Atividade fásica do sono rem em recém-nascidos e lactentes e sua relação com episódios de apnéia

Nunes, Magda Lahorgue; Costa, Jaderson Costa da; Taufer, Letícia

doi:10.1590/S0004-282X1997000200008

Resumos

A hipótese de que a apnéia pudesse ser o evento final da síndrome da morte súbita da infância (SMSI) deu origem a vários estudos avaliando as características deste evento do ponto de vista polissonográfico. Foi sugerido que a atividade fásica do sono REM estaria associada a ativação dos neurônios respiratórios prevenindo a ocorrência de apnéias prolongadas e protegendo os lactentes de evoluírem para SMSI. Em estudo prévio retrospectivo com recém-nascidos não confirmamos estes achados mas muitos destes bebês apresentavam comprometimento neurológico severo. O objetivo do presente estudo é verificar a relação existente entre períodos de atividade fásica do sono REM (movimentos oculares rápidos e movimentos de sucção) e apnéia. Estudamos do ponto de vista clínico c polissonográfico 86 recém-nascidos c lactentes encaminhados para avaliação por terem apresentado apnéia ou episódios com aparente risco de vida durante o sono. Dividimos os pacientes em 3 grupos: recém-nascidos (idade concepcional inferior a 44 semanas, n=31), lactentes com 1 -6 meses (n=48) e lactentes com >6m<12 meses (n=7). Todos foram submetidos a avaliação clínica e neurológica para detectar possíveis fatores etiológicos das apnéias. As polissonografias constavam de EEG, eletromiograma submentoniano, eletro-oculograma e monitorização cardiorrespiratória, todas com duração de 2 a 3 horas. Durante 5 minutos contínuos de sono REM verificamos a incidência de atividade fásica relacionada a períodos em apnéia e comparamos sua incidência em períodos semelhantes sem apnéia. Nossos resultados mostraram que a atividade fásica do sono REM ocorre com maior freqüência em períodos sem apnéia. No período neonatal os movimentos de sucção (p < 0.05) e nos lactentes com 1-6 meses os movimentos oculares rápidos (p=0,001). Não houve diferença estatisticamente significativa nos lactentes >6<12 meses. Nossos resultados mostram que a atividade fásica do sono REM é mais frequente cm períodos sem apnéia durante os 6 primeiros meses de vida, período que coincide com o maior risco de SMSI. Sugerimos que o "driving" excitatório que determina o aparecimento da atividade fásica possa ter efeito protetor contra apnéias através do bloqueio ou atenuação da inibição tônica do centro respiratório que determinaria a apnéia. Estudos futuros são necessários para avaliar a relação entre perda desse "mecanismo de proteção"e SMSI.

apnéia; polissonografia; síndrome da morte súbita da infância

When the apnea hypothesis turned to be an explanation for sudden infant death syndrome (SIDS) many authors tried to find if near-miss or apparent life-threatening events (ALTE) could be markers of SIDS. It was suggested that phasic REM activity is associated with increased respiratory neuron activity and prevents prolonged apnea in near-miss SIDS. In a previous retrospective study with newborns we did not confirm these results, nevertheless we had several babies with serious neurological disturbances. The aim of this study was to verify the relationship of phasic activity (rapid eyes movement and sucking bursts) with both apneic and non-apneic epochs during REM sleep. We studied 86 children refered for evaluation because they presented an ALTE during sleep or apneas. The subjects were divided in three groups by age (newborns, n=31; 1 -6 months, n= 48; and >6< 12 months, n=7). They were all submitted to a clinical and neurological evaluation in order to detect possible etiological factors to the apneic episode. The po.lysomnograms (PS) consisted of EEG, submental EMG, electro-oculogram and cardiorespiratory monitoring. The records were made between 11 am and 15 pm for 2 or 3 hours. The electrodes were disposed in the 10-20 system. During one five-minutes epoch of REM sleep we verified the incidence of phasic activity (rapid eyes movement or sucking bursts) time locked to apneic episodes and compared with a similar duration non-apneic epoch. To evaluate the relationship of phasic activity with apneic and non-apneic epochs we compared the incidence of rapid eyes movements and sucking bursts in each group. Our results showed that phasic activity of REM sleep (sucking bursts) seems to be more frequent in newborns in non-apneic epochs (p < 0.05). Between 1-6 months the number of rapid eyes movements were more frequent in non-apneic epochs (p=0.00l). In conclusion our findings suggest that phasic activity of REM sleep seems to be more evident in nonapneic epochs during the first six months of life. Although central apneas may have their origin in an intrinsic disturb of the respiratory control center they may be influenced by the phasic activity of REM sleep. The rapid eyes movements and sucking bursts may have a protection effect against apneas at least in the first 6 months of life, which is the predominant period for SIDS. We suggest that the excitatory driving related to generation of phasic activity in REM sleep may block or atenuate tonic inhibition of respiratory motoneuron and avoid apnea. It is still open for discussion the possible relation between failure of this protective mechanism and SIDS.

apnea; polysomnography; sudden infant death syndrome

Atividade fásica do sono rem em recém-nascidos e lactentes e sua relação com episódios de apnéia

The relationship of apnea and phasic activity of REM sleep in newborns and infants that presented an apparent life-threatening event

Magda Lahorgue Nunes^I; Jaderson Costa da Costa^II; Letícia Taufer^III

^IProfessora Adjunta de Neurologia da FM/PUC-RS

^IIProfessor Titular de Neurologia da FM/PUC-RS

^IIIAcadêmica da FM/PUC-RS, Bolsista de Iniciação Científica da Fundação de Amapro à Pesquisa do Rio Grande do Sul (FAPERGS)

RESUMO

A hipótese de que a apnéia pudesse ser o evento final da síndrome da morte súbita da infância (SMSI) deu origem a vários estudos avaliando as características deste evento do ponto de vista polissonográfico. Foi sugerido que a atividade fásica do sono REM estaria associada a ativação dos neurônios respiratórios prevenindo a ocorrência de apnéias prolongadas e protegendo os lactentes de evoluírem para SMSI. Em estudo prévio retrospectivo com recém-nascidos não confirmamos estes achados mas muitos destes bebês apresentavam comprometimento neurológico severo. O objetivo do presente estudo é verificar a relação existente entre períodos de atividade fásica do sono REM (movimentos oculares rápidos e movimentos de sucção) e apnéia. Estudamos do ponto de vista clínico c polissonográfico 86 recém-nascidos c lactentes encaminhados para avaliação por terem apresentado apnéia ou episódios com aparente risco de vida durante o sono. Dividimos os pacientes em 3 grupos: recém-nascidos (idade concepcional inferior a 44 semanas, n=31), lactentes com 1 -6 meses (n=48) e lactentes com >6m<12 meses (n=7). Todos foram submetidos a avaliação clínica e neurológica para detectar possíveis fatores etiológicos das apnéias. As polissonografias constavam de EEG, eletromiograma submentoniano, eletro-oculograma e monitorização cardiorrespiratória, todas com duração de 2 a 3 horas. Durante 5 minutos contínuos de sono REM verificamos a incidência de atividade fásica relacionada a períodos em apnéia e comparamos sua incidência em períodos semelhantes sem apnéia. Nossos resultados mostraram que a atividade fásica do sono REM ocorre com maior freqüência em períodos sem apnéia. No período neonatal os movimentos de sucção (p < 0.05) e nos lactentes com 1-6 meses os movimentos oculares rápidos (p=0,001). Não houve diferença estatisticamente significativa nos lactentes >6<12 meses. Nossos resultados mostram que a atividade fásica do sono REM é mais frequente cm períodos sem apnéia durante os 6 primeiros meses de vida, período que coincide com o maior risco de SMSI. Sugerimos que o "driving" excitatório que determina o aparecimento da atividade fásica possa ter efeito protetor contra apnéias através do bloqueio ou atenuação da inibição tônica do centro respiratório que determinaria a apnéia. Estudos futuros são necessários para avaliar a relação entre perda desse "mecanismo de proteção"e SMSI.

Palavras-chave: apnéia, polissonografia, síndrome da morte súbita da infância.

ABSTRACT

When the apnea hypothesis turned to be an explanation for sudden infant death syndrome (SIDS) many authors tried to find if near-miss or apparent life-threatening events (ALTE) could be markers of SIDS. It was suggested that phasic REM activity is associated with increased respiratory neuron activity and prevents prolonged apnea in near-miss SIDS. In a previous retrospective study with newborns we did not confirm these results, nevertheless we had several babies with serious neurological disturbances. The aim of this study was to verify the relationship of phasic activity (rapid eyes movement and sucking bursts) with both apneic and non-apneic epochs during REM sleep. We studied 86 children refered for evaluation because they presented an ALTE during sleep or apneas. The subjects were divided in three groups by age (newborns, n=31; 1 -6 months, n= 48; and >6< 12 months, n=7). They were all submitted to a clinical and neurological evaluation in order to detect possible etiological factors to the apneic episode. The po.lysomnograms (PS) consisted of EEG, submental EMG, electro-oculogram and cardiorespiratory monitoring. The records were made between 11 am and 15 pm for 2 or 3 hours. The electrodes were disposed in the 10-20 system. During one five-minutes epoch of REM sleep we verified the incidence of phasic activity (rapid eyes movement or sucking bursts) time locked to apneic episodes and compared with a similar duration non-apneic epoch. To evaluate the relationship of phasic activity with apneic and non-apneic epochs we compared the incidence of rapid eyes movements and sucking bursts in each group. Our results showed that phasic activity of REM sleep (sucking bursts) seems to be more frequent in newborns in non-apneic epochs (p < 0.05). Between 1-6 months the number of rapid eyes movements were more frequent in non-apneic epochs (p=0.00l). In conclusion our findings suggest that phasic activity of REM sleep seems to be more evident in nonapneic epochs during the first six months of life. Although central apneas may have their origin in an intrinsic disturb of the respiratory control center they may be influenced by the phasic activity of REM sleep. The rapid eyes movements and sucking bursts may have a protection effect against apneas at least in the first 6 months of life, which is the predominant period for SIDS. We suggest that the excitatory driving related to generation of phasic activity in REM sleep may block or atenuate tonic inhibition of respiratory motoneuron and avoid apnea. It is still

open for discussion the possible relation between failure of this protective mechanism and SIDS.

Key words: apnea, polysomnography, sudden infant death syndrome.

Texto completo disponível apenas em PDF.

Full text available only in PDF format.

Aceite: 20-dezembro-1996.

Estudo realizado com apoio da FAPERGS.

Laboratório de Neurofisiologia Clínica do Hospital São Lucas e Faculdade de Medicina da Pontifícia Universidade Católica do Rio Grande do Sul (FM/PUC-RS) Porto Alegre - Brasil.

Dra. Magda Lahorgue Nunes - Serviço de Neurologia, Hospital São Lucas, PUC-RS - Avenida Ipiranga 6690/322 - 90610-000 Porto Alegre RS - Brasil. Fax: 051 339 4936.

1. Anders T, Emde R, Parmelee A. A manual of standardized terminology, techniques and criteria for scoring states of sleep and wakefulness in newborn infants. UCLA Brain Service, Los Angeles: BRI Publications Office, 1971.
2. Brooks JG. Apparent life-threatening events and apnea of infancy. In Hunt CE (ed). Apnea and SIDS. Philadelphia: WB Saunders, 1992:809-838.
3. Da Costa JC. O sono em recém-nascidos: aspectos polissonográficos. In Reimão R (ed). Sono aspectos atuais. São Paulo: Atheneu, 1990:133-161.
4. Da Costa JC, Nunes ML, Wagner EM. A prospective study of the apneas and its relationship with the phasic activity of REM sleep in Newborns: clinical and polygraphia aspects. Electroenceph Clin Neurophysiol 1980;75:531.
5. Da Costa JC, Nunes ML, Nora DB, Lopes DK, Perondi G, Fagundes SC. Apneic seizures in newborns. Pediatr Neurol 1992;8:382.
6. Flores-Guevara R, Plouin P, Curzi-Dascalova L, Radvanyi MF, Guidasci S, Pajot N, Monod N. Sleep apneas in normal neonates and infants during the first 3 months of life. Neuropediatrics 1982; 13(Suppl):21 -28.
7. Guilleminaut C, Ariago R, Korobkin R, Coons S, Owen-Boediker M, Baldwin R. Sleep parameters and respiratory variables in near miss sudden infant death syndrome infants. Pediatrics 1981 ;68:354-360.
8. Guilleminaut C. Baker TL. Sleep and its disorders. In Asbnry K, Mc Kliann GM, McDonald WI (eds). Disorders of the nervous system clinical neurobiology. Philadelphia: WB Saunders 1986:867-879.
9. Hoffman H.I, Hillman LS. Epidemiology of the sudden infant death syndrome: maternal, neonatal and postnconatal risk factors. In Hunt CE (ed). Apnea and SIDS. Philadelphia: WB Saunders, 1992:717-737.
10. Kelly DH, Shannon DC. Periodic breathing in infants with near-miss sudden infant death syndrome. Pediatrics 1979;63:355-360.
11. Kohyama J, Iwakawa Y. Polygraphic features of a victim of sudden infant death syndrome and of infants with apparent life-threatening event. Brain Dev 1989:11:186-90.
12. Kohyama J, Iwakawa Y. Developmental changes in phasic sleep parameters as reflections of the brain-stem maturation: polysomnographical examinations of infants, including premature neonates. Electroenceph Clin Neurophysiol 1990,76:325-330.
13. Kohyama J, Iwakawa Y. Interrelationships between rapid eye and body movements during sleep: polysomnographic examinations of infants including premature neonates. Electroenceph Clin Neurophysiol 1991 ;79:277-280.
14. Kohyama J, Masayuki S, Itoh M, Fukumizu M, Iwakawa Y. Phasic muscle activity during REM sleep in infancy: normal maturation and contrastive abnormality in SIDS /ALTE and West syndrome. J Sleep Res 1993:2:241 -249.
15. Kohyama J, Masayuki S, Yoshihide I. Brainstem control of phasic muscle activity during REM sleep: a review and hypothesis. Brain Dev 1994;16:81-91.
16. Kohyama J, Shimohira M, Hasegawa T, Kouji T, Iwakawa Y. Phasic motor activity reduction occurring with horizontal rapid eye movements during active sleep in human. Exp Brain Res 1995; 107:137-144.
17. Lee D, Caces R. Kwiatkowski K, Cates D, Rigatto H. A developmental study on types and frequency distribution of short apneas in term and preterm infants. Pediatr Res 1987;22:344-349.
18. Niedermeyer E. Maturation of the EEG: development of waking and sleep patterns. In Niedermeyer E. Lopes da Silva F (eds). Electroencephalography. Baltimore-Munich: Urban & Schwarzenberg, 1987:133-157.
19. Nunes ML, Da Costa JC, Roitman I, Fernandes RMF. Guia técnico para execução de registro poligráfico e eletrencefalograma no período neonatal. BJECN 1996;2:27-42.
20. Reimão R, Lemmi H, Hamlet III J. Sander C, Zwaag RV. Densidade dos movimentos oculares rápidos durante o sono ativo em recém-nascidos pré-termo. Arq Neuropsiquiatr 1986;44:219-233.
21. Rigatto H, Brady J. Periodic breathing and apnea in preterm infants: evidence for hypoventilation possibly due to central respiratory depression. Pediatrics 1972;50:202-218.
22. Sakai K. Some anatomical and physiological properties of ponto-mesencephalic tegmental neurons with special reference to the PGO waves and postural atonia during paradoxal sleep in cat. In Hobson JA, Brazier MAB (eds). The reticular formation revisited. New York: Raven Press, 1980:427-447.
23. Steinschneider A. Prolonged apnea and the sudden infant death syndrome: clinical and laboratory observations. Pediatrics 1972;50:646.
24. Watanabe K, Inokuma K, Negoro T. Rem sleep prevents sudden infant death syndrome. Eur .J Pediatr 1983; 140:289-292.

Datas de Publicação

Publicação nesta coleção
10 Nov 2010
Data do Fascículo
Jun 1997

Histórico

Recebido
20 Dez 1996

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. Anders T, Emde R, Parmelee A. A manual of standardized terminology, techniques and criteria for scoring states of sleep and wakefulness in newborn infants. UCLA Brain Service, Los Angeles: BRI Publications Office, 1971.

[2] 2. Brooks JG. Apparent life-threatening events and apnea of infancy. In Hunt CE (ed). Apnea and SIDS. Philadelphia: WB Saunders, 1992:809-838.

[3] 3. Da Costa JC. O sono em recém-nascidos: aspectos polissonográficos. In Reimão R (ed). Sono aspectos atuais. São Paulo: Atheneu, 1990:133-161.

[4] 4. Da Costa JC, Nunes ML, Wagner EM. A prospective study of the apneas and its relationship with the phasic activity of REM sleep in Newborns: clinical and polygraphia aspects. Electroenceph Clin Neurophysiol 1980;75:531.

[5] 5. Da Costa JC, Nunes ML, Nora DB, Lopes DK, Perondi G, Fagundes SC. Apneic seizures in newborns. Pediatr Neurol 1992;8:382.

[6] 6. Flores-Guevara R, Plouin P, Curzi-Dascalova L, Radvanyi MF, Guidasci S, Pajot N, Monod N. Sleep apneas in normal neonates and infants during the first 3 months of life. Neuropediatrics 1982; 13(Suppl):21 -28.

[7] 7. Guilleminaut C, Ariago R, Korobkin R, Coons S, Owen-Boediker M, Baldwin R. Sleep parameters and respiratory variables in near miss sudden infant death syndrome infants. Pediatrics 1981 ;68:354-360.

[8] 8. Guilleminaut C. Baker TL. Sleep and its disorders. In Asbnry K, Mc Kliann GM, McDonald WI (eds). Disorders of the nervous system clinical neurobiology. Philadelphia: WB Saunders 1986:867-879.

[9] 9. Hoffman H.I, Hillman LS. Epidemiology of the sudden infant death syndrome: maternal, neonatal and postnconatal risk factors. In Hunt CE (ed). Apnea and SIDS. Philadelphia: WB Saunders, 1992:717-737.

[10] 10. Kelly DH, Shannon DC. Periodic breathing in infants with near-miss sudden infant death syndrome. Pediatrics 1979;63:355-360.

[11] 11. Kohyama J, Iwakawa Y. Polygraphic features of a victim of sudden infant death syndrome and of infants with apparent life-threatening event. Brain Dev 1989:11:186-90.

[12] 12. Kohyama J, Iwakawa Y. Developmental changes in phasic sleep parameters as reflections of the brain-stem maturation: polysomnographical examinations of infants, including premature neonates. Electroenceph Clin Neurophysiol 1990,76:325-330.

[13] 13. Kohyama J, Iwakawa Y. Interrelationships between rapid eye and body movements during sleep: polysomnographic examinations of infants including premature neonates. Electroenceph Clin Neurophysiol 1991 ;79:277-280.

[14] 14. Kohyama J, Masayuki S, Itoh M, Fukumizu M, Iwakawa Y. Phasic muscle activity during REM sleep in infancy: normal maturation and contrastive abnormality in SIDS /ALTE and West syndrome. J Sleep Res 1993:2:241 -249.

[15] 15. Kohyama J, Masayuki S, Yoshihide I. Brainstem control of phasic muscle activity during REM sleep: a review and hypothesis. Brain Dev 1994;16:81-91.

[16] 16. Kohyama J, Shimohira M, Hasegawa T, Kouji T, Iwakawa Y. Phasic motor activity reduction occurring with horizontal rapid eye movements during active sleep in human. Exp Brain Res 1995; 107:137-144.

[17] 17. Lee D, Caces R. Kwiatkowski K, Cates D, Rigatto H. A developmental study on types and frequency distribution of short apneas in term and preterm infants. Pediatr Res 1987;22:344-349.

[18] 18. Niedermeyer E. Maturation of the EEG: development of waking and sleep patterns. In Niedermeyer E. Lopes da Silva F (eds). Electroencephalography. Baltimore-Munich: Urban & Schwarzenberg, 1987:133-157.

[19] 19. Nunes ML, Da Costa JC, Roitman I, Fernandes RMF. Guia técnico para execução de registro poligráfico e eletrencefalograma no período neonatal. BJECN 1996;2:27-42.

[20] 20. Reimão R, Lemmi H, Hamlet III J. Sander C, Zwaag RV. Densidade dos movimentos oculares rápidos durante o sono ativo em recém-nascidos pré-termo. Arq Neuropsiquiatr 1986;44:219-233.

[21] 21. Rigatto H, Brady J. Periodic breathing and apnea in preterm infants: evidence for hypoventilation possibly due to central respiratory depression. Pediatrics 1972;50:202-218.

[22] 22. Sakai K. Some anatomical and physiological properties of ponto-mesencephalic tegmental neurons with special reference to the PGO waves and postural atonia during paradoxal sleep in cat. In Hobson JA, Brazier MAB (eds). The reticular formation revisited. New York: Raven Press, 1980:427-447.

[23] 23. Steinschneider A. Prolonged apnea and the sudden infant death syndrome: clinical and laboratory observations. Pediatrics 1972;50:646.

[24] 24. Watanabe K, Inokuma K, Negoro T. Rem sleep prevents sudden infant death syndrome. Eur .J Pediatr 1983; 140:289-292.