Apnoea

Pause(s) in breathing >20 sec (or less, when associated with bradycardia or cyanosis)

Bradycardia

Heart rate <100 bpm, associated with desaturation

Types

Central

• Caused by poorly developed neurological control
• Respiratory movements absent

Obstructive

• Caused by upper airway obstruction, usually at pharyngeal level
• Respiratory movements continue initially but then stop 

Mixed

• Initially central, followed by obstructive apnoea

Significance

• Most babies born <34 weeks’ gestation have primary apnoea of prematurity (PAP). Hence babies born <34 weeks should have SpO₂ monitoring until ≥34 weeks’ post conceptional age (PCA)
  
  • multiple aetiologic factors can exacerbate apnoea in preterm babies
  • sudden increase in frequency warrants immediate action 
• Consider causes other than apnoea of prematurity if occurs:
  
  • in term or near-term baby (>34 weeks’ gestation)
  • on first day after birth in preterm baby
  • onset of apnoea after aged 7 days in a preterm baby

Causes

Infection

• Sepsis

• Necrotising enterocolitis

• Meningitis

Respiratory

• Inadequate respiratory support
• Upper airway obstruction
• Surfactant deficiency

CNS

• Intracranial haemorrhage
• Seizure
• Congenital malformations

CVS

• Patent ductus arteriosus

Other

• Metabolic abnormalities, especially hypoglycaemia
• Haematological: anaemia
• Inherited metabolic disorders e.g. non-ketotic hyperglycinaemia

Terminate episode

• If apnoea not self-limiting (clinician to agree threshold to intervene), perform the following in sequence to try to terminate episode:
  
  • ensure head in neutral position
  • stimulate baby by tickling feet or stroking abdomen
  • if aspiration or secretions in pharynx suspected, apply brief oropharyngeal suction 
  • face mask ventilation
  • emergency intubation
• Once stable, perform thorough clinical examination to confirm/evaluate cause

Screen for sepsis

• If apnoea or bradycardia increasingly frequent or severe, screen for sepsis as apnoea and bradycardia can be sole presenting sign 

• Treat specific cause, if present
• Primary apnoea of prematurity is a diagnosis of exclusion and may not require treatment unless pauses are:
  
  • frequent (>8 in 12 hr) or
  • severe (>2 episodes/day requiring positive pressure ventilation) 

Pharmacological treatment

• Caffeine citrate 20 mg/kg loading dose oral/IV (over 30 min) followed, after 24 hr, by maintenance dose of
  5 mg/kg oral/IV (over 10 min) once daily, increasing to 20 mg/kg if required until 34 weeks’ PCA
• If desaturations and bradycardias persist, may continue beyond 34 weeks’ PCA. If so, review need for treatment regularly

Non-pharmacological treatment

• CPAP, SiPAP/BiPAP [see Ventilation: continuous positive airway pressure (CPAP) guideline]
• If above fails, intubate and ventilate