Chapter 25:

Apnoea in the Newborn Definition

• Apnea of prematurity is defined as sudden cessation of breathing
that lasts for at least 20 seconds or is accompanied by bradycardia
or oxygen desaturation (cyanosis) in an infant younger than 37
weeks’ gestational age.
• It usually ceases by 43 weeks’ postmenstrual age but may persist
for several weeks beyond term, especially in infants born before 28
weeks’ gestation with this risk decreasing with time.

Classification Types:
• Central: absence of respiratory effort with no gas flow and no
evidence of obstruction.
• Obstructive: continued ineffective respiratory effort with no gas
flow • Mixed central and obstructive: most common type Aetiology
Symptomatic of underlying problems, commoner ones of which are:
• Respiratory conditions (RDS, pulmonary haemorrhage, pneumothorax,
upper airway obstruction, respiratory depression due to drugs).
• Sepsis
• Hypoxaemia
• Hypothermia
• CNS abnormality (e.g. IVH, asphyxia, increased ICP, seizures) • 
Metabolic disturbances (hypoglycaemia, hyponatraemia, hypocalcaemia)
• Cardiac failure, congenital heart disease, anaemia
• Aspiration/ Gastro-oesophageal reflux
• Necrotising ennterocolitis, Abdominal distension
• Vagal reflex: Nasogastric tube insertion, suctioning, feeding

Differentiate from Periodic breathing

• Regular sequence of respiratory pauses of 10-20 sec interspersed
with periods of hyperventilation (4-15 sec) and occurring at least
3x/ minute, not associated with cyanosis or bradycardia.
• Benign respiratory pattern for which no treatment is required. • 
Respiratory pauses appear self-limited, and ventilation continues
cyclically.
• Periodic breathing typically does not occur in neonates in the
first 2 days of life

Management

Surface stimulation (Flick soles, touch baby)

Gentle nasopharyngeal suction (Be careful: may prolong apnoea)

Ventilate with bag and mask on previous FiO2 Be careful not to use
supplementary oxygen if infant has been in air as child’s lungs are
likely normal and a high PaO2 may result in ROP

Intubate, IPPV if child cyanosed or apnoea is recurrent/persistent

Try CPAP in the milder cases

• Review possible causes (as above) and institute specific therapy,

e.g. septic workup if sepsis suspected and commence antibiotics
Remember to check blood glucose via glucometer.
• Management to prevent recurrence.
• Nurse baby in thermoneutral environment.
• Nursing prone can improve thoraco-abdominal wall synchrony and
reduce apnoea. • Variable flow NCPAP or synchronised NIPPV can reduce
work of breathing and reduce risk of apnoea.
• Monitoring: - Pulse Oximeter - Cardio-respiratory monitor
• Drug therapy - Methylxanthine compounds: - Caffeine citrate
(preferred if available) - IV Aminophylline or Theophylline.
• Start methylxanthines prophylactically for babies < 32 weeks
gestation. For those > 32 weeks of gestation, give methylxanthines if
babies have apnoea. To stop methylxanthines if : • Gestation > 34
weeks
• Apnoea free for 1 week when the patient is no longer on NCPAP
• Monitor for at least 1 week once the methylxanthines are stopped.
After discharge , parents should be given advice for prevention of
SIDS:
• Supine sleep position.
• Safe sleeping environments.
• Elimination of prenatal and postnatal exposure to tobacco smoke.