a pheromone‐like effect at the newborn's first attempt to locate the nipple. Newborns are generally responsive to breast odours produced by lactating women. Olfactory recognition may be implicated in the early stages of the mother‐infant attachment process, when the newborns learn to recognize the own mother's unique odour signature–a process possibly facilitated by the high norepinephrine release and the arousal of the locus coeruleus at birth. New knowledge about human odour physiology may have diagnostic and therapeutic implications–the initiation and stabilization of breastfeeding and termination of apnoeic spells are mentioned as examples.

Olfaction and human neonatal behaviour: clinical implications.

About 1-2% of the human genome is allocated to production of receptors for the olfactory epithelium--a hint as to the possible importance of this chemical sense, which includes two anatomically distinct systems: the main olfactory system with sensory cells located in the upper part of the nasal cavity, and the vomero-nasal organ with sensory cells on the nasal septum. In adults, individual odours may influence mate preferences and a growing body of evidence indicates that naturally occurring odours play an important role in the mediation of the infant's behaviour. Even foetal olfactory learning seems to occur and breast odours from the mother exert a pheromone-like effect at the newborn's first attempt to locate the nipple. Newborns are generally responsive to breast odours produced by lactating women. Olfactory recognition may be implicated in the early stages of the mother-infant attachment process, when the newborns learn to recognize the own mother's unique odour signature--a process possibly facilitated by the high norepinephrine release and the arousal of the locus coeruleus at birth. New knowledge about human odour physiology may have diagnostic and therapeutic implications--the initiation and stabilization of breastfeeding and termination of apnoeic spells are mentioned as examples.

Laryngologic management of infants with the Chiari II syndrome

As a part of a prospective multi-disciplinary study, all children born with a Chiari II malformation within the Uppsala region during a 3-year period were evaluated for any difficulties in breathing or swallowing. The evaluation was repeated at regular intervals during their first 18 months. Direct laryngoscopies were performed using flexible fiberscopes. Four out of 22 children were found to have disturbed breathing. Among those, two suffered from central apnoeic spells as well as bilateral vocal fold motion impairment, one from apnoeic spells only and one from bilateral vocal fold motion impairment only. All four also had dysphagia with aspiration. Three of the children developed respiratory symptoms within the first 3 months and the symptoms of the fourth begun within the first 6 months. One infant with severe symptoms expired at the age of 3 months. The vocal fold paralysis, apnoeic spells and swallowing difficulties of another infant resolved following active neurosurgical management. The conclusion that laryngologic issues are prominent in the severe Chiari II syndrome was further supported by a review of four more cases managed in recent years. Laryngologic assessment in the neonatal period can help to raise the issue of early neurosurgical intervention as well as identify some of the infants who will need extensive habilitation. Screening of laryngeal function by means of flexible fiberoptic laryngoscopy is recommended.

Hypothalamic dysfunction in a child: A distinct syndrome?

We report the case of a 9-year-old girl with multiple problems due to hypothalamic dysfunction of obscure origin: apnoeic spells, behavioural problems, developmental delay, hypodipsia with bouts of hypernatraemia, episodes of spontaneous hypothermia, obesity, petit-mal seizures, non-progressive precocious puberty, absence of respiratory response to CO2 and probably insensitivity of hyposensitivity to pain. She also had hyperprolactinaemia and decreased human growth hormone secretion. Hypothyroidism of central origin and hyposecretion of cortisol were also present. Multiple brain CT-scans failed to reveal any tumour or other anatomical abnormality. Her clinical course was improved initially by treatment with clomipramine, but she died suddenly, and the autopsy failed to disclose any anatomical lesion. We compare this case with three similar previously reported cases.

Spinal Anaesthesia for Inguinal Hernia Repair in High-Risk Neonates

To avoid the high incidence of respiratory complications associated with general anaesthesia in premature neonates, 44 spinal anaesthetics for inguinal hernia repair in very low birthweight infants were administered in 47 attempts. Hyperbaric tetracaine with epinephrine 1:200,000 was administered in a dose range of 0.27–1.10 μg · kg−1. Attempted lumbar puncture failed in three infants. In 24 procedures, spinal anaesthesia alone provided satisfactory operating conditions; in 20, supplementary inhalational general anaesthesia or iv ketamine was necessary. Perioperative apnoeic episodes requiring bag/mask assisted ventilation occurred in six infants. In five infants, apnoeic spells occurred in the postoperative period. No infant required tracheal intubation; there was no haemodynamic instability. Twenty-four infants required no postoperative analgesia. Our experience suggests that spinal anaesthesia for inguinal hernia repair in very low birth weight infants reduces but does not eliminate the risk of respiratory instability, and that supplementary anaesthesia is often necessary to provide satisfactory operating conditions.