Apnea of prematurity is a pause in breathing that lasts for 20 seconds or more in a premature newborn (born before 37 weeks of gestation) who is not known to have any underlying disorder that causes apnea.
Apnea episodes may occur in premature newborns if the part of their brain that controls breathing (respiratory center) has not matured fully.
Apnea may lower the amount of oxygen in the blood, resulting in a slow heart rate and color changes in the lips and/or skin.
This disorder is diagnosed by observation or by the alarm of a monitor attached to the newborn.
If gentle prodding does not cause the newborn to resume breathing, artificial respiration may be needed.
Newborns with significant apnea are given caffeine, along with other treatments, to stimulate breathing.
As the respiratory center of the brain matures, apnea episodes become less frequent and then stop altogether.
(See also Overview of General Problems in Newborns.)
Babies born before 37 weeks of gestation are premature (also called preterm). The more premature a newborn is, the greater the risk of developing apnea of prematurity. Almost all premature infants who are born before 28 weeks of gestation have some degree of apnea of prematurity.
This disorder usually begins 2 to 3 days after birth. Newborns who develop apnea of prematurity on the first day of life may have a brain or spinal cord defect or injury. Newborns who develop apnea of prematurity more than 14 days after birth but who are otherwise healthy may have a serious illness such as sepsis.
In apnea of prematurity, newborns may have repeated episodes of normal breathing alternating with pauses in breathing that last 20 seconds or longer. In some premature newborns, the pause in breathing may last less than 20 seconds but causes a slow heart rate (bradycardia) or a decrease in the amount of oxygen in the blood.
There are 3 types of apnea:
Central
Obstructive
Mixed
Central apnea occurs when the part of the brain that controls breathing (respiratory center) is not functioning properly because it has not matured fully. This is the most common type of apnea of prematurity.
Obstructive apnea is caused by temporary blockage of the throat (pharynx) due to low muscle tone or a bending forward of the neck. This type may occur in full-term babies as well as those born prematurely.
Mixed apnea is a combination of central apnea and obstructive apnea.
In all types of apnea, the heart rate can become slow and levels of oxygen in the blood can decrease.
Although some babies who have a sudden unexplained infant death (SUID), which includes sudden infant death syndrome (SIDS), are premature, apnea of prematurity itself does not seem to be a cause of SUID or SIDS.
Not all pauses in breathing are problematic. Periodic breathing is 5 to 20 seconds of normal breathing followed by periods of apnea that last less than 20 seconds. Periodic breathing is common among full-term and premature newborns and is not considered apnea of prematurity. It does not cause the heart rate to slow or oxygen levels to drop and usually does not lead to apnea of prematurity.
Symptoms of Apnea of Prematurity
In the hospital, premature newborns are routinely attached to a monitor that sounds an alarm if they stop breathing for episodes of 20 seconds or more or if their heart rate slows. Depending on the length of the episodes, pauses in breathing may decrease the oxygen levels in the blood, which results in a bluish discoloration of the skin and/or lips (cyanosis) or pale skin (pallor).
In newborns with dark skin, the skin may change to yellow-gray, gray, or white. These changes may be more easily seen in the mucous membranes lining the inside of the mouth, nose, and eyelids.
Low levels of oxygen in the blood may then slow the heart rate.
Diagnosis of Apnea of Prematurity
Observation or monitor alarm
Other causes ruled out
The diagnosis of apnea is usually made by observing the newborn breathe or by hearing the alarm of a monitor attached to the newborn and noting no breathing movements when the newborn is checked.
Apnea can sometimes be a sign of a disorder, such as infection in the blood (sepsis), low blood sugar (hypoglycemia), or a low body temperature (hypothermia). Therefore, doctors evaluate the newborn to rule out these causes when apnea begins suddenly or unexpectedly or the frequency of apnea episodes increases. Doctors may take samples of blood, urine, and cerebrospinal fluid to test for serious infections and test blood samples to determine whether the level of blood sugar is too low.
Treatment of Apnea of Prematurity
Gentle prodding or touching
Treatment of cause
Stimulants (such as caffeine)
Measures to support breathing
When apnea is noticed, either by observation or monitor alarm, newborns are touched or prodded gently to stimulate breathing, which may be all that is required.
Further treatment of apnea depends on the cause. Doctors treat known causes such as infections.
If episodes of apnea become frequent, and especially if newborns have a bluish discoloration, they remain in the neonatal intensive care unit (NICU). They may be treated with a medication that stimulates the respiratory center, such as caffeine. (NICU). They may be treated with a medication that stimulates the respiratory center, such as caffeine.
If caffeine does not prevent frequent and severe episodes of apnea, newborns may need treatment with continuous positive airway pressure (CPAP). This technique allows newborns to breathe on their own while receiving slightly pressurized oxygen or air given through prongs placed in their nostrils. Newborns who have apnea spells that are difficult to treat may need a ventilator (a machine that helps air get in and out of the lungs) to help them breathe.
Hospital discharge and home care
Premature newborns, especially those with apnea of prematurity, should have a car seat challenge test before leaving the hospital. This test makes sure infants do not experience apnea or low oxygen levels because of the position of their head and neck in the car seat.
When newborns have had no episodes of apnea of prematurity for 3 to 10 days, they are usually ready to go home from the hospital. Rarely, infants who still have episodes of apnea that do not slow their heart rate and that go away without medical intervention (for example, stimulation or assisted breathing) are sent home with a prescription for caffeine, or a home apnea (breathing and oxygen level) monitor.When newborns have had no episodes of apnea of prematurity for 3 to 10 days, they are usually ready to go home from the hospital. Rarely, infants who still have episodes of apnea that do not slow their heart rate and that go away without medical intervention (for example, stimulation or assisted breathing) are sent home with a prescription for caffeine, or a home apnea (breathing and oxygen level) monitor.
Parents should be taught how to properly use the monitor and any other equipment, what to do when the alarm sounds, how to do cardiopulmonary resuscitation (CPR) in case it is needed, and how to keep a record of events. Most monitors electronically store information about events that occur. There is no proof that discharging a premature newborn from the hospital with an apnea monitor decreases the risk of sleep-related deaths, including SIDS, or of brief, resolved, unexplained events.
Parents and the infant's doctor together decide how long to use the monitor.
Once at home, newborns should always be placed on their back on a firm, flat sleep surface for every sleep. Stomach sleeping, side sleeping, and propping are unsafe. Safe sleeping practices should be followed for all infants whether they are premature or not.
Prognosis for Apnea of Prematurity
Over time, as the respiratory center matures, episodes of apnea become less frequent, and by about the time of a premature newborn's original due date, the episodes usually no longer occur.
Apnea may continue for weeks in infants who were born extremely prematurely (such as at 23 to 27 weeks gestation).
Apnea of prematurity is rarely fatal.
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