Neonatal Apnea

Neonatal Apnea: Excerpt from The 5-Minute Pediatric Consult

Carl Tapia, MD

Neonatal Apnea - BASICS

Neonatal Apnea - description

• Apnea of infancy is the unexplained cessation of breathing for 20 seconds or more—or a shorter pause associated with cyanosis, pallor, bradycardia, hypoxia, or hypotonia—with an onset after 37 weeks’ gestational age.
• Apnea has been traditionally classified into 3 categories:
  • Central: No evidence of upper airway obstruction
  • Obstructive: Obstructed upper airway, typically with respiratory effort but no airflow
  • Mixed: Obstructed respiratory efforts, usually heralded by central pauses
• Apnea of prematurity is an abrupt respiratory pause for ≥20 seconds, accompanied by desaturation and bradycardia, in an infant <37 weeks’ gestational age.
• Periodic breathing is a normal neonatal breathing pattern, defined by 3 or more pauses, each ≥3 seconds, with <20 seconds of regular respiration between pauses.
• Apparent life-threatening event (ALTE) is a sudden event that is frightening to the observer, and characterized by apnea, color change, change in tone, and/or gagging.

Neonatal Apnea - epidemiology

• Apnea of prematurity occurs in >50% of premature infants and in almost all neonates <1,000 g at birth.
• Apnea and bradycardia occur in ~2% of all healthy term infants.

Neonatal Apnea - risk factors

• Prematurity
• Respiratory syncytial virus (RSV) infection
• Gastroesophageal reflux
• Sepsis
• Fluctuating incubator temperatures
• Large patent ductus arteriosus
• CNS insult, such as hemorrhage, hypoxia, or seizures
• Head flexion during holding or sleeping
• Maternal medications, such as magnesium sulfate, prostaglandins, or narcotics
• Following pertussis vaccine administration

Neonatal Apnea - pathophysiology

• Immature carbon dioxide chemoreceptors in the brainstem may be responsible for the decrease in respiratory drive.
• Hypercapnia leading to decreased muscle tone and incoordination of the upper airway muscles may result in mixed apnea.
• Activation of laryngeal afferent nerves, as with gastroesophageal reflux, may result in glottal closure.
• Vagally mediated responses to hypoventilation have been suggested as the cause of bradycardia.

Neonatal Apnea - DIAGNOSIS

Neonatal Apnea - signs & symptoms

Neonatal Apnea - history

• Review the prenatal history for prematurity, birth weight, maternal tobacco or substance use, and the immediate postpartum course. In breastfeeding infants, ask about maternal medications that might cause drowsiness, such as pain or anxiety medications.
• Relevant factors in the past medical history include prior ALTE, feeding and respiratory patterns, and history of seizure, breath-holding spells, reflux, foreign-body aspiration, cardiac disease, metabolic or endocrine disease, or food allergy.
• Evaluate for recent illness, fever, poor feeding, irritability, weight trends, recent vaccine administration, and sick contacts.
• Probe for evidence or suspicion of child maltreatment.
• Pertinent family history includes sudden infant death syndrome (SIDS), home tobacco use, previous infant deaths, congenital problems, and cardiac disease.
• The event should be reviewed in detail for location, timing and duration, associated respiratory effort, color change, infant position and tone, relation to feeding, and resuscitative measures used.

Neonatal Apnea - physical exam

• Monitor vital signs for fever, respiratory effort, arrhythmia, and oxygen saturation.
• Evaluate for dysmorphic features, abnormal growth parameters, and distress.
• Cardiac exam for evidence of arrhythmia or heart failure
• Respiratory evaluation for cyanosis, breathing pattern and effort, wheezing, crackles, and absent air sounds
• Complete neurological exam, with emphasis on abnormalities in tone or development
• Examine for signs of child abuse, including bruises, loop marks, and other suspicious lesions.

Neonatal Apnea - tests

Neonatal Apnea - lab

• CBC with differential to look for infection or anemia
• Electrolytes, glucose, calcium, magnesium to evaluate for acidosis, dehydration, or metabolic disease
• Lactate to evaluate for hypoxia, toxic ingestions which cause acidosis, or inborn errors of metabolism
• Liver function tests when hepatic dysfunction or severe hypoxia is a consideration
• Ammonia when an inborn error of metabolism or a liver disorder is suspected
• Arterial blood gas when acidosis is considered
• Blood culture if sepsis is suspected
• Urinalysis to evaluate for infection
• Urine drug screen when ingestion or overdose is a concern

Neonatal Apnea - imaging

• Chest x-ray to evaluate for infection or cardiac disease
• Brain CT or head ultrasound (if <6 months old) to look for evidence of acute bleed if trauma or elevated intracranial pressure is suspected
• Head MRI, if indicated, to evaluate for congenital malformations
• Skeletal survey if child abuse is suspected

Neonatal Apnea - diag proced-surgery

• EKG to evaluate arrhythmias or conduction problems
• Lumbar puncture if sepsis/meningitis is in the differential
• Nasal aspirate for RSV if respiratory infections are considered
• Pertussis culture and serology if suspected contact with pertussis, or a prolonged or paroxysmal cough
• Pneumography may be used when the diagnosis of apnea is uncertain. A 5-channel pneumogram records chest wall excursion, heart rate, electrocardiogram, pulse oximetry, and nasal airflow. A pH probe for gastroesophageal reflux or end-tidal CO

  Neonatal Apnea - differencial diagnosis

  As apnea of infancy and apnea of prematurity are diagnoses of exclusion, careful attention and evaluation should be made for underlying illness or medical conditions.

  • Infections:
    • Respiratory illness, particularly due to RSV, pertussis, mycoplasma, or bacterial pneumonia
    • Sepsis, urinary tract infection, or CNS infection
  • Environmental:
    • Suffocation
    • Head injury or child abuse
    • Hypothermia or hyperthermia
  • Tumors:
    • CNS tumors, metastasis, or chest mass
  • Neurologic:
    • Seizure
    • CNS bleeding
    • Brainstem malformation
    • Hydrocephalus
  • Pulmonary/Airways:
    • Obstruction: Obstructive sleep apnea, airway obstruction, foreign-body aspiration
    • Breath-holding spells
    • Vocal cord abnormality
    • Laryngotracheomalacia
  • Metabolic:
    • Inborn errors
    • Neuromuscular disease
    • Hypoglycemia or electrolyte disturbance
  • Cardiovascular:
    • Congenital heart disease
    • Arrhythmia: Long QT syndrome, Wolff-Parkinson-White syndrome
    • Cardiomyopathy
    • Myocarditis
  • GI:
    • Gastroesophageal reflux
    • Dysphagia or swallowing disorder
    • Intussusception
  • Toxin/Drugs:
    • Overdose: Sedatives, seizure medications, pain medications

  Exclusion of specific causes should be performed before specific treatment for apnea is undertaken.

  Neonatal Apnea - TREATMENT

  Neonatal Apnea - general measures

  • Appropriate resuscitation and supportive care directed at underlying disease and presenting signs/symptoms
  • Continuous positive airway pressure may decrease airway obstruction and improve oxygenation. Positive pressure ventilation may be needed for severe or persistent apnea.

  Neonatal Apnea - medication

  • Theophylline and caffeine citrate have been the mainstays of treatment, but should be undertaken in consultation with a pulmonary or neonatal specialist. Caffeine has the advantage of a higher therapeutic index, lower toxicity, and once-daily dosing.
  • Caffeine citrate is commonly administered as a 20 mg/kg bolus (IV or oral), followed by a once-daily dose of 5 mg/kg. The therapeutic range of caffeine is 5–25 mg/L. The alternative salt, caffeine benzoate, is not commonly used, as there is a theoretical risk of bilirubin displacement from albumin.
  • Common side effects of theophylline and caffeine include tachycardia, arrhythmia, feeding intolerance, seizures, and diuresis.
  • Gastroesophageal reflux and apnea frequently co-exist; however, there is little evidence that treatment of reflux has a beneficial effect on apnea of prematurity.

  Neonatal Apnea - FOLLOW UP

  • A car seat challenge test should be considered for preterm infants with respiratory problems and all infants born at <37 weeks. Parents should be advised to use car seats only for travel and with careful supervision during the 1st few months of life.
  • Home cardiorespiratory monitoring may be considered for premature infants at high risk for recurrent apnea. Monitoring of these infants should be discontinued at 43 weeks’ corrected gestational age or when episodes cease.
  • Infants who are technology-dependent, have unstable airways, symptomatic chronic lung disease, and medical conditions affecting the regulation of breathing may also be candidates for home monitoring.

  Neonatal Apnea - prognosis

  • Most apnea of prematurity resolves by 36–40 weeks corrected gestational age. After 43–44 weeks corrected gestational age, the rate of apnea for preterm infants is the same as for term infants.
  • Large studies have not found apnea of prematurity to be a precursor or predictor of SIDS.
  • The mortality rate for ALTE is between 0% and 4%. There may be an increased risk of SIDS in infants with apnea of infancy and ALTE.
  • There is mixed evidence regarding the occurrence of neurodevelopment delay or behavioral disorders in infants with ALTE. One study found that 5 or more apneic events in infants who were home monitored were associated with lower developmental achievement at 1 year.

  Neonatal Apnea - bibliography

  1. American Academy of Pediatrics Committee on Fetus and Newborn. Policy statement: Apnea, sudden infant death syndrome, and home monitoring. Pediatrics. 2003;111:914–917.
  2. American Academy of Pediatrics Committee on Injury and Poison Prevention. Safe transportation of newborns at hospital discharge. Pediatrics. 1999;10:986–987.
  3. Finer NN, Higgins R, Kattwinkel J, et al. Summary proceedings from the apnea-of-prematurity group. Pediatrics. 2006;117(3 Pt 2):S47–S51.
  4. Hall KL, Zalman B. Evaluation and management of apparent life-threatening events in children. Am Fam Physician. 205;71:2301–2308.
  5. Hunt CE, Corwin MJ, Baird T, et al. Cardiorespiratory events detected by home memory monitoring and one-year neurodevelopmental outcome. J Pediatr. 2004;145:465–471.
  6. Martin RJ, Abu-Shaweesh JM. Control of breathing and neonatal apnea. Biol Neonate. 2005;87:288–295.
  7. Stokowski LA. A primer on apnea of prematurity. Adv Neonatal Care. 2005;5:155–170.
  8. Thomson AH, Kerr S, Wright S. Population pharmacokinetics of caffeine in neonates and young infants. Ther Drug Monit. 1996;18:245–253.

  Neonatal Apnea - CODES

  Neonatal Apnea - icd9

  • 770.82 Apnea of infancy or prematurity
  • 786.03 Aymptom, apnea
  • 798.0 SIDS

  Neonatal Apnea - FAQ

  • Q: What recommendations should be given at discharge for neonates with apnea?
  • A: Appropriate instruction in the supine sleeping position, a safe sleeping environment (adequate mattress size and removal of pillows and toys that represent a suffocation hazard), and tobacco cessation should be provided. Training in cardiopulmonary resuscitation/basic life support and monitor training should be provided.
  • Q: What should be included in home monitoring training?
  • A: When home monitoring is prescribed, families should be provided with realistic expectations (i.e., lack of efficacy regarding the prevention of SIDS), anticipated cessation of the monitor, and guidelines for intervention when the monitor alarms.
  • Q: Is there an association between anemia and apnea of prematurity?
  • A: There has been no evidence that aggressively treating anemia reduces the incidence of apnea.
  >>>>>

  Book Source Details

  • Book Title: The 5-Minute Pediatric Consult
  • Author(s): M. William Schwartz MD; et al.
  • Year of Publication: 2008
  • Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
  
  

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  Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

  
  

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  More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

  
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