a . infants , ≦ 6 months of age , at increased risk for sids based on epidemiologic characteristics . b . infants , ≦ 6 months of age , for whom there is concern because of prolonged apnea or sids . a . infants to be observed in an environmentally controlled ( quiet , ambient temperature 90 °± 2 ° f .) test room . c ) ekg / heart rate ( eg , tape flat disc surface electrodes to mid - sternum and mid - posterior thorax ), d ) pulse o 2 saturation ( eg , tape pulse oximeter to foot ), e ) sucking pressure ( eg , insert sterile catheter through base of nipple and into milk bottle ; catheter to be attached to pressure transducer ). infant to be bottle fed ( burped as needed ) until satisfied while recording all of the above biologic activities ( respiration : chest , respiration : nasal , ecg , heart rate , pulse changes , peripheral o 2 saturation , sucking ). physiologic feeding study to be done prior to sleep study and while hungry . if not successful , feeding study should be done after sleep study . c ) ekg / heart rate ( eg , tape flat disc surface electrodes to mid - sternum and mid - posterior thorax ), d ) pulse o 2 saturation ( eg , tape pulse oximeter to foot ), e ) eeg ( eg , tape flat disc surface electrodes to c3 - a2 and c4 - a1 ), f ) eog ( eg , tape flat disc surface electrodes to the outer canthi bilaterally and nasion ). 2 ) procedure : above physiological activity to be recorded continuously throughout entire natural sleep period . sleep onset and end of sleep to be determined visually . observer also records the occurrence of gross motor activity . one hour of sleep time , excluding time of gross motor activity , is the minimum acceptable sleep period . 1 ) all sucking bursts ≧ 5 . 0 sec in duration are identified and measured to an accuracy of 0 . 1 sec . a sucking burst is defined as a series of sucks with an interval between successive sucks of & lt ; 2 . 0 sec . sucking bursts & lt ; 5 . 0 sec long are rejected from further analysis . 2 ) all periods of apnea or a decrease in amplitude of the respiration : nasal signal by at least 80 % ( ao ) of ≧ 2 sec in duration beginning within a sucking burst are measured to an accuracy of 0 . 1 sec . 3 ) statistical measures derived from these basic data include : longest burst duration , mean burst duration , longest ao , ao / d % ( the total sum of ao duration per 100 sec of sucking time ), and ao density ( the number of ao episodes per 100 sec of sucking time ). 4 ) an ao measure is defined as &# 34 ; abnormal &# 34 ; if it is in the upper 5th percentile of the normative values ( corrected for postnatal age ). 1 ) the sleep period is divided into 15 - sec successive epochs and each epoch characterized as either a rem epoch or nrem epoch based on the occurrence of rapid eye movements ( detected primarily from an examination of the eog recordings ). 2 ) an epoch is excluded from further analysis if it includes at least 5 sec of movement artifact . 3 ) central apnea is detected as the cessation of respiratory activity in both respiration : nasal and respiration : chest sensors . all periods of central apnea & gt ; 2 sec in duration are measured to a tenth of a sec . duration is measured from the end of a respiratory cycle to the beginning of the next respiratory cycle . 4 ) periods (≧ 2 sec in duration ) of airway obstruction ( mo ) are identified as rem activity in the respiration : nasal sensor occurring in conjunction with respiratory activity in the respiration : chest sensor . these periods are measured to a tenth of a sec . 5 ) all periods of o 2 desaturation ≦ 85 % are identified and durations measured to a tenth of a sec . 6 ) ekg is examined for gross evidence of a cardiac arrhythmia or prolonged qt interval . 7 ) a number of statistical measures are derived and compared to age corrected norms . those observed measures in the upper 5th percentile of the normative population are considered &# 34 ; abnormal .&# 34 ; these statistical measures include : c ) percentage of apneic pauses (≧ 2 sec ) initiated within rem epochs , nrem epochs , and total sleep d ) percentage of sleep time involved in periodic apnea (≧ 22 sec ) e ) a2 / d %: summed duration of apneic pauses ≧ 2 sec divided by the duration of sleep times 100 ar is % of rem epochs during which apnea ≧ 2 sec was initiated nr is % of nrem epochs during which apnea ≧ 2 sec was initiated . g ) percentage of apneic pauses (≧ 6 sec ) initiated within rem epochs , nrem epochs , and total sleep h ) percentage of sleep time involved in periodic apnea (≧ 6 sec ) i ) a6 / d %: summed duration of apneic pauses ≧ 6 sec divided by the duration of sleep times 100 k ) mo2 %: percentage of airway obstruction episodes (≧ 2 sec ) initiated within rem epochs , nrem epochs , and total sleep l ) mo2 / d %: summed duration of airway obstruction episodes ≧ 2 sec divided by the duration of sleep times 100 m ) mo6 %: percentage of airway obstruction episodes (≧ 6 sec ) initiated within rem epochs , nrem epochs , and total sleep n ) mo6 / d %: summed duration of airway obstruction episodes ≧ 6 sec divided by the duration of sleep times 100 a . asymptomatic infants and infants who had an apparent life threatening event : an abnormal psa4 or a6 / d % or ao / d % increases the risk for prolonged apnea 5 - 6 times greater than that of infants with normal scores . b . small premature infants : an equation was developed based on a logistic regression analysis which revealed that infants whose overall score is abnormal will be at 12 - 13 times greater risk to develop prolonged apnea than infants whose score is within normal limits . this equation includes the a6 / d and mo2 / d % measures along with information on the infant &# 39 ; s sex , method of feeding , race , gestational age , postnatal age , and whether the infant has gastroesophageal reflux disease or being treated with a respiratory stimulant . information regarding maternal smoking and the number of prior pregnancies are also included in this equation . a . this evaluation provides objective information that will assist a physician in deciding whether to recommend home monitoring . b . this evaluation provides objective information to be used medically in deciding when to discontinue home monitoring . c this evaluation provides objective information to be used in deciding when to employ a respiratory stimulant and when to discontinue this form of treatment . d . an abnormal physiologic feeding study will confirm the clinical impression of dysphagia and the need for further diagnostic evaluation or medical intervention . e . the detection of a cardiac arrhythmia or prolonged qt interval could result in a more in - depth cardiac evaluation and possible treatments . a . studies should be conducted in an environmentally controlled test chamber . c . studies should be conducted by persons skilled in the conduct of such studies and in working with infants . e . physiologic recordings should include both respiratory effort and air flow . f . recordings should include measures of respiratory difficulty ( eg , o 2 saturation , heart rate ). g . ekg should be obtained as a means of evaluating the validity of the heart rate recordings and for to detect a possible cardiac arrhythmia . h . need an objective means of determining the beginning and end of sucking bursts . i . need an objective means of determining the occurrence of rapid eye movements during sleep . j . apnea duration should be measured as the interval between the end of a respiratory cycle and the beginning of the next cycle . k . data extraction from the two studies should be done by persons skilled in this activity . l . interpretation of statistical measures should include not only summary measures but also the individual components . this can best be done by persons ( eg , md ) skilled in the interpretation of such data . a . studies conducted under uncontrolled environmental conditions ( noise level , ambient temperature ). b . studies conducted by persons poorly trained in the conduct of these studies . c . the use of techniques that alters respiratory activity ( eg , simultaneous use of an esophageal probe to measure ph ). d . failure to provide an objective measure of the beginning and end of a sucking burst . e . failure to adequately define the beginning and end of sleep . f . failure to measure both respiratory effort and airflow and to differentiate between central apnea and airway obstruction episodes . h . failure to obtain an objective measure of rapid eye movements . i . use of different criteria for defining rem and nrem epochs . j . use of different criteria for defining the duration of an epoch ( eg , 10 sec , 30 sec , 60 sec ). l . use of different criteria for determining if a study is abnormal . m . use of relative risk statements for inappropriate measures and / or for statistical measures obtained under non - standardized conditions . a . the initial set of normative data for both the apnea measures during sleep and all measures during feeding were obtained from 128 infants , born at the upstate medical center ( syracuse , n . y .). each infant was studied initially within the first week of age and then on four separate occasions over 180 day period . the norms for the first four weeks of life were replaced by data obtained from over 570 term infants born at the university of maryland hospital . these latter studies were conducted under a research project supported by a grant from the national institute of child health and human development . b . supported by a research grant from the department of health and human services ( bureau of maternal and child health and resources development ), a prospective study was conducted , in part , to evaluate the effectiveness of neonatal measures of respiratory instability obtained during feeding and sleep in identifying the infant at risk for prolonged apnea . data were obtained from 154 infants ( siblings of a sids victim ) tested within the first and fourth week of life . all infants , regardless of test scores , were followed at home on an apnea / bradycardia monitor with event recording capability . the results provided support for the hypothesis and demonstrated that infants with an abnormal psa4 or a6 / d % or ao / d % when studied within the first week of life were at increased risk to develop prolonged apnea . these results were statistically significant . abnormal test results in the first week of life identified 71 % of infants who developed prolonged apnea . furthermore , infants who had abnormal test results were at 6 . 9 times greater risk for developing apnea . c . the most recent study involved 810 infants , all of whom had been referred to the institute at less than six months of age for home monitoring . all were tested ( sleep and physiologic feeding studies ) and , regardless of the laboratory results , followed at home on an apnea / bradycardia monitor with event recording capabilities . for the purpose of statistical analyses , infants were placed into one of two groups . one group consisted of infants ( asymptomatic / alte group , n = 526 ) who were referred because : a ) of an apparent life threatening event , b ) a sibling died of sids , c ) a sibling was on a monitor , or d ) parental anxiety . twenty - four percent of these infants had an abnormal evaluation ( abnormal psa4 or a6 / d % or ao / d %) and accounted for 62 percent of the infants who had an episode of prolonged apnea . infants who had an abnormal evaluation were at 5 . 2 times greater risk to develop prolonged apnea when compared to infants who had a normal evaluation . the second group ( premie apnea group , n = 284 ) consisted of infants born prematurely who had episodes of apnea or bradycardia while in the neonatal intensive care unit . through the use of an equation derived from a logistic regression analysis ( see footnote 2 , which included measures from the sleep study , it was possible to identify ( abnormal evaluation ) 23 % of these infants who had 78 % of the episodes of prolonged apnea . infants within the premie apnea group who had an abnormal evaluation had a 12 . 3 times greater risk to develop prolonged apnea when compared to those infants within this group whose evaluation was normal .
a method for determining the probability of an episode of prolonged apnea in an infant less than or equal to 6 months of age has been developed . the method includes conducting a physiological feeding study wherein the subject is bottle fed while monitoring respiration , heart rate , o 2 saturation , and sucking pressure , conducting a sleep study wherein the subject is allowed to sleep naturally while monitoring respiration , heart rate , o 2 saturation , and brain activity , and analyzing the data to make a prediction of the probability of a prolonged episode of sleep apnea . the method can further include correlating the results of the physiological feeding study and the sleep study with age , epidemiologic characteristics , and birth age . in the preferred embodiment , the sleep study is conducted in an environmentally controlled test chamber at 90 °± 2 ° f ., and both respiratory effort and air flow are measured .