What Can Lower Oxygen Saturation Do to a Babies Body

Pediatrics. Author manuscript; available in PMC 2022 October 2.

Published in final edited class as:

PMCID: PMC4182863

NIHMSID: NIHMS630284

Oxygen Desaturation Complicates Feeding in Infants With Bronchopulmonary Dysplasia After Belch

Lynn Vocalist, PhD,^* Richard J. Martin, MD,^* Suzanne West. Hawkins, MS,^* Laura J. Benson-Szekely, MSRD,^‡ Toyoko S. Yamashita, PhD,^* and Waldemar A. Carlo, Doc^§

Lynn Vocalizer

^*Case Western Reserve University School of Medicine, Cleveland, OH

Richard J. Martin

^*Case Western Reserve Academy School of Medicine, Cleveland, OH

Suzanne W. Hawkins

^*Case Western Reserve University School of Medicine, Cleveland, OH

Laura J. Benson-Szekely

^‡University Hospitals of Cleveland

Toyoko S. Yamashita

^*Case Western Reserve University School of Medicine, Cleveland, OH

Waldemar A. Carlo

^threeUniversity of Alabama at Birmingham School of Medicine

Abstract

Recurrent episodes of hypoxemia may affect the growth, cardiac function, neurologic outcome, and survival of infants with bronchopulmonary dysplasia (BPD). As oral feeding might stress these infants past compromising pulmonary function fifty-fifty after hospital discharge, we measured oxygen saturation (Sao_two) via pulse oximetry earlier, during the initial 10 minutes of, and immediately after oral feeding in 11 patients with BPD, 12 very low birth weight infants, and 23 healthy total-term infants. All infants with BPD had been previously discharged from the hospital after weaning from supplemental oxygen. Studies were done at a mean postconceptional age of 43 weeks while the infants were fed at home by one of their parents. Levels of Sao₂ for the three groups were comparable before and during feeds. Later feeding, the infants with BPD had significantly lower mean levels of Sao_ii (84 ± 8% [SD] vs 93 ± 4% and 93 ± iii%, respectively; P < .01). They also spent more than time later on feeding with an Sao₂ <ninety% (64 ± 34% of time vs 27 ± 33% for the very low birth weight and 22 ± 20% for the term grouping; P < .01) and greater time with an Sao_ii <lxxx% (37 ± 28% vs iv ± 10% and 4 ± 8%, respectively; P < .01). Desaturation in infants with BPD was related to larger volume and faster oral intake during feeding. Thus, the data indicate that desaturation later on feeding remains a recurrent problem for survivors of BPD after discharge. Private approaches which incorporate parental education and behavioral interventions might decrease the risk of significant hypoxemia during oral feeding in infants with BPD.

Bronchopulmonary dysplasia (BPD) has become a substantial problem among very low nativity weight (VLBW) infants, especially with their increasing survival rates.ⁱ This disorder is associated with pregnant morbidity and mortality, including an increased incidence of poor cognitive event and growth,^ii–four cerebral palsy,ⁱⁱ increased risk for sudden death,^5–vi and feeding problems.ⁱ Recurrent, unrecognized episodes of hypoxemia have been implicated as contributing to some of these sequelae.^vii,eight In one study,^viii infants with BPD had significantly more episodes of severe desaturation during feedings than either premature infants who had recovered from respiratory distress syndrome or good for you term infants. In another written report, infants with BPD who had been recently weaned from oxygen were constitute to take lower average oxygen saturation levels and more than fundamental apnea than preterm VLBW infants without BPD.⁹ However, infants in these latter studies were still hospitalized during the assessments. To determine whether differences in episodes of oxygen desaturation between infants with BPD, VLBW infants, and term infants persist across discharge, we studied infants with BPD who had been discharged domicile later on advisable weaning from oxygen while nevertheless in the hospital. We besides sought to determine whether potentially modifiable aspects of the feeding were related to such desaturation. Therefore, we additionally assessed the relationships of volume of formula, velocity of oral intake, and the human relationship of these variables to frequency of desaturation episodes.

MATERIALS AND METHODS

Study Group

We studied 46 infants, including 11 infants with BPD, 12 preterm VLBW infants without BPD, and 23 total-term infants, all matched by postconceptional age (see Table 1). The BPD group comprised preterm infants with respiratory distress syndrome who were treated with supplemental oxygen and/or assisted ventilation for a minimum of 28 days. All infants had some radiographic evidence for chronic lung injury, which could include areas of persistent opacification, hyperinflation, or cystic changes. The VLBW control infants were preterm infants with respiratory distress syndrome who required supplemental oxygen and/or assisted ventilation for no more than xiv days. Infants were excluded from any group if in that location was a history of known drug exposure during gestation. At the time of study, at that place was no clinical evidence for any syndrome or major malformation, or for sepsis, significant neurologic problems (other than intraventricular hemorrhage [IVH]), cardiac malformations, or anatomic bug which interfered with feeding.

Tabular array 1

Medical Characteristics

Variable	BPD (n = 11)	VLBW (n = 12)	Term (north = 23)
Age, wk (mean ± SD)
Gestational, at birth*	27 ± 2	30 ± 2	39 ± 1
Postconceptional, at study	43 ± 2	42 ± 2	43 ± 1
Weight, chiliad (mean ± SD)
At birth*	927 ± 276	1219 ± 151	3430 ± 454
At study*	3114 ± 115	3305 ± 892	4384 ± 762
Weight, percentile for age (range)	ten–25th	25th	50–75th
Height, percentile for age (range)	5–10th	10th	fifty–75th
Duration of supplemental O2, d (mean ± SD)	sixty ± 25	6 ± three	0

We studied only infants with BPD who had been discharged domicile later beingness weaned from oxygen while nevertheless hospitalized. Weaning from oxygen was determined individually past the clinicians responsible for patient care and follows no set protocol, but by and large information technology was performed when average oxygen saturation savage within or exceeded an approximate range of 88% to xc%. Infants were seen as function of a longitudinal follow-up of infants with BPD and were studied as near as possible to term, based on their postconceptional ages. This report was approved by the Institutional Review Board for Human Investigations at University Hospitals of Cleveland, OH, and informed consent was obtained from the parent of each baby.

Recordings

Oxygen saturation was assessed by noninvasive monitoring during a normal home feeding past one of the infant'south parents. Arterial oxygen saturation (Sao_ii) was measured via a portable pulse oximeter (Nellcor N-10, Nellcor Inc, Hayward, CA).^10–12 Pulse oximetry has been shown to be an accurate, simple measure of Sao₂ in infants with and without lung disease.^10–12 Oxygen saturation values were recorded automatically on a strip chart and were accepted if the pulse rate obtained with the oximeter was consistent with the infant'southward heart rate, which was simultaneously recorded.

For each infant, the following parameters were calculated: mean Sao₂, highest Sao₂ reading, lowest Sao₂ reading, percent of time with readings less than 90%, and percentage of time with readings less than 80%. Oxygen saturation readings were taken for each group at three separate time periods in relation to the feeding, so that changes in oxygenation over those time periods could be examined. Oxygen saturation was sampled at 30-2nd intervals within each flow. Data were analyzed for a 5-infinitesimal menses before the feeding, for a 5- to 10-minute period immediately after the initiation of feeding, and for a five-minute menstruation immediately after the feed was completed. For these data, mean values were obtained for each of the three groups of infants.

Parents were asked to feed their infants as was their usual custom, in lodge to observe the feeding in as typical a context as possible. They were non trained in any specific feeding protocol. Since nosotros were interested in how specific aspects of the feeding might relate to oxygen desaturation, the following information on book and caloric density of formula consumed was recorded. The total book in milliliters of formula consumed over the entire feeding time was measured in a standard measuring cup. Length of the feeding to the nearest infinitesimal was too recorded. Caloric content was computed past a registered dietician (L.J.B.Southward.), based on each infant'due south individual blazon of formula. The ratio of kilocalories per kilogram and the ratio of kilocalories per kilogram per length of feeding was calculated for each infant. The erstwhile served as a measure out of caloric intake in relationship to infant weight, and the latter as a mensurate of velocity of caloric intake related to infant weight. Because such behavioral aspects of the feeding could also be influenced by maternal characteristics such as social grade, total years of maternal education was besides recorded.

All oximetry, feeding, and weight measures were taken by trained research assistants blinded to the infant's BPD condition. Birth weight in grams was taken from the medical records. Gestational age was calculated through a combination of maternal diets and standard Ballard examination^thirteen performed when the infants were admitted to the neonatal intensive intendance unit. All infants were weighed prior to feeding on one of two Health-O-Meter scales, model 431KL, which were calibrated weekly. In the preterm infants, the presence of IVH was determined by routine cranial ultrasonography during hospitalization. Hemorrhages were graded based on the method of Papile et al.¹⁴ The presence of periventricular leukomalacia (PVL) was also noted.

Descriptive statistics (means, standard deviations, and ranges) were used to quantify the characteristics of the iii groups of infants. Values were compared between report groups through a serial of one-way analyses of variance which were followed with appropriate postal service hoc comparisons using Tukey's method. Paired sample t tests were compared within each grouping to determine differences between time periods. All results are expressed as mean ± the standard deviation. Correlation analyses (Pearson'due south r) were used to limited the relationships among variables.

RESULTS

Babe Characteristics

Clinical variables of the study groups are shown in Table one. Infants with BPD had significantly lower gestational ages than VLBW infants. Infants with BPD also did not differ statistically from VLBW infants in weight at fourth dimension of study, although their percentiles for tiptop and weight tended to be lower. The groups did not differ in postconceptional age at testing or on maternal social class. As indicated in Table i, infants with BPD required significantly more oxygen supplementation during the neonatal period. No term baby required any supplemental oxygen or assisted ventilation. Five infants in the BPD group had a clinical history of patent ductus arteriosus, compared with iv in the VLBW group. One babe in the VLBW group and five in the BPD grouping had grades I or II IVH. Four infants in the BPD group had grades III or IV IVH, or PVL, while one VLBW infant had PVL.

Oxygen Saturation

Earlier feedings (see Table 2), mean Sao₂, highest Sao_ii, and periods of desaturation <90% and <lxxx% were not significantly dissimilar among groups. However, the lowest Sao₂ reading was significantly less for the BPD group (F = vii.2, P < .01). There were no significant differences in percentages of Sao_ii readings <90% and <80%. No VLBW or term infant had periods of desaturation <lxxx% before feedings, while infants with BPD had Sao₂ <80% for 7% of the time, although these differences were not pregnant.

Table 2

Oxygen Saturation Before Feeding^*

Variable	BPD	VLBW	Term
Mean Saoii	93 ± 2	96 ± iii	95 ± iii
Highest Saoii	98 ± 2	99 ± 2	98 ± 2
Lowest Sao2 †	82 ± 4	90 ± two	90 ± 5
Percent of time with Saoii <90	21 ± 12	7 ± eight	12 ± 18
Percentage of time with Sao2 <lxxx	7 ± 12	0	0

Every bit shown in Table 3, during the initial 10 minutes of feedings, there were no pregnant differences among groups on whatsoever of the readings of Sao_ii, except for percent of time with saturations <90% and <lxxx%, which was greater in infants with BPD.

Table 3

Oxygen Saturation During Initiation of Feeding^*

Variable	BPD	VLBW	Term
Mean Saoii	90 ± vii	94 ± 4	94 ± 3
Highest Sao2	98 ± i	98 ± 1	98 ± ane
Lowest Saoii	75 ± 16	84 ± viii	83 ± nine
Pct of time with Sao2 <90†	38 ± 26	14 ± eighteen	20 ± 25
Per centum of fourth dimension with Sao2 <80	10 ± 23	2 ± iv	i ± 2

In readings taken immediately after the feedings (see Table 4), infants with BPD were significantly dissimilar from both VLBW and term comparing groups, who did non differ from each other on any of the oxygen saturation measures. Mean Sao_ii for infants with BPD was 84 ± 8% (SD), and ranged from 73% to 99%, suggesting marked variability within the BPD group. Infants with BPD spent 64% of their fourth dimension after feeding in desaturation <ninety%, compared with 27% and 22% of time for VLBW and term infants. Infants with BPD also had significantly longer desaturation episodes <80%, with 37% of readings <80%, in comparison with 4% for VLBW and term infants.

TABLE 4

Oxygen Saturation Immediately Afterward Feeding^*

Variable	BPD	VLBW	Term
Mean SaO2 ‡	84 ± eight	93 ± 4	93 ± 3
Highest SaOii †	94 ± five	97 ± 2	98 ± 2
Everyman SaO2 ‡	72 ± xiii	87 ± seven	84 ± 6
Pct of time with SaO2 <90‡	64 ± 34	27 ± 33	22 ± 20
Percentage of fourth dimension with SaO2 <eighty‡	37 ± 28	4 ± ten	iv ± 8

Results of pair-wise comparisons indicated no significant differences on Sao_two measures between fourth dimension periods for the VLBW and term groups. Yet, mean Sao₂ levels of infants with BPD decreased significantly from the period at the beginning of feeding to the catamenia afterwards feeding (t = 2.78, df = 8, P < .05). This decrement over time and differences amongst the groups are illustrated in the Figure.

Mean arterial saturation by group: before, during, and after feedings. BPD, bronchopulmonary dysplasia; VLBW, very low birth weight.

Since there was a college incidence of IVH/PVL in the BPD grouping, Pearson's correlations were also computed for presence and severity of hemorrhage (rated from 0 through 4, and all Sao₂ measures. There were no significant relationships betwixt presence of and/or severity of hemorrhage and any of the pulse oximetry readings, suggesting that IVH/PVL were non the precipitants of infants' desaturation episodes.

Reading Characteristics

Equally indicated in Table 5, there were no differences among groups in length of feeding, ratio of caloric intake to infant weight, ratio of caloric intake corrected for weight to length of feed, or volume of formula taken during the feed.

TABLE five

Feeding Characteristics^*

Variable	BPD	LVBW	Term
Book, mL	50 ± 22	51 ± 22	59 ± 34
Intake, kcal/kg	16 ± viii	15 ± 6	14 ± 8
Intake, kcal/kg/min	0.8 ± 0.4	1 ± 0.7	1 ± 0.viii
Length of feed, min	21 ± 10	16 ± 8	eighteen ± 9

Correlation analyses indicated that some behavioral and physical characteristics of the feeding were associated with oxygenation measures but within the BPD grouping. Increased book of feed was significantly associated with lower saturation levels during feeding (r = −.66, P < .05) and increased incidence of Sao₂ (r = .72, P < .05) in the BPD group. Higher volume of intake in relationship to infant body weight, and faster feeding of higher volume, were also significantly related to increased incidence of desaturations less than fourscore% (r = .73, P < .01 and r = .77, P < .01). These relationships were non pregnant for VLBW or term infants. Length of feed did not relate to any oxygen saturation measures. Even so, length of feed was associated with infant socioeconomic condition every bit higher social class mothers gave longer feedings (r = −.69, P < .05). For infants with BPD, weight at assessment was unrelated to any oxygenation or feeding measures but was significantly associated with birth weight (r = .63, P < .05).

DISCUSSION

This study employed pulse oximetry to examine the impact of feeding on oxygenation in VLBW infants with and without BPD, compared with salubrious term infants. In contrast to prior studies, we assessed infants in the home environment during a normal oral feeding administered by one of their parents. We were primarily interested in assessing whether the episodes of desaturation during feeding observed during prior studies of infants with BPD⁸ persisted in one case infants had been weaned from supplemental oxygen and discharged from the hospital.

This study demonstrated that preterm infants with BPD differed significantly from both preterm infants without BPD and healthy term control infants in oxygenation levels measured before, during, and after the stress of feeding. In this report, VLBW infants without BPD were comparable with salubrious term control infants as they did not differ on any measure of Sao₂. However, infants with BPD had more hypoxemia before, during, and immediately after feeding. These findings are congruent with and extend the findings of Garg et al,⁸ which indicated that hospitalized infants with BPD experienced unsuspected hypoxia during feeding even in the absence of apnea, bradycardia, or clinical cyanosis. As infants in the present study were studied from 3 to five weeks after oxygen weaning and infirmary discharge, our findings indicate that desaturations related to feeding are a continuing problem for infants with BPD.

Prior studies have too documented that oxygenation varies with state, specially during sleep and feeding, as reported in infants with BPD,^8,fifteen preterm infants,^sixteen and term healthy infants.¹⁷ Marked declines in oxygenation accept been seen with feeding in healthy term and VLBW infants near term.^17,eighteen Withal, the incidence, duration, and extent of desaturations in preterm and healthy term infants in these prior studies are less frequent, shorter in duration, and less severe than those observed in infants with BPD.

Because repeated episodes of hypoxia have been suspected to play a function in the increased take chances for sudden, unexpected death⁸ and in later on intellectual deficits¹⁹ in children who have had BPD, it would be of import to assess whether clinically significant periods of desaturation proceed to occur after hospital discharge. The present information signal that current clinical practices related to weaning infants with BPD from oxygen need to be reassessed in light of the pronounced variability in oxygen saturation levels in relation to oral feeding.

Sekar and Duke^nine have found that lower levels of oxygen saturation in infants with BPD recently weaned from oxygen are associated with increased episodes of primal apnea and periodic breathing densities, which indicates a need for neonatal centers, including our ain, to reassess the practices and protocols for oxygen weaning, both prior to and after infirmary discharge. Information technology is certainly possible that some infants in this report were weaned prematurely. Furthermore, at that place may be limitations in the utilise of average values for oxygen saturation in determining the need for supplemental oxygen. Perchance time to come studies could allow randomization of infants to protocols for oxygen assistants to identify standardized procedures indicating their readiness for weaning.

Our written report also suggests that some behavioral and physical characteristics of the feeding, such every bit increased volume and faster feeding, are related to increased incidence of severe desaturations in infants with BPD or term infants. There is significant variability for all infants in the volume of formula taken at one feeding. For infants with BPD, however, increased volume and faster feeding were associated with lower oxygen saturation levels, suggesting that clinical observations of slower feeding in infants with BPD may be related to attempts of the infant to minimize desaturation. Individualized approaches to intervention could include assessments of care giver-infant interaction during feeding to determine whether care givers can acquire ways to "wearisome down" an infant'southward feeding through frequent pauses or through amending of nipple size. Whether such behavioral changes might prevent desaturation episodes in infants with BPD requires further investigation. In add-on, dwelling oxygen should exist considered for feedings in selected children who do not gain weight fairly, demonstrate marked and prolonged saturations, and are difficult feeders secondary to hypoxia.

Within this sample of BPD infants, desaturations were unrelated to neurologic status; however, future studies should explore the possibility that severity of neurologic issues might conduct some relationship to hypoxemic episodes. Gastroesophageal reflux, non clinically noted in our BPD grouping, might also exist a gene to be assessed in other studies. Longitudinal investigations of oxygenation in infants with BPD across a diverseness of behavioral states are necessary to appraise the correlates and potential sequelae of desaturation episodes in such infants.

ACKNOWLEDGMENTS

This work was supported through grants HL-38193, HL-25830, and MCJ-390592.

Thanks to Margaret Bruening, Marilyn Davillier, Bridgette Davis, Lori Bias, P. Ganesh, Diane Cairns, and Charisse Peoples for research assistance; to Drs Maureen Hack, Mark Collins, John Moore, and Lawrence Lillien for patient contacts; to Rose Marie Ashley and Carolyn Grier for manuscript preparation; and to Dr Maureen Hack for helpful comments.

ABBREVIATIONS

BPD	bronchopulmonary dysplasia
VLBW	very depression nascency weight
IVH	intraventricular hemorrhage
Sao2	arterial oxygen saturation
PVL	periventricular leukomalacia

Footnotes

Portions of this paper were presented at the Guild for Pediatric Enquiry meetings. May 1991, and the American Academy of Pediatrics meetings, October 1991, New Orleans, LA.

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