Seminars in Neonatology (2004) 9, 169e180

www.elsevierhealth.com/journals/siny

Maturation of respiratory reex responses in the fetus and neonate

Jalal M. Abu-Shaweesh)
Department of Pediatrics, Case Western Reserve University, 11000 Euclid Ave., Cleveland, OH 44106, USA

KEYWORDS
Regulation of breathing; Apnoea; Hypercapnia; Hypoxia

Summary Respiratory control in the fetus and neonate is quite immature when compared to that of adults. This immaturity involves all facets of respiration including respiratory responses to hypoxia, hypercapnia, an exaggerated apnoeic response to laryngeal stimulation and immature responses to activation of pulmonary afferents. The net result of this immaturity of breathing responses is the vulnerability of neonates and especially preterm infants to apnoea and respiratory pauses. The mechanisms behind immature control of breathing are not fully understood, but seem to originate from a predominance of inhibitory input early in life on respiratory centres. The relative contribution of up-regulation of inhibitory pathways versus down-regulation of excitatory ones is not clear. Multiple neurotransmitters have been implicated in the regulation of breathing in mammals and some of them are discussed in this chapter. 2004 Elsevier Ltd. All rights reserved.

So when I have made him complete and breathed into him of My spirit, fall down making obeisance to him Holy Quran, Al-Hijr, 15.029. Although many aspects of the regulation of breathing in humans and mammals have been explored in the past century, more questions have yet to be answered. Breathing results in the exchange of PaO2 and PaCO2 between the lungs and the environmental air maintaining homeostasis and control of blood pH, and yet energy-consuming breathing movements are present in utero where such exchange of gas is not possible. Maturation of

breathing is a continuous process that bridges fetal and neonatal life. Many features of immature fetal breathing responses are present to a lesser degree in the neonate. In this chapter we will discuss the maturation of respiratory reexes in the fetus and neonate and touch on the mechanisms involved in developmental regulation of these reexes.

Fetal breathing
Fetal breathing activity has been described in many species1 and is identied very early in gestation. Breathing activity in the human fetus can be detected using ultrasound by 11 weeks gestation2 and as early as 0.3 weeks gestation in the lamb.2,3 Since the placenta is the site of gas exchange in

) Tel.: D1-216-8443387; fax: D1-216-8443380. E-mail address: jxa16@po.cwru.edu.

1084-2756/$ - see front matter 2004 Elsevier Ltd. All rights reserved. doi:10.1016/j.siny.2003.09.003

170 utero, the function of fetal breathing movements (FBM) is not clear. There are several clear indications that FBM are important for fetal lung growth and development. Increasing or decreasing the frequency of FBM had a direct correlation with accelerating or inhibiting lung growth, respectively.4,5 Furthermore, decreasing the negative intrathoracic pressure generated during FBM, by replacing part of the chest wall with a silicon membrane, resulted in fetal pulmonary hypoplasia.6 In addition, FBM has been shown to signicantly increase fetal cardiac output and blood ow to a number of vital organs including the heart, brain and placenta.7 Early in gestation breathing activity consists of almost continuous, irregular tonic movements and occurs in conjunction with similar activity of other somatic muscles. This early breathing activity seems to originate from the spinal cord since it persists after spinal cord resection at the C1 level. With advancing gestational age this random tonic activity of the diaphragm decreases and the proportion of centrally mediated phasic phrenic activity increases.8 Electroencephalograph (EEG) activity at the early stages of FBM is undifferentiated. This contrasts with the differentiated EEG activity in later gestation, which consists of high frequency, low voltage activity (LVEEG) associated with rapid eye movement sleep (REM), and high voltage and low frequency activity (HVEEG) associated with non-rapid eye movement (NREM) sleep. In the third trimester of gestation FBM becomes limited to REM sleep and there is total cessation of breathing during NREM sleep, even in the presence of hypercapnia.9 The mechanism behind the absence of FBM during NREM sleep seems to originate from the predominance of descending inhibitory pathways from the lateral pons or midbrain to the medullary rhythm generating centre.10 Sectioning the neuroaxis at the midcollicular level causes continuous FBM activity independent of cycling between REM and NREM sleep.11 The periodic nature of fetal breathing has to change into a continuous pattern in order to allow for the survival of the newborn. The mechanisms responsible for overriding the pontine inhibition during NREM sleep are not clear. However, several factors that might be associated with the fetal transition to extra-uterine life have been shown to induce continuous breathing in the fetus. These include pretreatment with serotonin precursor 5-hydroxytryptophan,12 bolus injections of the g-aminobutyric acid (GABA) antagonist picrotocin,13 intraventricular administration of thyrotropin-releasing hormone14 or corticotrophin-releasing factor15 and prolonged infusion of large doses of the prostaglandin synthase inhibitors

J.M. Abu-Shaweesh meclofenamate and indomethacin.16 Whether one or more factors contribute to the transition to continuous breathing in the newborn remains to be claried. The disappearance of a placental inhibitory factor after cord occlusion has been suggested as a possible mechanism for the establishment of continuous breathing at birth.17 Recently, Alvaro et al.18 described a peptide produced by the placenta in sheep, with a molecular mass of between 2.5 and 4.5 kDa, that inhibits fetal breathing. However, other studies have failed to induce continuous FBM after cord occlusion while using extracorporeal membrane oxygenation (ECMO) to support the fetus,19 therefore, the presence of a placental factor that inhibits FBM continues to be an unsettled issue. Fetal hypercapnia, either through maternal inhalation of 4e6% CO2 or by using ECMO, increases the incidence and depth of FBM although it does not affect breathing frequency.20,21 This response is present in fetal lambs from 75 days22 and in human fetuses from 24 weeks with an increase in its sensitivity with advancing gestational age.23 The fetal hypercapnic response is limited however, to LVEEG and hypercapnia can only stimulate FBM after lesions to the lateral pons during HVEEG. In contrast, fetal hypocapnia causes a decrease or disappearance of FBM,23 which implies that CO2 is essential for the presence of FBM. Although the fetus lives in a relatively hypoxaemic condition (PaO2 25e30 torr), oxygen delivery in utero is adequate since it matches oxygen consumption and it allows for fetal activity and growth. Unlike adults, the fetus responds to hypoxia by a decrease in breathing activity.9,24 Hypoxaemia has been shown to inhibit diaphragmatic activity in sheep as early as 75 days.22 The effect is transient, since FBM resume within 3e16 h after prolonged exposure to hypoxia. The cause of this hypoxic ventilatory depression in utero appears to be central in origin. After brainstem transection or lesions in the lateral upper pons, acute hypoxaemia stimulates FBM even in the absence of the carotid bodies.25 Unlike the fetal breathing response to hypercapnia, the hypoxic response is logical in the sense that for the energy-strapped fetus to increase breathing in response to hypoxia will be counterproductive.

Postnatal development of breathing responses

Breathing in the neonate, although much developed from fetal breathing, is still immature. This immaturity is manifested in almost all aspects of

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Figure 1 Proposed pathophysiological mechanisms predisposing or leading to apnoea of prematurity.

respiratory control starting from peripheral afferent input, central respiratory output including reex responses and responses of respiratory muscle groups. Moreover, preterm infants exhibit more pronounced immaturity of respiratory control, the net result of which is a high incidence in the occurrence of apnoea and bradycardia (Fig. 1). There seems to be an overriding inhibitory inuence of central origin in the control of breathing in the neonate. This is manifested by a decrease in breathing response to CO2, a paradoxical response to hypoxia, an exaggerated reex apnoea and irregularities of breathing pattern including the presence of periodic breathing, apnoea and tachypnoea. This predominantly inhibitory effect on the breathing of the neonate could be secondary to an increase in inhibitory pathways, a decrease of excitatory pathways or a combination of both.

decreases with advancing gestational age from at least 80% in infants weighing ! 1000 g at birth until 43e44 weeks corrected gestational age when the incidence is equal to that of a term neonate.30 Paradoxical inward movements of the rib cage during inspiration are common in the neonate and especially in preterm infants.31 The mechanism behind this paradoxical movement is a combination of the highly compliant rib cage and diminished intercostal muscular tone versus the maximal diaphragmatic contraction. The muscular effort required to produce a tidal volume during these paradoxical movements is four times greater than during normal breathing,32 which further hinders an already immature breathing pattern in the neonate.

Hypercapnia and acidosis

In humans and animals, small increases in arterial PCO233 or small changes in brain uid pH34 increase ventilation dramatically. The ventilatory response to CO2 is the net result of activation of both peripheral and central chemoreceptors. The contribution of the peripheral chemoreceptors, mainly through the carotid body, has been estimated as being between 10e40% of the total hypercapnic response.33 Central chemoreceptors originally thought to be conned to the ventrolateral medulla have been found to be widely spread in the brainstem, for a recent review, see Nattie.35 Focal acidosis induced by application of the carbonic anhydrase inhibitor acetazolamide increased phrenic nerve activity after injections at the ventral surface of the medulla including the retrotrapezoid nucleus, the region of the nucleus tractus solitaris, the region of the locus coeruleus, the rostral aspect of the ventral respiratory group and the medullary raphe.36,37 Other sites of chemoreception include the fastigial nucleus of the cerebellum38 and the pre-Botzinger complex.39 It is unclear at this point if there is developmental maturation in location of central chemoreceptors since most studies have been done in adult animals hence this issue remains to be explored. The ventilatory response to CO2 increases with advancing postnatal40e42 and gestational age40,41 in preterm human infants. Therefore, the breathing response to CO2 in preterm infants is impaired when compared to term neonates or adults.40e42 This difference is both quantitative and qualitative. Whereas term neonates and adults increase their ventilation through an increase in both tidal volume and frequency, preterm infants were not able to increase frequency in response to CO2.41e43 Several mechanisms have been proposed to explain this

Neonatal breathing pattern

Neonatal respiratory activity is characterized by irregularity and spontaneous changes in the breathing pattern between eupnoea, apnoea, periodic breathing and tachypnoea. Respiratory frequency, often inversely proportional to body weight, may be quite variable in the preterm infant. Periods of slow respiratory frequency in the human neonate are secondary to prolongation of expiratory time (TE) while inspiratory time (TI) remains unchanged during development. In fact, as will be discussed later, prolongation of TE is a prominent feature of decreasing respiratory frequency to hypoxia, hypercapnia and reex stimulation of the larynx.26e28 In animals, however, there is lengthening of TI together with shortening of TE with advancing age.29 The extreme form of prolongation of TE is respiratory pauses and apnoea, which occur frequently in preterm and, to a lesser extent, in term neonates. The incidence of central apnoea

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J.M. Abu-Shaweesh ceptors, or changes in the central integration of chemoreceptor or other neuronal signals. Krauss et al.41 characterized simultaneous improvement in lung compliance and increasing postconceptional age in parallel with maturation of the hypercapnic response in infants. Frantz et al.40 conrmed that ventilatory responses to CO2 are decreased in premature infants and, by measuring end-expiratory occlusion pressures, suggested that decreased respiratory centre sensitivity contributed to this phenomenon. We have described in vagotomized, intubated and ventilated rats a hypercapnic ventilatory response that is impaired in newborn rats relative to adult rats, signifying a central origin for such a response,26 as seen in Fig. 2. Even more impaired is the hypercapnic breathing response in preterm infants with apnoea when compared with non-apnoeic controls.44e46 Gerhardt et al.44 and others have documented that the CO2 response in preterm infants with apnoea was shifted to the right and had a lower slope than in infants without apnoea. In other words, at the same level of CO2 and for the same degree of change in alveolar CO2, minute ventilation in babies with apnoea was lower. Pulmonary mechanics, respiratory frequency and dead space volume were similar between the two groups indicating a central origin for this disturbed breathing in preterm infants with apnoea.44 These data indicate a central origin for the attenuated CO2 response in preterm babies, in particular in those with apnoea. However, a cause and effect relationship between apnoea of prematurity and the attenuated response to CO2 has not been clearly established, and both might simply represent facets of a decreased respiratory drive.

Hypoxia
Figure 2 The effect of 5-min exposure to 5% CO2 on (A) minute ventilation (VE), (B) tidal volume (VT) and (C) frequency at 5 (open circles) and 22e23 (closed circles) days of age in unrestrained rats. Hypercapnia caused a signicantly greater increase in VE at 22e23 days compared with 5 days. Percentage increase in VT was similar at the two ages. Frequency decreased signicantly from baseline at 5 days, whereas it increased signicantly from baseline at 22e23 days (reprinted with permission from Ref.26).

attenuation in the hypercapnic ventilatory response to CO2 exhibited by premature and immature newborns of various species. Possibilities include changes in the mechanical properties of the lung, maturation in the peripheral or central chemore-

The hypoxic ventilatory response has been well characterized in newborn (especially preterm) infants. Unlike adults who express a sustained response to hypoxia, neonates have an initial increase in ventilation that lasts 1e2 min, followed by a decline in breathing to below baseline ventilation in preterm infants.47,48 This late decline has been traditionally termed hypoxic ventilatory depression (Fig. 3). The initial rise in ventilation increases while the magnitude of late depression decreases with advancing postnatal age. The initial increase in ventilation is secondary to stimulation of peripheral chemoreceptors primarily in the carotid body, since the response is eliminated by carotid body denervation.49 The late decrease in ventilation is mainly secondary to a decrease in

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Figure 3 The effect of hypoxic exposure on the ventilatory response in 12 preterm infants at 2e3 weeks postnatal age. A 5 min exposure to 15% O2 caused a transient increase in minute ventilation (min vent) at 1e2 min, followed by a decrease to below baseline at 5 min. While the tidal volume exhibited a sustained increase, respiratory frequency decreased signicantly during the hypoxic exposure (reprinted with permission from Ref.50).

frequency in preterm infants while the increase in tidal volume is relatively sustained. The biphasic ventilatory response to hypoxia, thought initially to recover by 2e3 weeks postnatal age, has been shown more recently to persist in convalescing preterm neonates at 4e6 weeks of age.50 The origin of the late depression is not well understood. Several theories have been postulated to explain hypoxic ventilatory depression (for a recent review, see Bissonnette51). These include: a time-dependent decrease in carotid body stimulation, a decrease in PaCO2 secondary to the initial hyperventilation or an increase in cerebral blood ow causing CO2 washout, a decrease in metabolism52 and hypoxia-mediated central depression of ventilation.47 The contribution of the carotid body to the late hypoxic depression is still controversial. While in kittens hypoxia caused a sustained increase in carotid body discharge while minute ventilation decreased,53 piglets showed a decline in carotid body discharge that occurred over a similar time course as the decline in ventilation.54 Exposure to a combination of CO2 and hypoxia did not prevent the late respiratory depression, suggesting that a decrease in PaCO2 is not the origin of this hypoxic depression.55 Multiple neurotransmitters have been implicated as mediators for the hypoxic depression including adenosine, endorphins and GABA. The use of blockers for these neurotransmitters, such as methylxanthines for adenosine, naloxone for endorphins and bicuculline for GABA, was successful in preventing the late hypoxic depression and caused a sustained ventilatory response. Recently, Moss and Laferriere56 reported that acute and chronic hypoxia produced an enhancement of neurokinin-1 receptor endocytosis, making it less available at the cell membrane, while failing to affect endocytosis of m-opioid receptors. They suggested that the resulting predominance of the inhibitory m-opioid receptors might contribute to the late hypoxic depression.56 Furthermore, the depressive response to hypoxia is diminished by experimental lesions in the upper brainstem and midbrain of the fetal lamb,57 indicating the presence of descending inhibitory tracts that contribute to hypoxic ventilatory depression. Consistent with these ndings is the observation that a progressive decrease in inspired oxygen concentration causes a signicant attening of carbon dioxide responsiveness in preterm infants.58

Laryngeal afferent reexes

Stimulation of the laryngeal mucosa, either chemically (by water, ammonium chloride or acidic

174 solutions) or mechanically causes inhibition of breathing and apnoea in humans and animals.59e62 This reex-induced apnoea is mediated through the superior laryngeal nerve, since bilateral sectioning of the superior laryngeal nerve abolishes laryngeal stimulation-induced apnoea.59,63,64 The reex apnoea has been shown to be associated with contraction of the thyroarytenoid (TA) muscle causing closure of the glottis and swallowing movements, signifying active stimulation of expiratoryrelated brain stem centres. There appears to be a clear maturational change in reex-induced apnoea. Chemical stimulation of the larynx in newborn piglets caused respiratory arrest, while older piglets did not express a similar response.63,64 Maturation of the laryngeal inhibitory reex is also common to a wide variety of other animals including dogs, monkeys, sheep and cats.62,65e67 Preterm infants also appear to express such an exaggerated inhibitory reex as they elicit prolonged apnoea in response to instilling saline in the oropharynx.61 The mechanisms underlying such maturational change in reex-induced apnoea are not known, however, they do not seem to be related to either changes in laryngeal receptors,68 changes in central synaptic connections, or maturation of the carotid body.69 It has been shown that hypercapnia increases while hypocapnia decreases the threshold for superior laryngeal nerve (SLN) stimulation-induced apnoea.70,71 Cooling of the ventromedullary surface, a technique used to decrease central chemosensitivity by inhibiting synaptic transmission at this site, also decreased the threshold for laryngeal stimulation-induced apnoea.71 Theophylline, which stimulates respiratory neural output, has been shown to block SLN stimulation-induced apnoea.64 It seems, therefore, that the exaggerated reex-induced apnoea seen in newborn infants and animals is related to decreased central neural output or a dominance of inhibitory pathways. Furthermore, blocking GABAA receptors resulted in complete abolition of superior laryngeal nerve stimulation-induced apnoea in piglets (Fig. 4).27

J.M. Abu-Shaweesh the vagus nerve and results in termination of respiration.72 Preterm infants seem to be more dependent than term infants on the HeringeBreuer reex to regulate breathing frequency. Olinsky et al.75 used airway occlusion, thereby aborting lung afferents, to estimate the contribution of stretch receptors on respiratory timing in term and preterm infants. Preterm infants had more prolongation of inspiratory time following occlusion than term infants, signifying that in preterm infants the HeringeBreuer reex is more active and contributes to their higher respiratory frequency.75 The purpose of such an exaggerated reex is probably to prevent full emptying of the lung and maintain lung volume at end expiration. However, the HeringeBreuer reex was found to be weak in infants of 32 weeks gestation, increasing in strength at 36e38 weeks and decreasing thereafter.76 The HeringeBreuer deation reex is also activated on deation of the lung and results in inspiratory augmentation.72 Hannam et al.77 found that, unlike term infants, preterm infants responded to the deation reex by shortening inspiratory time. Preterm infants also had short apnoeas during chest compression that were mostly central in origin and infants with apnoea had even greater shortening of inspiratory time.77 Such data indicate that on deation of the lung, as during an apnoea, preterm infants were less likely to initiate breathing and tended to have respiratory pauses.

Neurotransmitters and neuromodulators

There are limited data regarding the balance of excitatory and inhibitory neurotransmitters during development of respiratory control. For obvious reasons invasive studies cannot be performed in newborn infants and there is no optimal animal model for apnoea of prematurity. Therefore, most studies on the relationship of neurotransmitters to respiratory control are based on the effect of these substances, or their inhibitors, on the breathing responses to hypoxia, hypercapnia and reex apnoea in animals and, to a lesser extent, in neonates. The most widely studied neurotransmitters in relation to disturbances in control of breathing include, adenosine, GABA, prostaglandin, endorphins and serotonin. Adenosine is a product of ATP that is present in various portions of the brain and cerebrospinal uid (CSF).78,79 Adenosine is known to depress neural function80 and analogues of adenosine have been shown to decrease respiration in neonatal rabbits and pigs.81e83 The involvement of adenosine in

Pulmonary afferent reexes

Lung afferents play an important role in regulating respiratory timing and may play a role in apnoea of prematurity. Stimulation of pulmonary stretch receptors through increasing lung volume causes shortening of inspiratory time, prolongation of expiratory time or both.72e74 This reex, known as the HeringeBreuer reex, is mediated through

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Figure 4 Phrenic nerve electroneurogram (ENG) and end-tidal CO2 (PETCO2) in response to superior laryngeal nerve (SLN) stimulation before (A) and after (B) intracisternal administration of GABAA receptor blocker bicuculline. SLN stimulation before bicuculline caused apnoea that persisted beyond the duration of stimulation. The same level of stimulation after bicuculline caused a decrease in phrenic nerve amplitude and frequency but failed to produce apnoea. ABP, arterial blood pressure (reprinted with permission from Ref.27).

hypoxic ventilatory depression is suggested by the observation that hypoxia increases adenosine in the interstitial uid of the brain as well as the CSF and plasma in newborn piglets.78,79 Furthermore, adenosine antagonists reversed hypoxic depression in anaesthetized newborn piglets.81 The role of adenosine in apnoea of prematurity is suggested by the ability of adenosine antagonists, the xanthine derivatives theophylline and caffeine, to decrease the incidence of apnoea of prematurity. However, the exact mechanism and location of action of adenosine as well as the interaction of adenosine with other neurotransmitters remain to be identied. GABA is the major inhibitory neurotransmitter in the CNS. Its involvement in the control of breathing is suggested by the ability of exogenous GABA to

inhibit breathing and cause apnoea in animals.84,85 Both structural and functional differences in GABAA receptors have been observed during development.86e89 GABAA receptors are hetero-oligomers assembled from ve subunits.88 During embryonic and early postnatal development, the mix of GABAA receptor subunits differs from that in adults.86,87 Furthermore, Xia and Haddad90 demonstrated that the newborn rat brainstem has a much higher GABAA receptor density than does the adult brainstem. GABA has been implicated in the attenuated ventilatory responses to hypoxia, hypercapnia and reex-induced apnoea in piglets. GABA antagonist was able to prevent the hypoxic depression induced by repeated hypoxia and prevent apnoea induced by hypoxia in newborn piglets.91 Blocking GABAA receptors also prevents the

176 decrease in breathing frequency in response to CO2 in newborn rats.26 Administration of bicuculline, a GABAA receptor blocker both systemically and intra cisternally prevented the reex apnoea originating from superior laryngeal nerve stimulation in newborn piglets.27 Therefore GABA has the potential to play a key role in the vulnerability of preterm infants to disturbed breathing including apnoea of prematurity. Endorphins have been widely studied in the control of breathing. Exogenous endorphin and enkephalin analogues produced a consistent decrease in respiration in fetal and neonatal animals.92,93 However, administration of endorphin antagonists to adult subjects had no effect on their breathing.94 Endorphin levels are elevated in the human neonate at birth.95 Although b-endorphin is increased in neonatal piglets, this effect is conned to the plasma and does not involve the CSF or respiratory-related regions.96 However, endogenous opioids were found to modulate the hypoxic ventilatory response in newborn infants and animals.97,98 Furthermore, naloxone produced an improvement in apnoea and periodic breathing in infants in whom b-endorphin-like immunoreactivity in the CSF was elevated.99 Although these data support a role for opioids in respiratory control in neonates, the effect of anaesthesia in such studies and the interaction of opioids with other inhibitory neurotransmitters needs to be claried. Infusion of prostaglandin E1 (PGE1) produces respiratory depression in 12% of infants during treatment for congenital heart disease.100 PGE1 also decreases, and indomethacin enhances, phrenic activity in newborn piglets.101 Hammerman and Zangen102 described a case of apnoea of prematurity that was resistant to conventional management but responded to treatment with indomethacin. Although the involvement of serotonin in respiratory control is well established, the nature of this involvement is complex. The most consistent effect of serotonin is augmentation of phrenic motor neuron activity at the level of the spinal cord. However, systemic and central effects of serotonin are variable. Systemic or ionophoretic administration of large doses of the 5-hydroxytryptophan (5-HT) agonist, 5-methoxy-N,N, dimethyltryptamine (5MeODMT), causes a decrease in the discharge frequency of inspiratory and expiratory neurons, while administration of smaller doses resulted in an opposite effect.103 Furthermore, local application of 5-HT to respiratory neurons or stimulation of endogenous release of 5-HT by activating different sites of the raphe neurons resulted in variable changes in phrenic nerve activity, either facilitating or suppressing it.104 The different responses

J.M. Abu-Shaweesh to 5-HT may be due, in part, to the subtypes of 5-HT receptors preferentially expressed on different respiratory neurons. Serotonin has been implicated as a regulatory factor in the production of apneusis. Blocking 5-HT-1A receptors has been shown to reverse apneustic breathing, which might result during hypoxia or ischaemia.105 Serotonergic neurons found in the raphe nuclei share multiple properties of chemosensory neurons. These neurons are stimulated by acidosis, project widely to all major respiratory nuclei and have processes that are closely apposed to blood vessels, for a recent review, see Richerson et al.106 In vitro, raphe neurons stimulated by acidosis have been shown to undergo developmental changes in rats. The percentage of these neurons increases from 3e18% in the rst 12 days of life, a change that parallels an increase in central chemoreception in vivo.107 This points to the possible importance of serotonergic neurons in chemoreception during development. Further evidence of this importance is the recent data in victims of sudden infant death syndrome (SIDS). Abnormalities of the human arcuate nucleus, which is homologous to the rat and cat medullary raphe, have been reported in infants that died of SIDS.108 More recently, in two cohorts of SIDS victims (Japanese, AfricanAmericans and Caucasians) there was a signicant positive association with the presence of a homozygous gene that encodes for the long allele of the 5-HT transporter promoter (5-HTT), as well as the long allele itself.109,110 In both studies, SIDS victims were more likely to express the long allele, as well as to miss the short allele, of 5-HTT than controls. Therefore, it is possible that a delay in development of serotonergic neurons or over-expression of the long allele for 5-HTT in the arcuate nucleus as well as in other respiratory groups might contribute to the lack of respiratory responses to a stressful condition, as an underlying mechanism in the pathogenesis of SIDS. In conclusion, breathing responses early in life are immature and undergo developmental changes between fetal and neonatal life. This immaturity of breathing control in the preterm infant includes an attenuated hypercapnic ventilatory response, a paradoxical response to hypoxia and an exaggerated response to laryngeal stimulation, one or more of which might contribute to the pathogenesis of apnoea of prematurity. The mechanisms behind this immaturity of breathing responses are not clear but seem to originate from the predominance of inhibitory input on respiratory centres. Although descending inhibitory pontine tracts, up-regulation of inhibitory neurotransmitters, and down-regulation of excitatory neurotransmitters

Maturation of respiratory reex responses in the fetus and neonate have all been shown to alter breathing responses in the newborn, the relative contribution of each remains to be claried.

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References
1. Jansen AH, Chernick V. Development of respiratory control. Physiol Rev 1983;63:437e83. 2. Boddy K, Dawes GS. Fetal breathing. Br Med Bull 1975;31: 3e7. 3. Berger PJ, Cooke IRC. Ontogeny of the respiratory pattern generator in the fetal lamb. In: Proceedings of the annual meeting of the society of fetal physiology, Cairns, Australia; 1988. 57 pp. 4. Nagai A, Thurlbeck WM, DeBoeck C, Ioffe S, Chernick V. The effect of maternal CO2 breathing on lung development of their fetuses. Morphology and morphometric studies. Am Rev Respir Dis 1987;135:130e6. 5. Wigglesworth JS, Desai R. Effects on lung growth of cervical cord section in the rabbit fetus. Early Hum Dev 1979;3: 51e65. 6. Liggins GC, Vilos GA, Campos GA, Kitterman JA, Lee CH. The effect of bilateral thoracoplasty on lung development in fetal sheep. J Dev Physiol 1981;3:275e82. 7. Jansen AH, Belik J, Ioffe S, Chernick V. Control of organ blood ow in fetal sheep during normoxia and hypoxia. Am J Physiol Heart Circ Physiol 1989;257:H1132e9. 8. Cooke IRC, Berger PJ. The organization of the respiratory pattern generating system of the fetal lamb early in gestation. In: Proceedings of the annual meeting of the society of fetal physiology, Cairns, Australia; 1988. 25 pp. 9. Clewlow F, Dawes GS, Johnston BM, Walker DW. Changes in breathing, electrocortical and muscle activity in unanesthetized fetal lambs with age. J Physiol 1983;341:463e76. 10. Johnston BM, Gluckman PD. Lateral lesions affect central chemosensitivity in unanesthetized fetal lamb. J Appl Physiol 1989;67:1113e8. 11. Dawes GS, Gardner WN, Johnston BM, Walker DW. Breathing in fetal lambs: the effect of brain stem section. J Physiol 1983;335:535e53. 12. Quilligan E, Clewlow F, Johnston B, Walker D. Effects of 5hydroxytryptophan on electrocortical activity and breathing movements of fetal sheep. Am J Obstet Gynecol 1981;141:271e5. 13. Brown ER, Lawson EE, Jansen A, Chernick V, Taeusch HW. Regular fetal breathing induced by pilocarpine infusion in the near-term fetal lamb. J Appl Physiol 1981;50:1348e52. 14. Umans JG, Umans HR, Szeto HH. Effects of thyrotropinreleasing hormone in the fetal lamb. Am J Obstet Gynecol 1986;155:1266e71. 15. Bennet L, Johnston BM, Vale WW, Gluckman PD. The effects of corticotrophin releasing factor and two antagonists on breathing movements in fetal sheep. J Physiol 1990;421: 1e11. 16. Kitterman JA, Liggins GC, Clements JA, Tooley WH. Stimulation of breathing movements in fetal sheep by inhibitors of prostaglandin synthesis. J Dev Physiol 1979;1:453e66. 17. Adamson SL, Kuipers IM, Olson DM. Umbilical cord occlusion stimulates breathing independent of blood gases and pH. J Appl Physiol 1991;70:1796e809. 18. Alvaro RE, Robertson M, Al-Saedi S, Lemke RP, Cates DB, Rigatto H. Preliminary characterization of a placental factor inhibiting breathing in fetal sheep. Reprod Fertil Dev 1997;9:641e9. 19. Kuipers IM, Maertzdorf WJ, Keunmen H, De Jong DS, Hanson MA, Blanco CE. Fetal breathing is not initiated after cord occlusion in the unanesthetized fetal lamb in utero. J Dev Physiol 1992;17:233e40. 20. Dawes GS, Gardner WN, Johnston BM, Walker DW. Effects of hypercapnia on tracheal pressure diaphragmatic and

Practice points
 Fetal breathing is quite immature, sleepstage dependent and seems to be important for lung development. Although the fetus responds to CO2 by an increase in breathing movements, this response is conned to low voltage brain activity.  Preterm infants exhibit an immature breathing response to hypoxia, hypercapnia and an exaggerated inhibitory response to stimulation of the upper airways, all of which might predispose to the initiation or propagation of apnoea.  The hypoxic ventilatory response in the neonate is biphasic, with later depression in ventilation to below baseline. The hypercapnic response is decreased when compared to adults, secondary mainly to a decrease in breathing frequency and hypoxia further impairs the hypercapnic response.  The mechanisms underlying the attenuated breathing control in the neonate are not clear. However, it is probably related to overriding of the inhibitory inuences in the form of persistent descending inhibitory pathways, up-regulation of inhibitory, or under-expression of excitatory, neurotransmitters.

Research directions
 Identify the pontine groups of neurons that contribute to the descending inhibitory tracts implicated in the hypoxic ventilatory response and immature fetal breathing.  Carry out follow up studies with precise monitoring to characterize the long term neurodevelopmental effects of repeated hypoxia and hypercapnia resulting from recurrent apnoea in preterm infants.  Longitudinal neuroanatomical and immunohistochemical studies are needed to evaluate the ontogeny of the balance between excitatory and inhibitory neurotransmitters in animals.  Identify the maturational changes to the neuronal network responsible for the production of apnoea during stimulation of the upper airways.

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