Apnea is a common problem in preterm infants that may be due to prematurity or illness. Apnea can be obstructive, central, or mixed. It is more common in younger preterm infants and during active sleep. Potential causes include respiratory, neurological, infectious, gastrointestinal, and metabolic issues. Treatment involves monitoring, stimulation, oxygen, and medications like caffeine or theophylline. Prognosis depends on associated conditions and apnea typically resolves by 36 weeks.

1. PAEDIATRICS AND CHILD HEALTH
• Paediatrics and Child Health
• Apnea
Dr. Chongo Shapi (Bsc. HB, MBChB)
Medical Doctor
3/20/2022 Dr. Chongo Shapi, BSc.HB, MBChB, CUZ 1

2. Introduction
• Apnea is a common problem in preterm infants
that may be due to prematurity or an associated
illness
• In term infants, apnea is always worrisome and
demands immediate diagnostic evaluation
• Periodic breathing must be distinguished from
prolonged apneic pauses because the latter may
be associated with serious illnesses
• Apnea is a feature of many primary diseases that
affect neonates

3. • These disorders produce apnea by direct
depression of the central nervous system's
control of respiration (hypoglycemia, meningitis,
drugs, hemorrhage, seizures), disturbances in
oxygen delivery (shock, sepsis, anemia), or
ventilation defects (pneumonia, RDS, persistent
pulmonary hypertension of the newborn [PPHN],
muscle weakness).
• Idiopathic apnea of prematurity occurs in the
absence of identifiable predisposing diseases

4. • Apnea is a disorder of respiratory control and may be
obstructive, central, or mixed
• Obstructive apnea (pharyngeal instability, neck flexion,
nasal occlusion) is characterized by absent airflow but
persistent chest wall motion
• Pharyngeal collapse may follow the negative airway
pressures generated during inspiration, or it may result
from incoordination of the tongue and other upper
airway muscles involved in maintaining airway patency
• In central apnea, which is caused by decreased central
nervous system (CNS) stimuli to respiratory muscles,
airflow and chest wall motion are absent

5. • Gestational age is the most important determinant of
respiratory control, with the frequency of apnea being
inversely related to gestational age
• The immaturity of the brainstem respiratory centers is
manifested by an attenuated response to carbon dioxide
and a paradoxical response to hypoxia that results in apnea
rather than hyperventilation
• The most common pattern of idiopathic apnea in preterm
neonates has a mixed etiology (50–75%), with obstructive
apnea preceding (usually) or following central apnea
• Short episodes of apnea are usually central, whereas
prolonged ones are often mixed.

6. • Apnea is sleep state dependent; the frequency
increases during active (rapid eye movement) sleep.
Paradoxical chest wall movement (inspiratory
abdominal expansion and inward chest wall
movement) is common during active sleep and may
cause a fall in PaO2 because of ventilation-perfusion
defects. Furthermore, increased negative pressure
during paradoxical breathing and inhibition of
pharyngeal muscle tone during active sleep may
contribute to upper airway collapse and obstructive
apnea.
•

7. Potential Causes of Neonatal Apnea and Bradycardia
• CNS
- Intraventricular hemorrhage (IVH)
- Drugs
- Seizures
- Hypoxic injury
- Herniation
- Neuromuscular disorders
- Leigh syndrome
- Brainstem infarction or anomalies (e.g.,
olivopontocerebellar atrophy)
- After general anesthesia

8. Respiratory
- Pneumonia
- Obstructive airway lesions
- Upper airway collapse
- Atelectasis
- Extreme prematurity (<1.5
kg)
- Laryngeal reflex
- Phrenic nerve paralysis
- Severe hyaline membrane
disease
- Pneumothorax
- Hypoxia
Infectious
- Sepsis
- Necrotizing enterocolitis (NEC)
- Meningitis (bacterial, fungal,
viral)
- Respiratory syncytial virus
- Pertussis
Gastrointestinal
- Oral feeding
- Bowel movement
- Esophagitis
- Intestinal perforation

9. Metabolic
- ↓ Glucose
- ↓ calcium
- ↓/↑ sodium
- ↑ ammonia
- ↑ organic acids
- ↑ ambient temperature
- Hypothermia
Cardiovascular
- Hypotension
- Hypertension
- Heart failure
- Anemia
- Hypovolemia
- Vagal tone
Other
- Immaturity of respiratory
center, sleep state

10. Clinical Manifestations
• The incidence of idiopathic apnea of prematurity
varies inversely with gestational age
• In preterm infants, it is rare on the 1st day of life;
apnea immediately after birth signifies another
illness
• The onset of idiopathic apnea occurs on the 2nd–7th
day of life
• In preterm infants, serious apnea is defined as
1. Cessation of breathing for longer than 20 sec, or
2. Any duration if accompanied by cyanosis and
bradycardia

11. • The incidence of associated bradycardia increases
with the length of the preceding apnea and
correlates with the severity of hypoxia
• Short apnea episodes (10 sec) are rarely
associated with bradycardia, whereas longer ones
(>20 sec) have a higher incidence of bradycardia
• Bradycardia follows the apnea by 1–2 sec in more
than 95% of cases and is most often sinus, but on
occasion can be nodal
• Vagal responses and, rarely, heart block are
causes of bradycardia without apnea.

12. Treatment
• Infants at risk for apnea should be placed on
cardiorespiratory monitors
• Gentle tactile stimulation is often adequate
therapy for mild and intermittent episodes
• Infants with recurrent and prolonged apnea
may require suctioning, repositioning, and bag
and mask ventilation
• Oxygen should be administered judiciously to
treat hypoxia

13. • The onset of apnea in a previously well premature
neonate after the 2nd wk of life or in a term infant at
any time is a critical event that warrants immediate
investigation
• Recurrent apnea of prematurity may be treated with
theophylline or caffeine
• Methylxanthines increase central respiratory drive by
lowering the threshold of response to hypercarbia, as
well as enhancing contractility of the diaphragm and
preventing diaphragmatic fatigue
• The specific effects appear to vary to some degree
between theophylline and caffeine.

14. • Evidence suggests that caffeine is a more potent centrally
acting respiratory agent with fewer side effects than
theophylline
• Loading doses of 5–7 mg/kg of theophylline (orally) or
aminophylline (intravenously) should be followed by doses
of 1–2 mg/kg given every 6–12 hr by the oral or
intravenous routes
• Loading doses of 20 mg/kg of caffeine citrate are followed
24 hr later by maintenance doses of 5 mg/kg/24 hr qd
orally or intravenously
• These doses should be monitored by observation of vital
signs, clinical response, and serum drug levels (therapeutic
levels: theophylline, 6–10 μg/mL; caffeine, 8–20 μg/mL)

15. • Caffeine may reduce the risk of BPD. Doxapram, known to be a potent
respiratory stimulant, acts predominantly on peripheral chemoreceptors
and has been used in neonates with apnea of prematurity, but has a
limited therapeutic role due to side effects
• Transfusion of packed red blood cells to reduce the incidence of idiopathic
apnea is reserved for severely anemic infants. Gastroesophageal reflux
may also occur in infants with apnea of prematurity
• Data do not support a causal relationship between gastroesophageal
reflux and apneic events or the use of antireflux medications to reduce the
frequency of apnea in preterm infants.
• Nasal continuous positive airway pressure (CPAP, 2–5 cm H2O) and high-
flow humidified nasal cannula (1–2.5 L/min) are effective therapies for
mixed or obstructive apnea
• The efficacy of CPAP is related to its ability to splint the upper airway and
prevent airway obstruction.

16. Prognosis
• Unless severe, recurrent, and refractory to therapy, apnea
of prematurity does not alter an infant's prognosis
• Associated problems of intraventricular hemorrhage (IVH),
bronchopulmonary dysplasia (BPD), and retinopathy of
prematurity are critical in determining the prognosis for
apneic infants
• Apnea of prematurity usually resolves by 36 wk PCA and
does not predict future episodes of sudden infant death
syndrome
• Some infants with persistent apnea are discharged as long
as cardiorespiratory monitoring can be performed at home
• In the absence of significant events, home monitoring can
be safely discontinued after 43 wk PCA