Emergence of physiological rhythmicity in term and preterm neonates in a neonatal intensive care unit
© ara et al. 2006
Received: 17 May 2006
Accepted: 11 September 2006
Published: 11 September 2006
Biological rhythmicity, particularly circadian rhythmicity, is considered to be a key mechanism in the maintenance of physiological function. Very little is known, however, about biological rhythmicity pattern in preterm and term neonates in neonatal intensive care units (NICU). In this study, we investigated whether term and preterm neonates admitted to NICU exhibit biological rhythmicity during the neonatal period.
Twenty-four-hour continuous recording of four physiological variables (heart rate: HR recorded by electrocardiogram; pulse rate: PR recorded by pulse oxymetry; respiratory rate: RR; and oxygen saturation of pulse oxymetry: SpO2) was conducted on 187 neonates in NICU during 0–21 days of postnatal age (PNA). Rhythmicity was analyzed by spectral analysis (SPSS procedure Spectra). The Fisher test was performed to test the statistical significance of the cycles. The cycle with the largest peak of the periodogram intensities was determined as dominant cycle and confirmed by Fourier analysis. The amplitudes and amplitude indexes for each dominant cycle were calculated.
Circadian cycles were observed among 23.8% neonates in HR, 20% in PR, 27.8% in RR and 16% in SpO2 in 0–3 days of PNA. Percentages of circadian cycles were the highest (40%) at <28 wks of gestational age (GA), decreasing with GA, and the lowest (14.3%) at >= 37 wks GA within 3 days of PNA in PR and were decreased in the later PNA. An increase of the amplitude with GA was observed in PR, and significant group differences were present in all periods. Amplitudes and amplitude indexes were positively correlated with postconceptional age (PCA) in PR (p < 0.001). Among clinical parameters, oxygen administration showed significant association (p < 0.05) with circadian rhythms of PR in the first 3 days of life.
Whereas circadian rhythmicity in neonates may result from maternal influence, the increase of amplitude indexes in PR with PCA may be related to physiological maturity. Further studies are needed to elucidate the effect of oxygenation on physiological rhythmicity in neonates.
Preterm neonates hospitalized in a neonatal intensive care unit (NICU) face many challenges to adapt to the new environment. Heat loss , weight loss , respiratory distress and cardiac instability  are very common features for them. An artificial environment in NICU is mandatory to support these neonates; however, external influences such as constant light, noise, and medical intervention may be stressful. Further, neonates are deprived of maternal influences, which is essential for their development. It has been thought that this environmental condition may influence the development of biological rhythm in preterm neonates [4–6].
Circadian rhythms are generated endogenously by a biological clock, which is located in the anterior hypothalamic suprachiasmatic nuclei (SCN) [7, 8], and are modulated by exogenous factors [9, 10]. Many physiological processes are now known to be cyclically organized . They show different cycles: circadian cycles last approximately 24 hours, ultradian cycles shorter than 24 hours, and infradian cycles longer than 24 hours . These rhythms interact mutually as well as with the outside fluctuating environment under the control of feedback systems providing an orderly function that enables life .
Circadian rhythms have been described in the human fetus [13–16] and have been attributed either to the maternal environment or to the maturation of the fetal nervous system [13, 17, 18]. The SCN has been detected as early as 18–20 weeks of gestational age , and primate studies indicated that the SCN is responsive to light at 24 weeks of gestational age . In term neonates, circadian rhythms have been reported to be present immediately after birth but to eventually disappear [4, 21], not being detected again until 3 to 4 weeks of postnatal life . Some studies showed that circadian rhythms are predominant in preterm neonates [4, 21, 23], while others showed ultradian rhythms to be dominant in preterm neonates [22, 24–27]. To elucidate the developmental process of physiological rhythmicities, we studied four physiological variables in preterm and term neonates.
Subjects and data collection
From January 2004 to March 2006, 520 neonates were admitted to the NICU at Miechuo Medical Center. All of them were monitored with electrocardiogram (ECG) for heart rate (HR), respiration rate (RR), and with pulse oxymetry on the wrist or the feet for saturation of pulse oxymetry oxygen (SpO2) and pulse rate (PR) throughout their stay in the NICU. Monitored physiological information was transformed as measurement variables at 10-second intervals by the Wave Achieving System (WAS-J; Philips Electronics Japan, Tokyo, Japan) through the local area network in the NICU. The data were recorded for 24 hours for the following postnatal periods: Period 1: days 0–3; Period 2: days 4–6; Period 3: days 7–13; and Period 4: days 14–21. Subjects with continuously disrupted data for more than 1 minute were excluded from the study. A total of 187 neonates (114 boys and 73 girls) were recorded from period 1 to period 4.
The NICU was maintained under a light-dark cycle. The light was dimmed (less than 30 lux) during the night from 21:00 pm to 07:00 am, while it was maintained at a higher level (300–580 lux) during the daytime. NICU staff also varied according to time of day: the number of attendants at night was one third that of attendants during daytime hours. Parent's visitations were allowed three times a day (11:00 to 12:00 in the morning, 14:00 to 15:00 in the afternoon, and 17:00 to 21:00 in the evening). Bathing and measurement of body weight were conducted daily in the morning. Medical examinations, such as blood sampling, radiography, or ultrasonography, were mostly provided in the morning if necessary.
Written informed consent was obtained from the parents, and the study was approved by the ethical committee of the institute. Demographics and health status information's were obtained from the medical records.
Analysis of rhythms
Amplitude index = amplitude ÷ mean of variables × 100.
Data were analyzed with SPSS and Statview. ANOVA was used to evaluate the differences between gestational age groups. The Pearson correlation coefficient was used to analyze the relationships between postconceptional age (PCA) and rhythmicity parameters. Univariate analysis using Mann-Whitney U-test for continuous variables or Fisher's exact test for categorical variables was used to compare clinical variables according to the development of physiological rhythmicity. A multiple logistic regression analysis was performed using a step-wise approach to determine the independent relationship of significant variables found in the univariate analysis.
Demographic characteristics of 187 preterm and term neonates.
114 (61)/73 (39)
Gestational age (wks), median (range)
Birth Weight (g), median (range)
Apgar score 1 min/5 min, median (range)
8 (0–10)/9 (2–10)
Age at hospitalization (day), median (range)
Hospitalization (day), median (range)
Intrauterine growth retardation
Respiratory distress syndrome
Transient tachypnea of the newborn
Descriptive profiles for significant cycles of HR, PR, RR and SpO2.
Without correction for multiple testing, circadian cycle (1440 minutes) was observed among 23.8% neonates in HR, 20% in PR, 27.8% in RR and 16% in SpO2 in Period 1. Because many samples were excluded from HR analysis, and the percentage of eligible samples was consistently lower than for PR, further analysis of cardiac rhythmicity used PR instead of HR.
Rhythmicity and gestational age
Distribution of circadian cycles according to gestational age groups in each period.
< 28 wks
< 28 wks
Relationship between rhythmicity and postconceptional age
Clinical conditions associated with rhythmicity
Univariate analysis for association of clinical parameters with existence of circadian rhythmicities in PR in Period 1.
Cycle 1440 (n = 20)
≤ 720 (n = 80)
Gestational age (wks)
32.7 ± 4.9
34.2 ± 4.6
Birth weight (g)
1930 ± 983
2077 ± 900
Apgar Score < 6 (5 min)
Mean of variables
Mean PR (/min)
140.2 ± 8.6
135.5 ± 12.8
Mean RR (/min)
45.7 ± 8.5
43.0 ± 8.5
Mean SpO2 (%)
97.9 ± 1.1
97.9 ± 1.3
Treatment of data sampling
Rhythmicity has been previously studied in preterm and term infants for various physiological variables, such as body temperature [24, 30], blood pressure , heart rate , sleep-wake pattern , rest-activity pattern , melatonin secretion , and electroencephalogram . In this study, we have investigated rhythmicity in PR, RR, and SpO2. All of these are important parameters in the regulation of human physiology, and yet little is known about rhythmicity of these variables in neonates. We have shown that most of the analyzed neonates had individual rhythmicity for these parameters with variable cycles after birth, even in extremely immature infants.
Emergence of circadian rhythmicity has been reported to be associated with brain maturation of preterm infants [33, 34]. In term neonates, circadian cycles are detected immediately after birth and subsequently disappear and are not detectable until 3 to 4 weeks of postnatal life . It has been suggested that circadian cycles in the early neonatal period are due to maternal influence in utero and that endogenous rhythmicity appears only later [13, 17, 18]. However, conclusive studies are limited by subject number because of the difficulty in collecting continuous data in NICU. Our sample size of 187 neonates is larger than that of previous studies. As a result, circadian cycles were confirmed in early neonatal period for all parameters either in preterm or term neonates. In PR, comparatively higher percentages of circadian cycles were observed during early neonatal period in preterm neonates and persisted through the later neonatal period, especially in extremely immature infants, while percentages of circadian cycles decreased through the later period in term neonates. These results partially support the previous studies [4, 21, 23]. The fact that environmental conditions were rhythmic in our study (i.e., presence of a light-dark cycle, of a cycle of NICU staffing, of a cycle of bathing, etc.) prevents us from making inferences about the endogenous or exogenous nature of biological rhythmicity in our subjects.
Although exact factors for the development of rhythmicity are still unclear, it has been suggested that physiological complications may play a role . Among clinical parameters, disease conditions such as respiratory problems or asphyxia, and therapeutic drugs such as phenobarbital or aminophylline, were not associated with emergence of circadian cycles. Only oxygen administration revealed significant association with emergence of circadian cycles in PR within 3 days of birth. Disruption of circadian rhythmicity by reduction of oxygen supply, and restoration by re-oxygenation, has been demonstrated in rats [36, 37]. Reduced oxygen activates hypoxia-inducible factor 1(HIF-1) , which is involved in oxygen homeostasis. Chilov and colleagues also indicated that oxygen supply modulates the circadian clock at the molecular levels via HIF-1 in the mouse brain . Our observations support these experimental results and suggested that oxygen supply may also influence rhythmicity in humans. Further analyses are required to explore the influencing mechanisms on emergence of rhythmicities in neonates.
Preterm neonates are at great risk of life-threatening events such as infection, respiratory distress or circulatory failure. As shown in this study, co-existence of circadian cycles with low amplitude in preterm neonates may complementarily support immature homeostasis and function against unstable physiological condition. Our results should aid further research on physiological rhythmicity in neonates.
We are grateful to Rebecca M. Warner for her invaluable advice and cooperation.
- Hammarlund K, Stromberg B, Sedin G: Heat loss from the skin of preterm and fullterm newborn infants during the first weeks after birth. Biol Neonate 1986, 50:1–10.View ArticlePubMedGoogle Scholar
- Bauer K, Versmold H: Postnatal weight loss in preterm neonates less than 1,500 g is due to isotonic dehydration of the extracellular volume. Acta Paediatr Scand Suppl 1989, 360:37–42.View ArticlePubMedGoogle Scholar
- Di Fiore JM, Arko MK, Miller MJ, Krauss A, Betkerur A, Zadell A, Kenney SR, Martin RJ: Cardiorespiratory events in preterm infants referred for apnea monitoring studies. Pediatrics 2001, 108:1304–1308.View ArticlePubMedGoogle Scholar
- Mirmiran M, Kok JH: Circadian rhythms in early human development. Early Hum Dev 1991, 26:121–128.View ArticlePubMedGoogle Scholar
- Rivkees SA: Developing circadian rhythmicity in infants. Pediatrics 2003, 112:373–381.View ArticlePubMedGoogle Scholar
- Mirmiran M, Kok JH, Boer K, Wolf H: Perinatal development of human circadian rhythms: role of the foetal biological clock. Neurosci Biobehav Rev 1992, 16:371–378.View ArticlePubMedGoogle Scholar
- Panda S, Hogenesch JB, Kay SA: Circadian rhythms from flies to human. Nature 2002, 417:329–335.View ArticlePubMedGoogle Scholar
- Tousson E, Meissl H: Suprachiasmatic nuclei grafts restore the circadian rhythm in the paraventricular nucleus of the hypothalamus. J Neurosci 2004, 24:2983–2988.View ArticlePubMedGoogle Scholar
- Reppert SM, Weaver DR: Coordination of circadian timing in mammals. Nature 2002, 418:935–941.View ArticlePubMedGoogle Scholar
- Rivkees SA, Mayes L, Jacobs H, Gross I: Rest-activity patterns of premature infants are regulated by cycled lighting. Pediatrics 2004, 113:833–839.View ArticlePubMedGoogle Scholar
- Glass L: Synchronization and rhthmic process in physiology. Nature 2001, 410:277–284.View ArticlePubMedGoogle Scholar
- Lewy H, Naor Z, Ashkenazi IE: From ultradian to infradian rhythms: LH release patterns in vitro. Chronobiol Int 1999, 16:441–450.View ArticlePubMedGoogle Scholar
- Lunshof S, Boer K, Wolf H, van Hoffen G, Bayram N, Mirmiran M: Fetal and maternal diurnal rhythms during the third trimester of normal pregnancy: outcomes of computerized analysis of continuous twenty-four-hour fetal heart rate recordings. Am J Obstet Gynecol 1998, 178:247–254.View ArticlePubMedGoogle Scholar
- Visser GH, Goodman JD, Levine DH, Dawes GS: Diurnal and other cyclic variations in human fetal heart rate near term. Am J Obstet Gynecol 1982, 142:535–544.PubMedGoogle Scholar
- Patrick J: Influence of maternal heart rate and gross fetal movements on the daily pattern of pattern of fetal heart rate near term. Am J Obstet Gynecol 1982, 533–538.Google Scholar
- Patrick J, Campbell K, Carmichael L, Natale R, Richardson B: Patterns of gross fetal body movements over 24-hour observation intervals during the last 10 weeks of pregnancy. Am J Obstet Gynecol 1982, 142:363–371.PubMedGoogle Scholar
- Seron-Ferre M, Ducsay CA, Valenzuela GJ: Circadian rhythms during pregnancy. Endocr Rev 1993, 14:594–609.PubMedGoogle Scholar
- D'Souza SW, Tenreiro S, Minors D, Chiswick ML, Sims DG, Waterhouse J: Skin temperature and heart rate rhythms in infants of extreme prematurity. Arch Dis Child 1992, 67:784–788.View ArticlePubMedGoogle Scholar
- Reppert SM, Weaver DR, Rivkees SA, Stopa EG: Putative melatonin receptors in a human biological clock. Science 1988, 242:78–81.View ArticlePubMedGoogle Scholar
- Hao H, Rivkees SA: The biological clock of very premature primate infants is responsive to light. Proc Natl Acad Sci USA 1999, 96:2426–2429.View ArticlePubMedGoogle Scholar
- Dimitriou G, Greenough A, Kavvadia V, Mantagos S: Blood pressure rhythms during the perinatal period in very immature, extremely low birthweight neonates. Early Hum Dev 1999, 56:49–56.View ArticlePubMedGoogle Scholar
- Ardura J, Andres J, Aldana J, Revilla MA, Aragon MP: Heart rate biorhythm changes during the first three months of life. Biol Neonate 1997, 72:94–101.View ArticlePubMedGoogle Scholar
- Updike PA, Accurso FJ, Jones RH: Physiologic circadian rhythmicity in preterm infants. Nurs Res 1985, 34:160–163.View ArticlePubMedGoogle Scholar
- Bueno C, Diambra L, Menna-Barreto L: Sleep-Wake and Temperature Rhythms in Preterm Babies Maintained in a Neonatal Care Unit. Sleep Research Online 2001,4(3):77–82.Google Scholar
- Schimmel M, Waterhouse J, Marques MD, Weinert D: Circadian and Ultradian Rhythmicities in very premature neonates Maintained in Incubators. Biol Rhythm Res 2002, 33:83–112.View ArticleGoogle Scholar
- Korte J, Wulff K, Oppe C, Siegmund R: Ultradian and circadian activity-rest rhythms of preterm neonates compared to full-term neonates using actigraphic monitoring. Chronobiol Int 2001, 18:697–708.View ArticlePubMedGoogle Scholar
- Weinert D, Sitka U, Minors DS, Waterhouse JM: The development of circadian rhythmicity in neonates. Early Hum Dev 1994, 36:117–126.View ArticlePubMedGoogle Scholar
- Warner RM: Spectral Analysis of Time-series Data The Goldford Press, New York, London 1998.Google Scholar
- Russell RJ: Significance table for the result of fast fourier transformations. British Journal of Mathematical and Statistical Psychology 1985, 38:116–119.Google Scholar
- Thomas KA: The emergence of body temperature biorhythm in preterm infants. Nurs Res 1991, 40:98–102.PubMedGoogle Scholar
- Ardura J, Gutierrez R, Andres J, Agapito T: Emergence and evolution of the circadian rhythm of melatonin in children. Horm Res 2003, 59:66–72.View ArticlePubMedGoogle Scholar
- Wakayama K, Ogawa T, Goto K, Sonoda H: Development of ultradian rhythm of EEG activities in premature babies. early Human Development 1993, 32:11–30.View ArticlePubMedGoogle Scholar
- Mirmiran M, Bernardo L, Jenkins SL, Ma XH, Brenna JT, Nathanielsz PW: Growth, neurobehavioral and circadian rhythm development in newborn baboons. Pediatr Res 2001, 49:673–677.View ArticlePubMedGoogle Scholar
- Mirmiran M, Baldwin RB, Boeddiker M, Ariagno RL: Development of circadian rhythms in premature infants. Sleep Research Online 1999.,2(Supplement 1): Google Scholar
- Thomas KA: Biological rhythm development in preterm infants: does health status influence body temperature circadian rhythm? Res Nurs Health 2001, 24:170–180.View ArticlePubMedGoogle Scholar
- Mortola JP, Seifert EL: Hypoxic depression of circadian rhythms in adult rats. J Appl Physiol 2000, 88:365–368.PubMedGoogle Scholar
- Bishop B, Silva G, Krasney J, Salloum A, Roberts A, Nakano H, Shucard D, Rifkin D, Farkas G: Circadian rhythms of body temperature and activity levels during 63 h of hypoxia in the rat. Am J Physiol Regul Integr Comp Physiol 2000, 279:R1378-R1385.PubMedGoogle Scholar
- Sharp FR, Bernaudin M: HIF1 and oxygen sensing in the brain. Nat Rev Neurosci 2004, 5:437–448.View ArticlePubMedGoogle Scholar
- Chilov D, Hofer T, Bauer C, Wenger RH, Gassmann M: Hypoxia affects expression of circadian genes PER1 and CLOCK in mouse brain. Faseb J 2001, 15:2613–2622.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.