Merck Manual

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Apnea of Prematurity


Arcangela Lattari Balest

, MD, University of Pittsburgh, School of Medicine

Reviewed/Revised Jul 2023

Apnea (not breathing) of prematurity is a pause in breathing that lasts for 20 seconds or more in an infant 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.

This disorder usually begins 2 to 3 days after birth and only rarely on the first day.

In apnea of prematurity, newborns may have repeated episodes of normal breathing alternating with brief pauses in breathing. In some premature babies, the pause in breathing may not last 20 seconds but does cause a decrease in the heart rate or in the amount of oxygen in the blood. Shorter pauses in breathing that cause decreases in heart rate or blood oxygen levels are still considered apnea of prematurity.

There are three types of apnea:

  • Central

  • Obstructive

  • Mixed

Central apnea occurs when the part of the brain that controls breathing (respiratory center Control of Breathing Breathing is usually automatic, controlled subconsciously by the respiratory center at the base of the brain. Breathing continues during sleep and usually even when a person is unconscious.... read more ) 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 can decrease.

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 premature newborns and is not considered apnea of prematurity. Full-term newborns can also have periodic breathing. It does not cause the heart rate or oxygen levels to drop and usually does not cause other problems.

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 Cyanosis Cyanosis is a bluish or grayish discoloration of the skin resulting from an inadequate amount of oxygen in the blood. Cyanosis occurs when oxygen-depleted (deoxygenated) blood, which is bluish... read more ) or pale skin (pallor).

In newborns of color, the skin may change to colors such as 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 (bradycardia).

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.

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 cyanosis, they remain in the neonatal intensive care unit Neonatal intensive care unit (NICU) Problems in newborns may develop Before birth while the fetus is growing During labor and delivery After birth About 10% of newborns need some special care after birth due to prematurity, problems... read more (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 Obstructive sleep apnea Obstructive sleep apnea (CPAP). This technique allows newborns to breathe on their own while receiving slightly pressurized oxygen or air given through prongs placed in the nostrils. Newborns who have apnea spells that are difficult to treat may need a ventilator Mechanical Ventilation Mechanical ventilation is use of a machine to aid the movement of air into and out of the lungs. Some people with respiratory failure need a mechanical ventilator (a machine that helps air get... read more (a machine that helps air get in and out of the lungs) to help them breathe.

Home care

Most newborns are able to go home from the hospital without a monitor. Infrequently, some newborns are sent home with an apnea monitor and may also need caffeine. However, infants are usually taken off caffeine before being discharged.

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 Cardiac Arrest and CPR Cardiac arrest is when the heart stops pumping blood and oxygen to the brain and other organs and tissues. Sometimes a person can be revived after cardiac arrest, particularly if treatment is... read more Cardiac Arrest and CPR (CPR) in case it is needed, and how to keep a record of events. Most monitors electronically store information about events that occur.

Parents should consult a doctor about when to stop using the monitor.

There is no proof that discharging a premature newborn from the hospital with an apnea monitor decreases the risk of SIDS.

Prognosis for Apnea of Prematurity

Over time, as the respiratory center matures, episodes of apnea become less frequent, and by the time the newborn approaches 37 weeks of gestation Gestational Age Problems in newborns may develop Before birth while the fetus is growing During labor and delivery After birth About 10% of newborns need some special care after birth due to prematurity, problems... read more , 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).

Apnea of prematurity rarely causes death.

Prevention of Apnea of Prematurity

Because all premature newborns, especially those with apnea of prematurity, are at risk of apnea, low levels of oxygen in the blood, and a slow heart rate while in a car seat, they should have a car seat challenge test Discharge from the hospital A preterm newborn is a baby delivered before 37 weeks of gestation. Depending on when they are born, preterm newborns may have underdeveloped organs that are not be ready to function outside... read more before leaving the hospital. This test determines whether the newborn is able to safely ride home in the semi-reclined position of a car seat.

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 Safe to Sleep: Reducing the Risk of Sudden Infant Death Syndrome Safe to Sleep: Reducing the Risk of Sudden Infant Death Syndrome should be followed for all infants whether they are premature or not.

Drugs Mentioned In This Article

Generic Name Select Brand Names
Cafcit, NoDoz, Stay Awake, Vivarin
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