Anemia as a cause of apnea in a young infant 117

CASE REPORT

Anemia as a cause of apnea in a young infant

Anemia como causa de apnéia em lactente jovem*
Israel Roitman1, Maria Regina Guillaumon2

ABSTRACT evaluates the rapid maturation modifications in the brain

The present case report emphasizes the respiratory change in the last trimester of fetal life. It also characterizes the
detected by neonatal poligraphy after improvement of the sleep stages in term and preterm newborns, presenting
circulating red blood cells obtained by means of erythrocyte technical advantages as compared with conventional EEG
transfusion in an infant presenting apnea during an infectious and polysonography(2). NP differs from polysonography
process of the respiratory tract. in terms of methodology and duration; the latter requires
more monitors and fewer channels for EEG and therefore
Keywords: Apnea/etiology; Anemia; Infant; Electrodiagnosis; is not appropriate for newborns(1).
Respitatory tract infections NP should be carried out in the acute phase of
clinical alterations and its progression control is very
RESUMO important for prognosis. However, NP requires time
and patience since placing the electrodes and monitors
O presente relato salienta a resposta respiratória detectada pela
and obtaining sleep stages take a long time. It also
poligrafia neonatal após melhoria de crase sangüínea, por meio de
requires avoiding interferences and a careful
transfusão de glóbulos vermelhos, em lactente que apresentava
crises de apnéia, na vigência de processo infeccioso de vias assessment and interpretation of the findings. The
respiratórias. minimum duration of a tracing is approximately 60
minutes(1).
Descritores: Apnéia/etiologia; Anemia; Lactente; Eletrodiagnóstico; Despite these apparent difficulties, NP is an
Infecções respiratórias objective method to assess brain bioelectrical maturity
and any neurological disease that may affect newborns
and young infants. It is extremely useful for healthcare
INTRODUCTION professionals that care for these patients.
Neonatal polygraphy (NP) is a neurophysiological
assessment method for prognosis of central nervous
system affections in the neonatal period and early CASE REPORT
infancy. M. T., 3 months- and 22-days-old, female. Date of birth:
It uses the basic parameters of electroencephalogram November 9, 1995.
(EEG) with the addition of physiological monitors for Date of admission: March 1st, 1996.
ocular movement, nasal and/or abdominal breathing, Date of discharge: March 15, 1996.
electromyogram and electrocardiogram (ECG)(1). NP

* Setting: Neonatal Unit, Maternity of Hospital Israelita Albert Einstein.

1
Neurologist in charge of the Neonatal Poligraphy Sector of the Clinical Neurophysiology Service, Hospital Israelita Albert Einstein.
2
Neonatologist of the Neonatal Unit, Maternity of Hospital Israelita Albert Einstein.
Corresponding author: Av. Albert Einstein, 627/701 - Morumbi - CEP 05651-901 - São Paulo (SP), Brazil.
Received on May 7 - Accepted on August 30

einstein. 2004; 2(2):117-119

118 Roitman I, Guillaumon MR
She was admitted to hospital for having flu-like
symptoms for one week, which worsened one day
before, and presenting persistent spastic cough, fever
and periods of apnea. She had been on cephalothin
for one day.
Presumptive diagnoses: respiratory infection
(syncytial respiratory virus?); whooping-cough-like
illness; central apnea; clinical anemia.
Personal history: Date of birth: November 9, 1995.
Date of discharge: December 20, 1995. First twin.
Weight: 1020 grams. Gestational age: 30 weeks.
The following diagnoses were made at discharge:
preterm newborn; appropriate for gestational age; low
birth weight/very low birth weight; hyalin membrane
disease; mild perinatal anoxia; physiologic jaundice.
In January 17, 1996, at the age of 2 months and 8
days, she was admitted to hospital and diagnosed as having
anemia of prematurity. Hb = 7.9 g/dl; Ht = 22.3%. She
received 30 ml of red blood cells transfusion. On January
18, Hb = 13.5 g/dl; Ht = 39%. She was discharged on
January 19, 1996, in good conditions.
Progression during hospital stay described in this
report (March 1st, 1996): admitted at the step-down
unit. Weight = 4000 g. She received antibiotics, oxygen
therapy and rehydratation. The erythrocyte indices
during admission are shown in table 1.
Table 1. Erythrocyte indices during stay in March 1996
Date 3/1st 3/3 rd 3/9 3/12 post-transfusion control
Hb (g/dl) 10.4 10.4 11.6 11.4 13.7
Ht (%) 31.1 30.5 34.3 32.3 40.4
On day 11, March 12, 1996, the first poligraphy was
performed and the result was central apnea. The
respiratory pattern was periodic, mainly during calm
sleep (NREM sleep) (figure 1). On this occasion, Hb
= 11.4g/dl and Ht = 32.3%.
Figura 1. Respiratory pattern characterized by periodic respiration
einstein. 2004; 2(2):117-119
On March 13, 1996, she received 40 ml of
erythrocyte concentrate transfusion. On March 14,
1996, another polygraphy was carried out and showed
improved conditions (figure 2).
Figura 2. Normal respiratory pattern
She was discharged on March 15, 1996, in good
general conditions, with no apnea crises.
DISCUSSION
The literature is quite controversial in relation to using
blood transfusion in preterms. There are studies
demonstrating little or no effect of transfusion in apnea
of prematurity, although there may be a significant
drop in heart and respiratory rates(3). Children with
unaffected cardiopulmonary function and no
extraordinary metabolic demand, do not seem to benefit
from transfusion when the hemoglobin concentration
is greater than 10-11 g/dl (4) . On the other hand,
apparently there is no relation between oxygen release
measures and respiratory irregularities, indicating that
volumetric expansion may play an important role in
improving pneumocardiographic abnormalities (5) .
Frequent episodes of apnea, bradycardia and
hypoxemia, per se, do not justify blood transfusion in
premature babies who have moderate anemia, that is,
mean hemoglobin concentration = 10.9 g/dl(6).
Red blood cell transfusion significantly alters some
cardiorespiratory variables in preterm newborns with
anemia (7) . Post-transfusional pneumocardiograms
revealed a significant reduction in apnea episodes
lasting for 11 to 15 seconds, in periodic breathing, and
in heart rate, as well as better oxygen saturation(8).
Preterm babies aged 1 to 3 months, with hematocrit
lower than 29% would benefit from erythrocyte
transfusion (9). The presence of tachycardia, apnea,
bradycardia or high blood lactate levels would identify

these patients. It is already known that anemia may
increase the risk of tissue hypoxia in preterm newborns.
This fact would lead to depression of the respiratory
centers and higher risk of apnea(9). After transfusion,
reduced periodic breathing was observed, as well as a
drop in respiratory arrests lasting 5 to 10 seconds and
those lasting 11 to 20 seconds; moreover, there were
less bradycardic episodes(10). These results indicate that
preterm babies have a more irregular respiratory pattern
when anemic than after correcting anemia. Irregular
breathing is probably caused by moderate hypoxia of
the respiratory centers(10).
Finally, it could be assumed that the indications
for transfusion have not been well established yet(11).
One could argue that the use of hemoglobin
concentration and hematocrit separately would not be
enough, unless some clinical evidence, such as oxygen
desaturation, apnea and bradycardia, be included as
criteria used to define the need for transfusion. The
co-morbidities that increase the demand for oxygen
consumption in these children, such as
bronchopulmonary dysplasia, and increased oxygen
consumption for growth, could be addressed when
deciding about transfusion. Moreover, some services
accept hematocrit lower than 21% in preterms who are
apparently stable before considering transfusions.
Premature babies with anemia who seem to be stable,
may present an unobserved clinical picture of high
cardiac output and the ecocardiographic measures may
not improve within 48 hours after transfusion(12). In
these cases, the benefits of transfusion should be
considered based on evaluation of cardiac function.
In the present case, the indication for transfusion
was based on clinical assessment. It must be highlighted
that hemoglobin concentration and hematocrit, per se,
would not be the most important determinants for
indicating transfusion. Hume (13) corroborates this
management stating that “the clinicians are increasingly
trying to base their decisions about management of
patients on the results of clinical trials, experts´
opinions and their own practical experience.”
Anemia as a cause of apnea in a young infant 119
CONCLUSION
The facts observed lead to further investigations on
the etiology of apneas or respiratory rate disorders in
infants, in relation to the presence of laboratory and/
or clinical anemia.
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