Chapter 125: Apnea

Definition · Obstructive vs central vs mixed · Apnea of prematurity · Causes · Caffeine · CPAP · Prognosis · SIDS prevention
🫁 Key therapy: Caffeine citrate (20 mg/kg load) reduces apnea and improves neurodevelopment

🌬️ Apnea in Newborns: Definitions, Causes & Management

📏 Definition
Cessation of breathing ≥20 sec, or shorter if associated with bradycardia (<80-100), cyanosis, or pallor.
🧠 Apnea of prematurity
Inverse relation to GA. Almost universal <28 wk. Caffeine + CPAP. Resolves by 37-40 wk PMA.
🚫 Obstructive apnea
No airflow but chest wall motion. Causes: craniofacial (Pierre Robin), laryngomalacia, choanal atresia.
🩺 Central apnea
No respiratory effort. Etiologies: infection, metabolic, CNS injury, congenital hypoventilation.
☕ Caffeine therapy
Load 20 mg/kg caffeine citrate, maintenance 5-10 mg/kg/day. Reduces BPD and improves neurodevelopment.
🛌 SIDS & home monitoring
Supine sleep, firm mattress, pacifier. Home monitors not proven to prevent SIDS.
⚠️ Pathologic apnea in term infant: Always requires evaluation (sepsis, IEM, seizure, intracranial hemorrhage, airway anomaly).

🔍 Approach to the neonate with apneic episodes

1
Determine type of apnea (central, obstructive, mixed) – Observe chest wall movement; pulse oximetry + respiratory inductance plethysmography if available.
2
Evaluate for underlying causes (especially in term or late preterm) – Sepsis workup (CBC, CRP, blood culture, LP), glucose, calcium, ammonia, lactate, head ultrasound (IVH), EEG (seizures).
3
Assess gestational age and postnatal day – Apnea of prematurity if <34 wk, no other cause, onset within first 2 weeks.
4
Anatomical evaluation for obstruction – Examine nares (patency), palate, mandible, laryngeal crepitus. ENT consult for suspected laryngomalacia, choanal atresia.
5
Monitor and treat – Cardiorespiratory monitoring, pulse oximetry. Treat underlying cause (antibiotics for sepsis, surgical for obstruction, caffeine for prematurity).

📋 Stepwise management of apnea in the neonate

1
Stabilization & support – Gentle tactile stimulation for mild episodes. Provide supplemental oxygen via nasal cannula if desaturation.
2
Noninvasive respiratory support – Nasal CPAP (5-8 cmH2O) for mixed/obstructive apnea. High-flow nasal cannula (1-4 L/min) alternative.
3
Caffeine citrate therapy (apnea of prematurity) – Loading dose 20 mg/kg IV/PO, then maintenance 5-10 mg/kg once daily. Continue until infant is free of significant apnea/bradycardia for 5-7 days or 34 weeks PMA.
4
Treat specific causes – Antibiotics for sepsis; dextrose for hypoglycemia; calcium for hypocalcemia; surgical referral for anatomic obstruction (e.g., supraglottoplasty, mandibular distraction).
5
Discharge planning – Event-free period (typically 5-7 days). Avoid home monitors unless extreme events or technology-dependent.
📌 Caffeine benefits: Reduces apnea, facilitates extubation, lowers BPD, improves neurodevelopmental outcomes (safe even without frequent apneas).

🧠 Rapid reflex prompts – Apnea

📌 Definition of apnea in neonate?
≥20 seconds, or shorter if with bradycardia (<80-100), cyanosis, or pallor.
📌 First-line medication for apnea of prematurity?
Caffeine citrate (20 mg/kg load, 5-10 mg/kg/day maintenance).
📌 When to suspect pathologic apnea in term infant?
Always pathologic; evaluate sepsis, metabolic, CNS, airway, seizures.
📌 Most common cause of obstructive apnea in newborn?
Craniofacial anomalies (Pierre Robin, retrognathia, choanal atresia, laryngomalacia).
📌 At what PMA does apnea of prematurity typically resolve?
By 37 weeks PMA (92%), 40 weeks PMA (98%), can persist to 44 weeks in extreme prematurity.
📌 Does GER cause apnea?
No causal evidence; acid suppression not recommended and may increase NEC/sepsis.
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