Development and maturation of the autonomic nervous system in premature and full-term infants using spectral analysis of heart rate fluctuations

Prenatal RR fluctuations dynamics: detecting fetal short-range fractal correlations

OBJECTIVE

Several studies have suggested that the analysis of heart rate variability (HRV) during gestation provides indications of the development or maturation of fetal cardiovascular regulatory mechanisms. In this study, we evaluate the existence of short-range fractal-like correlations in fetal RR fluctuations data from the second half of human gestation.

METHODS

Fifty-six short-term abdominal ECG recordings were obtained from low-middle-risk pregnant women. Gestational age varied from estimated 21 weeks to term. For comparison, RR-interval data of 51 healthy adults were also analysed.

RESULTS

Principal findings along the gestational period explored were the existence of fractal RR dynamics in prenatal fetal data as revealed by the short-range scaling exponent alpha(1). No significant differences of alpha(1) (p = 0.4770) were found between fetal (median 1.2879) and adult data (median 1.3214), either between the fetal cases before or after 24 weeks (p = 0.6116) despite observing more variation at early stages. However, fetal RR data did involve lower magnitude in comparison with adults as we found significant differences in pNN20 and SDNN values.

CONCLUSION

The fetal short-range fractal behaviour of RR data could then be linked to the functional development of the parasympathetic activity, which appears to become manifested before 21 weeks of gestation.

Maturation of the autonomic nervous system: differences in heart rate variability in premature vs. term infants

AIMS

Heart rate variability (HRV) reveals information on the functional state of the autonomic nervous system (ANS). This study was initiated to assess the physiological- and maturational development of the ANS by comparing HRV data of healthy prematures with term infants.

METHODS

Short-term recordings of HRV in 39 premature healthy infants (29-35 weeks' gestation) were performed and compared with normative data of term infants. Frequency domain HRV parameters are computed in three frequency bands.

RESULTS

Gestational age of newborn infants is correlated with HRV. Prematures showed significant lower HRV parameters than term infants. The most significant differences were discerned for HRV parameters reflecting parasympathetic activity, whereas the pulse of the baro-receptor reflex was similar for prematures and term infants at 0.07 Hz (0.1 Hz adults). A respiratory peak in the HF-band according to respiratory sinus arrhythmia (RSA), as is common in adults, was not detected for prematures as it is not detected in term infants.

CONCLUSIONS

Maturation of the ANS is accompanied by increasing HRV with a pronounced increase of parasympathetic activity. These changes are measurable by short-term recordings. The physiological pulses concerning baroreceptor reflex activity and respiratory modulation were similar in prematures and term infants.

Characteristics of arterial stiffness in very low birth weight premature infants

Premature birth is a factor of increased blood pressure in adulthood. Little is known about the physiologic characteristics of the arterial bed in neonates. The aim of this study was to characterize in vivo the arterial compliance in neonates and its maturation profile in very low birth weight (VLBW) premature infants. A group of stable, VLBW premature infants was compared with a control group of near term neonates. The abdominal aortic wall distensibility coefficient (DC) and whole-body arterial compliance (WBAC) were determined using specifically designed noninvasive methods, based on ultrasonic measurements in combination with synchronous, beat-to-beat recording of aortic pulse pressure (PP). On the fifth day of life, WBAC and the CD were lower in VLBW premature infants than in controls. Furthermore, WBAC and the DC remained unchanged in VLBW premature infants 7 wk after birth. In conclusion, VLBW premature infants are characterized as early as the fifth day of life by high arterial stiffness, which persists when they reach their theoretical term. It can be speculated that early alteration of arterial elastic properties may pave the way for long-term elevation of arterial pressure in VLBW premature infants.

Heart rate variability responses of a preterm infant to kangaroo care

OBJECTIVE

To examine the effect of kangaroo care on heart rate variability in a healthy preterm infant.

DESIGN

Case study.

SETTING

Private room on a postpartum unit.

PARTICIPANT

A mother-preterm infant dyad.

INTERVENTION

Kangaroo (skin-to-skin) care.

MAIN OUTCOME MEASURE

Heart rate variability, a noninvasive measurement of the sympathetic and parasympathetic components of the autonomic nervous system's influence on heart rate.

RESULTS

Heart rate variability, especially the parasympathetic component, was high when the infant was fussy in the open crib, indicating increased autonomic nervous system activity. With kangaroo care, the infant fell asleep, and both sympathetic and parasympathetic components of heart rate variability decreased.

CONCLUSIONS

The wide fluctuations in the parasympathetic component of heart rate variability suggest immaturity of the sympathovagal response. Overall, kangaroo care produced changes in heart rate variability that illustrate decreasing stress.

Heart Rate Characteristics Monitoring for Neonatal Sepsis

While heart rate variability has been measured in many clinical settings and has offered insights into how HR is controlled, rarely has it offered unique information that has led to changes in patient management. We review our experience in developing continuous HR characteristics monitoring to aid in the early diagnosis of sepsis in premature infants in the neonatal intensive care unit. A predictive algorithm, developed at one center and validated at another, has led to diagnosis and treatment of this subacute and potentially catastrophic illness prior to appearance of symptoms of severe illness.

Impaired parasympathetic response to feeding in ventilated preterm babies

BACKGROUND

Premature very low birthweight (VLBW) infants are born with an underdeveloped parasympathetic nervous system (PNS) which may limit their ability to respond adequately to feeding and may limit their capacities for extrauterine growth and development.

OBJECTIVES

To describe the patterns of autonomic response to feeding and identify relationships between change in heart period variability measures over time with selected infant characteristics.

METHODS

Individual growth curve analysis techniques were used to describe the patterns of change over time in sympathetic and parasympathetic tone as measured by low and high frequency heart period power.

RESULTS

Sixteen mechanically ventilated VLBW infants with a mean corrected gestational age of 30.4 weeks participated in the study. The low frequency (LF) power slope was -17.67 (p = 0.0002) and the high frequency (HF) power slope was -0.92 (0.0003). There was a significant relationship between HF slope and birth gestational age (r = -0.49, p = 0.05).

CONCLUSIONS

HF power, representing primarily parasympathetic activity, did not increase with enteral feeding as anticipated. LF power, an indicator of sympathetic tone, decreased during and after feeding suggesting the anticipated effect of inhibition of the sympathetic nervous system in response to the gut stimulus. Critically ill VLBW infants possess an overriding sympathetic response, but may not have adequate PNS tone development.

Approximate entropy of fetal heart rate variability as a predictor of fetal distress in women at term pregnancy

BACKGROUND

The aim of this study is to investigate the relationship between approximate entropy (ApEn) of fetal heart rate (FHR) with umbilical blood gas parameters and the power spectrum of FHR variability in Chinese and to test whether ApEn of FHR variability could be used as a predictor of fetal distress in women at term pregnancy.

METHODS

Sixty-seven pregnant women with singleton, term fetus were recruited for the recording of FHR variability and the data were used for the estimate of ApEn. Blood gases after birth were measured through umbilical artery.

RESULTS

In all 67 neonates, there was some amount of interinfant variability in the ApEn values with a mean of 1.139 +/- 0.169. The ApEn values were significantly (P < 0.05) correlated with pO(2), SO(2), pCO(2), pH, HCO(3), or base excess (BE). The 15 fetuses with low ApEn (ApEn <1.0) had higher risk of metabolic acidosis (BE less than -12 mmol/l) than those with high ApEn (ApEn > or =1) (likelihood ratio = 12.301, P < 0.001). The powers of FHR variability in all frequency ranges (0-0.256 Hz) were lower in the low-ApEn group than those in the high-ApEn group.

CONCLUSIONS

The ApEn of FHR variability significantly decreased during fetal asphyxia, including hypoxia, hypercapnia, and both respiratory and metabolic acidosis; low ApEn was linked to decreased power spectrum density in all frequency domains. The ApEn values may be used as a predictor of fetal distress in women at term pregnancy.

Postnatal intermittent hypoxia alters baroreflex function in adult rats

Chronic perinatal intermittent hypoxia (IH) could have long-term cardiovascular effects by altering baroreflex function. To examine this hypothesis, we exposed rats (n = 6/group) for postnatal days 1-30 or prenatal embryonic days 5-21 to IH (8% ambient O2 for 90 s after 90 s of 21% of O2, 12 h/day) or to normoxia (control). Baroreflex sensitivity (BRS) and cardiac chronotropic responses were examined in anesthetized animals 3.5-5 mo later by infusing phenylephrine or sodium nitroprusside (6-12 microg/min iv, 1-2 min) during normoxia and after 18 min of acute IH (IHA). In controls after IHA, baroreflex gain was 42% (P < 0.05) less than during normoxia. BRS in the postnatal IH group during normoxia was approximately 50% less than in control rats and similar to controls after IHA. The heart rate response to phenylephrine in the IH group was also less than in controls (P < 0.05) and was not changed by IHA. BRS and heart rate responses in the prenatal IH group were similar to the normoxic control group. Vagal efferent projections to atrial ganglia neurons in rats after postnatal IH (n = 4) were examined by injecting tracer into the left nucleus ambiguous. After 35 days of postnatal IH, basket ending density was reduced by 17% (P < 0.001) and vagal axon varicose contacts by 56% (P < 0.001) compared with controls. We conclude that reduction of vagal efferent projections in cardiac ganglia could be a cause of long-term modifications in baroreflex function.

Short term heart rate variability in healthy neonates: normative data and physiological observations

BACKGROUND

The measurement of heart rate variability (HRV) reveals information on the functional state of the autonomic nervous system (ANS). Moreover, several diseases are known to be accompanied by a reduction in HRV. Currently, there are no data on HRV within larger samples of healthy neonates.

AIM

This study was initiated to establish normative data of HRV parameters and to assess physiological observations in healthy newborn infants.

STUDY DESIGN

We performed 10 min recordings of HRV in 80 healthy neonates. We computed time domain parameters. Furthermore power spectrum analysis was calculated by Fourier Transformation in 3 frequency bands. The total power as well as the peak frequencies was estimated for each band.

RESULTS

The normative data of each HRV parameter for healthy newborns are presented as mean, standard deviation and the 5th and 95th percentiles. Increasing postnatal age is accompanied by a significant (p<0.05) elevation of HRV parameters. Baroreceptor loop fluctuations were delayed from 0.1 Hz (adults) to 0.07 Hz in healthy newborns. A respiratory peak according to respiratory sinus arrhythmia (RSA) as it is common in adults was not detectable.

CONCLUSIONS

Normative data of HRV allows the interpretation of clinical data in neonatal diseases affecting the ANS. Moreover, we observed physiological deviations in healthy newborns in comparison to adults.

Baroreceptor reflex sensitivity in human neonates: the effect of postmenstrual age

We performed a cross-sectional study in human infants to determine if indices of R-R interval variability, systolic blood pressure (SBP) variability, and baroreceptor reflex sensitivity change with postmenstrual age (PMA: gestational age+postnatal age). The electrocardiogram, arterial SBP and respiration were recorded in clinically stable infants (PMA, 28-42 weeks) in the quiet sleep state in the first days after birth. (Cross-)spectral analyses of R-R interval series and SBP series were performed to calculate the power of low-frequency (LF, indicating baroreceptor reflex activity, 0.04-0.15 Hz) and high-frequency (HF, indicating parasympathetic activity, individualized between the p-10 and p-90 values of respiratory frequency) fluctuations, and transfer function phase and gain. The mean R-R interval, and LF and HF spectral powers of R-R interval series increased with PMA. The mean SBP increased with PMA, but not the LF and HF spectral powers of SBP series. In the LF range, cross-spectral analysis showed high coherence values (>0.5) with a consistent negative phase shift between R-R interval and SBP, indicating a approximately 3 s lag in R-R interval changes in relation to SBP. Baroreceptor reflex sensitivity, calculated from LF transfer gain, increased significantly with PMA, from 5 (preterm) to 15 ms mmHg-1 (term). Baroreceptor reflex sensitivity correlated significantly with the (LF and) HF spectral powers of R-R interval series, but not with the LF and HF spectral powers of SBP series. The principal conclusions are that baroreceptor reflex sensitivity and spectral power in R-R interval series increase in parallel with PMA, suggesting a progressive vagal maturation with PMA.

Customized spectral band analysis compared with conventional Fourier analysis of heart rate variability in neonates

A customized filtering technique is introduced and compared with fast Fourier transformation (FFT) for analyzing heart rate variability (HRV) in neonates from short-term recordings. FFT is classically the most commonly used spectral technique to investigate cardiovascular fluctuations. FFT requires stability of the physiological signal within a 300 s time window that is usually analyzed in adults. Preterm infants, however, show characteristics of rapidly fluctuating heart rate and blood pressure due to an immature autonomic regulation, resulting in non-stationarity of these signals. Therefore neonatal studies use (half-overlapping or moving) windows of 64 s length within a recording time of 2-5 min. The proposed filtering technique performs a filtering operation in the frequency range of interest before calculating the spectrum, which allows it to perform an analysis of shorter periods of only 42 s. The frequency bands of interest are 0.04-0.15 Hz (low frequency, LF) and 0.4-1.5 Hz (high frequency, HF). Although conventional FFT analysis as well as the proposed alternative technique result in errors in the estimation of LF power, due to spectral leakage from the very low frequencies, FFT analysis is more sensitive to this effect. The response times show comparable behavior for both the techniques. Applying both the methods to heart rate data obtained from a neonate before and after atropine administration (inducing a wide range of HRV), shows a very significant correlation between the two methods in estimating LF and HF power. We conclude that a customized filtering technique might be beneficial for analyzing HRV in neonates because it reduces the necessary time window for signal stability.

Time domain correlation analysis of heart rate variability in preterm neonates

BACKGROUND AND AIM

A fuller understanding of the neural control mechanisms of heart rate during the early stages of human development would be of great value to obstetric and neonatal management. In this paper, we investigate the correlation between heart rate variability (HRV) and other physiological parameters such as blood pressure and respiration in preterm neonates with the aim of developing a numerical model to explain and predict heart rate variability.

STUDY DESIGN AND SUBJECTS

All the required data are readily available for premature babies who are routinely monitored while being nursed in intensive care, and we have collected large data sets for a random group of such neonates. For the quantitative analysis of the data, we have developed a time domain correlation method, which has a number of advantages over the more commonly used power spectral analysis. We have been able to study the dynamics of the different frequency components of HRV by this method.

RESULTS

Highly correlated behaviour of the different HRV components, previously observed in our work on fetal HRV, is also present in the neonate, with similar characteristic time constants. Furthermore, the correlation of high-frequency (HF) oscillations of HRV with respiration and that of low-frequency (LF) oscillations of HRV with blood pressure are demonstrated on timescales of a single oscillation. In neonates receiving artificial ventilation, the correlation between HRV and respiration depends on the type of ventilation involved and assumes opposite polarities for the two main types of equipment currently in use.

CONCLUSION

We demonstrate that it is possible to analyse HRV quantitatively by calculating the relative gains and characteristic time constants for the correlated parameters and components.

Autonomic Modulation of Sinus and Atrioventricular Nodes in Premature Low-Birth-Weight Infants

Respiratory vagal activity is expressed by heart rate variability (HRV) at approximately 1 month of age in premature low-birth-weight infants (PLBWI). However, the autonomic inputs into the sinus node (SAN) and atrioventricular node (AVN) in PLBWI are unclear. We evaluated the variability in PP and PR intervals at day zero (day 0) and 1 month (1 month) after birth in 16 PLBWI (gestation 32.3 +/- 1.3 weeks, birth weight 1.578 +/- 257 g). The polygraph was recorded during sleep on day 0 and at 1 month. PP and PR intervals and the number of respiratory cycles were measured, and frequency analysis was performed by auto-correlation fast Fourier transforms. Power spectral density (PSD: ms(2)) was calculated for the low frequency domain (LF: 0.036 approximately 0.146 Hz), high frequency domain (HF: 0.146 approximately 0.390 Hz), total frequency (TF: 0.036 approximately 2.000 Hz), and respiratory sinus arrhythmia (RSA: frequency bandwidth of 0.3 Hz with peak respiratory frequency as median), and the PSD ratio in the PP and PR intervals (LF/HF, RSA/TF) were compared. Compared with day 0, a decrease in the LF/HF ratio and an increase in the RSA/TF ratio in PP intervals were observed at 1 month, consistent with expression of respiratory vagal activity. For PR intervals, on the other hand, the LF/HF ratio increased, indicative of accentuated sympathetic activity. However, the respiratory vagal input was weak, and the RSA/TF ratio remained unchanged. These observations suggest that, in PLBWI at 1 month, AVN conduction was not predominatly influenced by respiratory-related vagal activity, but was controlled by autonomic regulation, independent of the SAN.

Cardiovascular autonomic regulation in preterm infants: the effect of atropine

To study cardiovascular autonomic control, we assessed the effect of atropine on heart rate (HR) and blood pressure (BP) variability in 12 preterm infants (range 26-32 wk) before intubation for respiratory insufficiency. Spectral power analysis of R-R interval and systolic BP (SBP) series were estimated in a low-frequency (LF; 0.04-0.15 Hz) and high-frequency (HF; 0.4-1.5 Hz) band and evaluated for a 10-min period before and a 10-min period after atropine sulfate (0.01 mg/kg). Baroreceptor reflex (BR) functioning was estimated using transfer function analysis at LF (coherence, gain, and phase). Atropine resulted in a significant 12% increase in steady-state HR (p < 0.01) and unchanged SBP. For R-R interval series, the total spectral power decreased 6-fold (p < 0.01), which was predominantly due to a reduction in the LF band (16-fold; p < 0.01). In contrast, we observed a significant increase (25%; p < 0.05) in total spectral power of SBP series partly as a result of an increase in HF power. The LF power of SBP series was not altered. The median LF transfer gain (BR sensitivity) between SBP and R-R interval decreased from 4.2 to 1.4 ms/mm Hg (p < 0.01) after atropine. The LF phase relationship (BP leads R-R interval fluctuations by approximately 4 s) was not changed after atropine. In conclusion, even in preterm infants in distress, atropine modulates HR and BP variability, suggesting that BR-mediated parasympathetic control of heart rate is of significance for cardiovascular control at that age.

Fetal heart rate variability and brain stem injury after asphyxia in preterm fetal sheep

This study was undertaken to determine the mechanisms mediating changes in fetal heart rate variability (FHRV) during and after exposure to asphyxia in the premature fetus. Preterm fetal sheep at 0.6 of gestation (91 ± 1 days, term is 147 days) were exposed to either sham occlusion ( n = 10) or to complete umbilical cord occlusion for either 20 ( n = 7) or 30 min ( n = 10). Cord occlusion led to a transient increase in FHRV with abrupt body movements that resolved after 5 min. In the 30 min group there was a marked increase in FHRV in the final 10 min of occlusion related to abnormal atrial activity. After reperfusion, FHRV in both study groups was initially suppressed and progressively increased to baseline levels over the first 4 h of recovery. In the 20 min group this improvement was associated with return of normal EEG activity and movements. In contrast, in the 30 min group the EEG was abnormal with epileptiform activity superimposed on a suppressed background, which was associated with abnormal fetal movements. As the epileptiform activity resolved, FHRV fell and became suppressed for the remainder of the study. Histological assessment after 72 h demonstrated severe brain stem injury in the 30 min group but not in the 20 min group. In conclusion, during early recovery from asphyxia, epileptiform activity and associated abnormal fetal movements related to evolving neural injury can cause a confounding transient increase in FHRV, which mimics the normal pattern of recovery. However, chronic suppression of FHRV was a strong predictor of severe brain stem injury.

Heart rate variability in response to the sleep-related movements in infants with and without colic

The activity of the autonomic nervous system depends on sleep stage. The imbalance of the autonomic nervous system together with over-reactivity to stimuli has been suggested to be an etiologic factor for infantile colic. This study was designed to estimate the reactivity of the autonomic nervous system to a sleep-time stimulus in non-rapid eye movement (NREM) and rapid eye movement (REM) sleep stages and in colic and control infants. Overnight sleep polygraphic recordings were performed for 12 colic and 14 control infants at the age of 8 weeks. Movements were detected by a static-charge-sensitive bed. Extent of heart rate variability (HRV) was measured in response to spontaneous sleep-related movements. HRV analysis was performed over 2-min segments during NREM and REM sleep before and after 5-36-s long movement periods. Total (0.04-1.0 Hz), low (0.04-0.15 Hz) and high frequency (0.15-1.0 Hz) HRV increased after the movement periods in light NREM sleep (p < 0.001). These changes were not observed in REM sleep. No differences were found between the colic and the control groups in HRV. The observed difference in the response of the HRV between sleep stages is likely to reflect the different characteristics of heart rate control in NREM and REM sleep, but our results do not suggest that colic infants would have abnormal autonomic reactivity to stimuli while asleep.

Heart rate variability as an indicator of outcome in congenital diaphragmatic hernia with and without ECMO support

OBJECTIVE

To examine differences in the spectral power content in neonates diagnosed with congenital diaphragmatic hernia (CDH) who survive or succumb.

STUDY DESIGN

A case-series study design evaluated four neonates diagnosed with CDH, two of which were supported by extracorporeal membrane oxygenation (ECMO). The electrocardiogram signal was digitized at 1000 Hz and the Lomb periodogram was computed for the series of interbeat intervals.

RESULTS

Neonates with CDH who survived had log total power values greater than 2. Those with CDH who did not survive had log total power less than 2, but generally exceeded 3 while they were supported by ECMO.

CONCLUSIONS

Neonates who consistently displayed increasing total spectral energies had a better outcome than those whose spectral energies were low. Subjects who succumbed expressed the lowest values, suggesting that a frequency-based evaluation of HRV may be a sensitive prognosticator of outcome that requires further investigation.

Spectral Analysis of Heart Rate Variability: An Emerging Tool for Assessing Stability During Transition to Extrauterine Life

Transition from fetal to neonatal life is likely the most physiologically demanding time of life. Complex changes in major organ system functioning and reorganization of metabolic processes must occur rapidly to achieve postnatal homeostasis. Identifying the neonate with subtle signs of unsuccessful transition is a challenge to the perinatal health care provider. Alterations in fetal or neonatal heart rate and heart rate variability may serve as an indicator of the neural control influencing cardiac function and a sensitive indicator of compromised health. Evaluation of the neural control of the heart can be done noninvasively and provides a discriminating measure of the level of stress vulnerability the fetus or newborn may be experiencing. This article reviews the origins of physiological variability of the fetal and neonatal heart rate in the transition to extrauterine life. The technique of spectral analysis as a new tool for surveillance of the at-risk fetus and neonate is then introduced, and implications for clinical practice and future research avenues are discussed.

An evidence-based guideline for introducing oral feeding to healthy preterm infants

The ability of a preterm infant to make the transition from gavage to oral nipple feeding depends on the infant's neurodevelopment in relation to behavioral organization, to a rhythmic suck-swallow-breathe pattern, and to cardiorespiratory regulation. Research-based knowledge about infant neurodevelopment in these three areas has led to the creation of a semidemand feeding method to aid in this transition. The method combines the use of nonnutritive sucking to promote awake behavior for feeding, use of behavioral assessment to identify readiness for feeding, and systematic observation of and response to infant behavior cues to regulate frequency, length, and volume of oral feedings. Semidemand feeding may be individualized for healthy preterm infants. This article discusses both the relevant knowledge about neurodevelopment and the semidemand feeding method itself.

Heart Period Variability of Intubated Very-Low-Birth-Weight Infants During Incubator Care and Maternal Holding

• Background Heart rate has been used to measure infants’ physiological stability during skin-to-skin holding. Variability in heart period (interbeat interval), a more sensitive measure of autonomic nervous system tone, has not.

• Objective To describe heart period variability in intubated very-low-birth-weight infants during incubator care and during maternal skin-to-skin holding.

• Design/Methods An experimental, interrupted time series, crossover design was used; infants served as their own controls. Infants were randomly assigned to treatment order: 2 hours of intermittent skin-to-skin holding for 2 consecutive days followed by 2 days of incubator care or vice versa. The analog signal representing heart period was sampled and quantized at 5 Hz via a dedicated computer system in multiple 300-second epochs each day.

• Results Fourteen infants with similar characteristics completed the protocol. The mean interbeat interval was 332 ms during skin-to-skin care and 368 ms during incubator care. Power within the low-and high-frequency regions of heart period was not significantly different between skin-to-skin holding and incubator care. Mean low-frequency power was 124.6 ms2 during skin-to-skin holding and ranged from 51.9 ms2 to 71.4 ms2 during all periods of incubator care. Mean high-frequency power was similar during skin-to-skin holding and incubator care (8.8 ms2 and 6.1 ms2). Infants of 32 to 34 weeks’ corrected gestational age had increased power in the low- and high-frequency regions.

• Conclusions Heart period variability did not improve during skin-to-skin holding. Gestationally older infants had increased power in the low- and high-frequency regions, suggesting a maturing autonomic nervous system.

Cardiovascular fluctuations and transfer function analysis in stable preterm infants

To examine the baroreceptor reflex function, a beat-to-beat analysis between systolic blood pressure (SBP) and R-R interval fluctuations was studied in 10 stable appropriate-for-gestational age preterm infants (range, 27.2-33.7 wk) in the first postnatal week during quiet sleep. Spectral power analysis, using fast Fourier transform, and transfer functions (gain and phase difference) between SBP and R-R fluctuations were estimated in a low-frequency band (LF, 0.03-0.2 Hz) and high-frequency band (HF defined as the frequency band between the 10th and 90th centiles of the individual respiratory frequency). The LF/HF ratio reflects the sympathovagal balance. The mean frequency (+/-SD) of LF peaks was centered at 0.07 +/- 0.02 Hz. The mean frequency (+/-SD) of the individual HF band was 0.82 +/- 0.21 Hz. The LF/HF ratio in the R-R interval series [median, 29; interquartile range (IQR), 16-40] was higher than in the SBP series (median, 8; IQR, 4-14). The gain between R-R interval and SBP fluctuations (median, 4.2 ms/mm Hg; IQR, 2.4-5.0) in the LF band was higher than in the HF band (median, 1.7 ms/mm Hg; IQR, 1.4-3.0). SBP fluctuations lead R-R interval fluctuations in the LF band with a median phase difference of +96 degrees (IQR, 67-132). At LF the fluctuations in SBP precede changes in R-R interval with a time delay of 3.8 s. These observations indicate a dominant role of the sympathetic system in stable preterm infants in comparison with published adult values. Cross-spectral analysis allows a test for tracking the development of the sympathetic system in neonates.

Methodological considerations for the use of heart rate variability as a measure of pain reactivity in vulnerable infants

Measures of HR and HRV offer multiple indices of reactivity to painful events. These measures are particularly helpful in preterm and ill infants where distress signals are often nonspecific and ambiguous. HR is easy to acquire, and a variety of widely used techniques are available for processing it. In general, the neuroanatomic and neurophysiologic bases for pain perception are in place even in the most preterm infant and produce patterns of HR and HRV responses that are similar across multiple settings. Developmental and experiential factors related to preterm birth, however, may affect these HR responses. Furthermore, evaluation of ill infants in an NICU setting adds multiple contextual factors that potentially influence HR and HRV and alter their specificity as measures of pain. In some cases, it may appear that pain reactivity is reduced when, in fact, HR reactivity is only an expression of the biologic capacity to produce a response, not the presence of a response itself. The nature of the setting and the infant's health, developmental stage, and behavioral state all contribute to potentially altering HR responses to painful events in this setting. Thus, the methodology used and its application must be flexible. A variety of HRV analysis techniques may be needed to identify a variety of response patterns and mechanisms that influence pain reactivity. Furthermore, careful selection of HR epochs for stationarity, an understanding of the potential discordance between biologic and behavioral measures, the effects of medication, and an accounting for developmental differences that occur during a typical NICU course are all critical factors for investigators to be aware of. Understanding cardiovascular reactivity as a measure of response to painful events in vulnerable infants requires ongoing work.

Development of baroreflex control of heart rate in preterm and full term infants

AIM

To study baroreflex maturation by measuring, longitudinally, baroreflex sensitivity in preterm (gestational age 24-37 weeks) and full term infants.

METHODS

Baroreflex sensitivity was quantified once a week, one to seven times, by a totally non-invasive method.

RESULTS

Baroreflex sensitivity at birth was lower in the preterm infant and increased with gestational age. It also increased with postnatal age, but the values for the preterm infants at term still tended to be lower than the values for full term babies.

CONCLUSION

Baroreflex control of heart rate is present in the premature infant, but is underdeveloped and increases with postnatal age. Ex utero maturation seems to be delayed compared with in utero maturation assessed by full term values. These results may reflect sympathovagal imbalance in preterm infants and could identify a population more vulnerable to stress.

Assessment of autonomic cardiovascular changes associated with recovery from anaesthesia in children: a study using spectral analysis of blood pressure and heart rate variability

Recovery from anaesthesia is associated with large changes in cardiovascular autonomic activity, which are poorly documented in children. This study was undertaken to investigate the cardiovascular autonomic activity in anaesthetized and recovering children, using a noninvasive approach based on spectral analysis of heart rate (HR) and blood pressure (BP) variability. Ten children (aged 5-13 years) undergoing major surgery were studied. Continuous HR and BP were recorded using a noninvasive device during deep anaesthesia and recovery. Spectral analysis was used to determine the main oscillatory components of HR and BP signals. For each power spectrum, the frequency components were identified as follows (i): the low frequency (LF) component (0.04-0.14 Hz) both parasympathetically and sympathetically mediated for HR and corresponding to vasomotor sympathetic modulation for BP; and (ii) the high frequency (HF) component (0.2-0.6 Hz) parasympathetically mediated for HR, and reflecting mechanical influence of ventilation on cardiac output for BP. In addition, the LF : HF ratio for HR, reflecting the cardiac sympathovagal balance, was calculated. Under deep anaesthesia, HR variability and BP variability were very low and mainly due to mechanical influence of intermittent positive pressure ventilation. Conversely, the recovery period was associated with a marked increase of HR and BP overall variability. Compared to anaesthesia, spectral analysis of HR and BP revealed that the LF component of BP and HR spectra increased 40-fold during recovery; the LF : HF ratio of HR was also increased during recovery (0.1 +/- 0.1 versus 1.3 +/- 1.2, P=0.008). The results of this study demonstrate that the recovery period is associated with an increase of cardiovascular sympathetic drive in children after major surgery.

Spectral analysis of heart rate variability in premature infants with feeding bradycardia

An elevated level of baseline parasympathetic activity was noted in a group of premature infants suffering from bradycardia during feeding. At approximately 34 wk post-conceptional age, the heart rates of 12 infants with feeding bradycardia (birth weight = 1539 +/- 279 g; gestational age = 31.0 +/- 1.6 wk) and 10 controls (birth weight = 1710 +/- 304 g; gestational age = 32.0 +/- 1.4 wk) were recorded 1 h before and 1 h after feeding. EKG data were digitized and 3.2-min segments of data were analyzed to determine the spectral power at very low (VLF = 0.003-0.03 Hz), low (LF = 0.03-0.39 Hz), and high (HF = 0.40-1.00 Hz) frequencies. In preterm infants with feeding bradycardia, an elevation in baseline parasympathetic activity was evident before feeding, as indicated by significantly higher HF power and a lower LF/HF ratio. This elevation in baseline parasympathetic activity may contribute to the observed bradycardia during feeding.

Measurement of baroreceptor-mediated effects on heart rate variability in fetal sheep

To determine if alterations in arterial pressure influenced fetal heart rate variability (HRV), experiments were carried out in chronically catheterized fetal sheep aged 128-138 d. Arterial pressure was raised or lowered by intravenous infusion of phenylephrine or sodium nitroprusside, and the effects on heart rate (HR) and HRV were measured (HRV, as the coefficient of variation (CV) in mean pulse interval or by power spectral analysis). Experiments were carried out before and during beta-adrenoceptor blockade with propranolol or before and during cardiac vagal blockade with atropine. There were positive relationships between mean arterial pressure and HRV (slope = 0.074+/-0.001, r = 0.81+/-0.06, p<0.001, measured as the CV of pulse interval) and between mean arterial pressure and power spectral density (slope = 4+/-0.5, r = 0.89+/-0.02, p<0.001) in the frequency range 0.04-0.08 Hz. Beta-adrenoceptor blockade had no effect on these relationships, but they were abolished by cardiac vagal blockade. The sigmoid relationship between fetal HR and mean arterial pressure, i.e. the cardiac baroreflex, was affected, however, by blockade of cardiac sympathetics and abolished by blockade of cardiac vagal activity. Thus, fetal HRV was affected by alterations in arterial pressure, and these effects depended on the integrity of the cardiac vagus, not on alterations in cardiac sympathetic activity. Therefore, although baroreflex control of fetal HR depends on the integrity of both sympathetic and parasympathetic efferent pathways, baroreceptor-induced changes in HRV depend only on the cardiac vagus.

Effects of sleep stage and age on short-term heart rate variability during sleep in healthy infants and children

STUDY DESIGN

Power spectrum analysis of heart rate variability (HRV) is a noninvasive technique that provides a quantitative assessment of cardiovascular neural control. Using this technique, we studied the autonomic nervous system changes induced by sleep in 14 healthy subjects: 7 infants (mean age, 9.40 +/- 2.32 months) and 7 children (mean age, 8.93 +/- 0.65 years) during a standard all-night polysomnographic recording. Our primary aim was to assess the effect of sleep stage and age on short-term HRV during sleep in healthy infants and children. Power spectral density was estimated by autoregressive modeling over 250 consecutive R-R intervals. In this study, we mainly considered two spectral components: the high-frequency (HF) component (0.15 to 0.40 Hz), which reflects parasympathetic cardiovascular modulation; and the low-frequency (LF) component (0.04 to 0.15 Hz), generally considered due to both parasympathetic and sympathetic modulation.

RESULTS

Heart rate was higher (p < 0.01 in all sleep stages) and total power lower (p < 0. 02) in infants than in children. HF power was higher in children than in infants (p < 0.05). In infants and children, the ratio between LF and HF powers changed with the various sleep stages (p < 0.02 in infants; p < 0.01 in children): it decreased during deep sleep and increased during rapid eye movement sleep. However, it was invariably lower in children than in infants.

CONCLUSION

These findings show that the sleep stage and age both significantly influence short-term HRV during sleep in healthy infants and children. Hence, to provide unbiased results, HRV studies investigating the effects of age on autonomic nervous system activity should segment sleep into the five stages. In addition, despite a relatively small study sample, our data confirm greater parasympathetic control during sleep in children than in infants.

Low frequency spontaneous fluctuations in tissue blood volume in neonates

Low frequency spontaneous fluctuations in tissue blood volume (BV) which originate from the activity of the autonomic nervous system were studied in the toes of healthy adults and in the feet of preterm and full-term neonates. Fluctuations of cardiac-induced blood volume changes (AM) were also investigated using photoplethysmography, the measurement of changes in light absorption by tissue and its constituents. Both fluctuations showed right-left correlations, which indicates mediation of central origin. The average right-left correlation coefficient for adults was significantly higher than that for neonates, probably due to incomplete maturation of the autonomic nervous system for some of the neonates.

Procedural pain in newborn infants: the influence of intensity and development

OBJECTIVE

Previous reports have shown that pain is managed inadequately in newborn infants. Ironically, clinicians believe that infants can experience pain much like adults, that infants are exposed daily to painful procedures, and that pain protection should be provided. In adults, a close relationship has been shown in how adults behave in response to pain, how painful they sense the stimulus to be, and physical measurements of the intensity of the stimulus. Whether similar parallels exist in newborn infants has not been examined. If these parallels do not exist in infants, it may help explain why clinicians fail to manage procedural pain in infants more effectively. The objective of this study was to determine whether the magnitude of infants' responses to nursing/medical procedures: 1) differs as a function of the invasiveness or intensity of the procedure; 2) differs as a function of intrauterine (gestational age at birth) and/or extrauterine (conceptional age) development; and 3) parallels the subjective pain ratings of clinicians for those procedures.

METHODS

A broad developmental and clinical range of newborn infants was studied shortly before (baseline and preparatory periods), throughout, and shortly after (recovery period) required nursing/medical procedures during hospitalization. Heart rate, oxygen saturation, mean arterial pressure, and behavioral state (percentage of time spent in sleep or in agitation) were measured, and the magnitude of change in each in response to procedures was calculated. Procedures were categorized as mildly, moderately, and highly invasive to examine differences in response magnitude as a function of procedural invasiveness. Responses were compared as a function of prematurity and postnatal age. Clinicians' procedural pain ratings were compared with the magnitude of infants' responses.

RESULTS

Of the original 152 infants, 135 were studied at least two times (range 2-27). Significant changes occurred in physiologic and behavioral measures in response to procedures indicative of pain responses. The magnitude of response generally increased with increased procedural invasiveness although there was considerable overlap of magnitude with invasiveness. Both premature and full-term infants differentiated procedural invasiveness. Very premature infants (<28 weeks' gestational age) exhibited increased increments in response magnitude with increasing postnatal age. Clinician's ratings of procedural painfulness were correlated with and predicted the magnitude of heart rate response to individual procedures.

CONCLUSIONS

Similar to what has been shown in adults, newborn and developing infants show increased magnitude physiologic and behavioral responses to increasingly invasive procedures, demonstrating that even very prematurely born infants respond to pain and differentiate stimulus intensity. However, the considerable overlap of magnitude with invasiveness suggests that there is not a physiologic or behavioral threshold that clearly marks the presence of pain. Inconsistencies in physiologic and behavioral responses make reliance on a pain index difficult. The best approach may be one of universal precaution to provide pain management systematically to reduce the acute and long-term impact of early procedural pain. development, stimulus intensity, pain response.

Heart rate variability of preterm neonates quantified by energy entropy

Identifying variables predictive of neurobehavioural sequelae is a key objective in the study of high-risk neonates. Examination of heart rate variability (HRV) characteristics may be a finer discriminator of the neonate's response to physiologic stressors than the mean heart rate. The energy entropy of the heart beat tachogram, computed in four different domains, was used to quantify the HRV in 13 preterm neonates. The entropies of energies were computed from 1024 interbeat time intervals obtained once per week from 26 to 35 weeks postconceptional age (PCA). The energy entropy computed in three of the domains, like the standard deviation of intervals, distinguished between the 10 neonates that were measured at 35 weeks PCA with 100% specificity and 67% sensitivity, but did not distinguish between healthy and unhealthy neonates at earlier ages. The findings suggest that energy entropy may be a discerning measure of physiologic stress in the preterm infant, although future research is needed to refine the test and determine statistical significance.

The developmental character of cardiac autonomic responses to an acute noxious event in 4- and 8-month-old healthy infants

Heart rate (HR) has been widely studied as a measure of an individual's response to painful stimuli. It remains unclear whether changes in mean HR or the variability of HR are specifically related to the noxious stimulus (i.e. pain). Neither is it well understood how such changes reflect underlying neurologic control mechanisms that produce these responses, or how these mechanisms change during the first year of life. To study the changes in cardiac autonomic modulation that occur with acute pain and with age during early infancy, the relationship between respiratory activity and short-term variations of HR (i.e. respiratory sinus arrhythmia) was quantified in a longitudinal study of term born healthy infants who underwent a finger lance blood collection at 4 months of age (n = 24) and again at 8 months of age (n = 20). Quantitative respiratory activity and HR were obtained during baseline, lance, and recovery periods. Time and frequency domain analyses from 2.2-min epochs of data yielded mean values, spectral measures of low (0.04-0.15 Hz) and high (0.15-0.80 Hz) frequency power (LF and HF), and the LF/HF ratio. To determine sympathetic and parasympathetic cardiac activity, the transfer relation between respiration and HR was used. At both 4 and 8 months, mean HR increased significantly with the noxious event (p > 0.01). There were age-related differences in the pattern of LF, HF, and LF/HF ratio changes. Although these parameters all decreased (p > 0.01) at 4 months, LF and LF/HF increased at 8 months and at 8 months HF remained stable in response to the noxious stimulus. Transfer gain changes with the lance demonstrated a change from predominant vagal baseline to a sympathetic condition at both ages. The primary finding of this study is that a response to an acute noxious stimulus appears to produce an increase in respiratory-related sympathetic HR control and a significant decrease in respiratory-related parasympathetic control at both 4 and 8 months. Furthermore, with increasing age, the sympathetic and parasympathetic changes appear to be less intense, but more sustained.

More awakenings and heart rate variability during supine sleep in preterm infants

OBJECTIVE

The Task Force of The American Academy of Pediatrics (1996) recommends the nonprone sleeping position for asymptomatic preterm infants to prevent sudden infant death syndrome. The mechanism by which the nonprone sleeping position reduces the rate of sudden infant death syndrome is unclear for full-term infants and the precise effect of sleeping position on sleep and cardiorespiratory characteristics has never been addressed in preterm infants. The purpose of the present study was to clarify the effect of sleeping position on sleep and cardiorespiratory characteristics in preterm infants at an age when they are ready for discharge.

STUDY DESIGN

Sixteen asymptomatic preterm infants were studied in both supine and prone sleeping positions at 36.5 +/- 0.6 weeks' postconceptional age using videosomnography. Sleep, respiratory, and heart rate characteristics were compared between the two positions using each infant as his/her own control.

RESULTS

More awakenings (ie, arousals >/=60 seconds) were seen during all sleep states in the supine sleeping position but overall the total sleep and percent sleep state were not affected by sleeping position. After each feeding, the first quiet sleep was significantly shorter, with more heart rate variability and awakenings in the supine position. There were no significant differences in the occurrence of arousals (<60 seconds) or the incidence or severity of apnea and periodic breathing. No clinically significant apnea (>/=15 seconds), bradycardia, or oxygen desaturations were seen.

CONCLUSION

In 36-week-postconceptional age preterm infants, the supine sleeping position had less quiet sleep and was associated with greater heart rate variability during the first sleep cycle after the feeding. More awakenings were seen during all sleep states in the supine position. These data support the American Academy of Pediatrics recommendation for "Back to Sleep" for asymptomatic preterm infants because more awakenings and lower threshold for arousal may provide some benefit for the infant responding to a life-threatening event. However, further studies are needed to address positional effect on the physiologic measures in preterm infants at older ages (later stages of development). Precisely what constitutes the most healthy or advantageous sleep for newborn infants remains an important question.

Development of baroreflex influences on heart rate variability in preterm infants

To investigate developmental changes in autonomic cardiovascular reflexes in preterm infants, we used autoregressive power spectral analysis to analyze the effect of upright tilting on heart rate variability in preterm infants. Twenty-eight infants were studied in a longitudinal fashion beginning at 28-32 weeks postconceptional age (postnatal age 1-5 weeks). Each week, heart rate variability in the supine position and after 45 degrees head-up tilt was analyzed by spectral analysis. With the initial study of each infant, there was no significant change in heart rate following head-up tilt compared with baseline (-0.5+/-0.9 bpm). However, linear regression analysis revealed that with increasing postnatal age, the change in heart rate in response to tilting became more positive (mean slope of regressions 0.45+/-0.12 bpm/week, P<0.005). The power spectral density of R-R interval variability in the low-(LF; 0.02-0.15 Hz) and high-(HF; 0.15-1.5 Hz) frequency ranges were obtained and the values normalized by dividing each component by the total power. For measurements obtained in the supine position, the LF/HF ratio progressively decreased with increasing postnatal age, indicating a maturational change in sympathovagal balance. We used the difference in the LF/HF ratio between tilt and the recumbent position as a measure of the change in autonomic input to the heart in response to unloading of the arterial baroreceptors. No significant change in these ratios were observed when infants were first studied between 28 and 32 weeks postconceptional age, suggesting that the cardiac baroreflex is poorly developed at this stage of development. However, with postnatal maturation, the LF component of the power spectrum became progressively larger with tilt relative to the basal state, such that the difference between LF/HF(tilt) and LF/HF(base) became progressively more positive (P <0.006). These findings suggest that in premature infants, cardiac baroreceptor reflexes become more functional with postnatal development.

The effect of thermal stimulation on the heart-rate variability in neonates

Thermoregulation in humans can be divided into three broad mechanisms of control, namely: shivering, sweating and vasomotor activity. Previous investigations suggested the presence of an autonomic rhythm, originating in the central nervous system, possibly related to thermal vasomotor control and directly affecting heart rate by reflex changes in cardiac sympathetic and parasympathetic activity. The objective of the present work was to study the maturation process of the thermoregulatory system in newborns. We used peripheral thermal entrainment and focused on the reflections of vasomotor control in the heart-rate (HR) power spectrum (PS). The study included three groups of neonates at three different ages: 10 premature infants, 6 full-terms and 7 older infants (4 to 6 months). Thermal stimulation was achieved by placing a hot and cold surface on the subject's right palm alternately at three different rates: replacing the touching surface every 4 s (0.25 Hz), 7 s (0.14 Hz) and 10 s (0.1 Hz). 'Double period' stimulation was defined as the total duration of each period of hot and cold stimulation at the three rates, namely 8 s (0.125 Hz), 14 s (0.07 Hz), 20 s (0.05 Hz). The ECG of every infant was measured and recorded during the various stages of the experiment. The HR power spectrum from 0.02 Hz up to 2.00 Hz was considered, focusing on narrow ranges around the thermal stimulation frequencies. We found that in most subjects, clear peaks arise in the HR PS at the thermal entrainment frequency and its corresponding half frequency ('double period'). In premature infants, the reaction is best in response to the longest (10 s) stimulus (9 out of 10 prematures reacted positively), in group B (full-term infants) the reaction responds best to the 7-s stimulus (6 out of 6 reacted) and in older infants the reaction is slightly better at the 4-s stimulus. Since sympathetic control is slower, this ability to entrain the control system at increasing frequencies, might be related to the gradual maturation of parasympathetic control after birth. The different reaction of the three groups may help to understand the maturation process of the thermoregulation system.

Cross-spectral analysis of cerebral autoregulation dynamics in high risk preterm infants during the perinatal period

In preterm infants intraventricular hemorrhage occurs predominantly within the perinatal period, which may be due to a "lost autoregulation" of cerebral blood flow (CBF). In this study, perinatal autoregulation dynamics were investigated in high risk preterm infants by cross-spectral analysis (CSA), which is a statistical tool in the analysis of time series. In 15 ventilated preterm infants of 25-32 gestational weeks, a total number of 30 records were made between 24 and 96 h of life. Doppler-derived CBF velocity (CBFv), used as a quantitative measure for CBF, and direct mean arterial blood pressure (MABP) were measured continuously for 10 min. The spectral power of low frequency (LF, 0.02-0.2 Hz) oscillations in CBFv and MABP was quantified by spectral analysis. From the results of CSA, a LF phase-shift between the CBFv and MABP LF oscillations was calculated in each record. Within the study group, the LF spectral power of CBFv and MABP was initially low and increased significantly until 96 h of life. The LF phase-shift was about 0 degrees at 24 h and increased significantly to 55 degrees at 96 h of life. The initially low LF spectral power of CBFv and MABP may indicate a perinatal depression of autonomic nervous centers, which are thought to control LF oscillations of vital parameters. In the light of a high pass filter model for autoregulation, the initially low LF phase-shift may indicate an initially impaired autoregulation, which supports the "lost autoregulation" hypothesis.

Autoregressive analysis of cardiac RR intervals in preterm and full-term infants

For the purpose of obtaining information on the maturation process of the autonomic nervous system in pre- and full-term infants, polygraphs were recorded during sleep from a total of 52 appropriate-for-dates infants at a conceptional age of 28-41 weeks. The 104 RR interval time series was calculated by autoregressive (AR) and component analysis. Histograms of damping frequencies obtained were divided into two frequency bands: low frequency fluctuations (LF) of less the 0.1 cycle/beat (c/b) and high frequency fluctuations (HF) of more than 0.15 c/b. Total power and LF power decreased with increases in the conceptional age or postnatal age at a significance level of 0.01, respectively. In addition, the HF amount of bio-informing activity increased (P < 0.001) and the damping time of HF also increased (P < 0.01). From these results, it was speculated that the activity of the sympathetic system decreases with increases in conceptional or postnatal age. It was also speculated that increased regularity and oscillatory duration in HF might be caused by the development of the reciprocal response of respiration to heart rate variation.

Spectral pattern of neonatal cerebral blood flow velocity: comparison with spectra from blood pressure and heart rate

The cerebral blood flow velocity (CBFV) frequency spectra were studied in 106 premature and term newborns (gestational age range. 24-42 wk) and compared with the heart rate (HR) and mean arterial blood pressure (BP) spectra over the 0.005-0.5 Hz range. CBFV, BP, and HR were shown to have similar but not identical spectral patterns. Adjustment of a l/f model to these spectra produced highly significant fittings, but the residuals were not independent. This condition was met only by the CBFV and BP spectra over a limited frequency range (0.005-0.06 Hz). These results provide a characterization of the CBFV spectra for a much larger population of newborns than hitherto available, indicating that under certain conditions CBFV and BP might show the properties of chaotic systems. In infants without major complications, gestational age (GA) did not have a significant influence on the CBFV spectrum, whereas the spectral power to 0.5 Hz of both BP and HR was found to increase with GA. The spectral power increased over the first 24 h of postnatal life for all three variables: only CBFV showed a significant spectral change in the low frequency (LF, 0.02-0.08 Hz) range. A matched group comparison, adjusted for GA and postnatal age, indicated a reduction in CBFV LF power for term infants with birth asphyxia when compared with normal infants, which was not reproduced in the HR spectra.

Nonlinear control of heart rate variability in human infants

Nonlinear analyses of infant heart rhythms reveal a marked rise in the complexity of the electrocardiogram with maturation. We find that normal mature infants (gestation greater than or equal to 35 weeks) have complex and distinctly nonlinear heart rhythms (consistent with recent reports for healthy adults) but that such nonlinearity is lacking in preterm infants (gestation > or = to 27 weeks) where parasympathetic-sympathetic interaction and function are presumed to be less well developed. Our study further shows that infants with clinical brain death and those treated with atropine exhibit a similar lack of nonlinear feedback control. These three lines of evidence support the hypothesis championed by Goldberger et al. [Goldberger, A.L., Rigney, D.R. & West, B.J. (1990) Sci. Am. 262, 43-49] that autonomic nervous system control underlies the nonlinearity and possible chaos of normal heart rhythms. This report demonstrates the acquisition of nonlinear heart rate dynamics and possible chaos in developing human infants and its loss in brain death and with the administration of atropine. It parallels earlier work documenting changes in the variability of heart rhythms in each of these cases and suggests that nonlinearity may provide additional power in characterizing physiological states.