AAP Issues Guidance on Apnea of Prematurity

Diana Phillips

December 04, 2015

Apnea of prematurity reflects immaturity of respiratory control and generally resolves by 36 to 37 weeks in infants born at or after 28 weeks' gestation, according to a new clinical report from the American Academy of Pediatrics.

In the report, published online December 1 in Pediatrics, the authors clarify the definition, epidemiology, and treatment of apnea of prematurity as well as discharge recommendations for preterm infants diagnosed with recurrent apneic events. Inconsistencies in the definition of apnea of prematurity and a lack of consensus regarding the clinical significance of these apneic episodes lead to significant variations in monitoring, treatment, and discharge practices, they note.

Although apnea of prematurity is one of the most common diagnoses in the neonatal intensive care unit (NICU), "it is unknown whether recurrent apnea, bradycardia, and hypoxemia in preterm infants are harmful," Eric C. Eichenwald, MD, professor and chairman, Department of Pediatrics, University of Texas Medical School and chief, Department of Neonatology, Children's Memorial Hermann Hospital in Houston, Texas, and colleagues on the AAP Committee on Fetus and Newborn write in the report.

Generally defined as sudden cessation of breathing that lasts for at least 20 seconds in an infant younger than 37 weeks, apnea of prematurity frequently also includes shorter pauses in airflow that are accompanied by bradycardia or oxygen desaturation. Most apneic episodes in preterm infants are mixed events "in which obstructed airflow results in a central apneic pause, or vice versa," the authors state.

A review of the available evidence indicates that the proportion of infants with apnea decreases significantly with increasing gestational age, particularly beyond 30 weeks' gestation. "This relationship has important implications for NICU policy, because infants born at less than 35 weeks' gestation generally require cardiorespiratory monitoring after birth because of their risk of apnea," the authors write. Infants born at less than 28 weeks' gestation may have apnea that persists to or beyond term gestation, they say.

In most infants, apnea of prematurity follows a common natural history, with more severe events that require intervention resolving first, according to the authors. The last events to resolve are "isolated, spontaneously resolving bradycardic events of uncertain clinical significance."

Apnea monitoring practices, particularly the duration of continuous pulse oximetry, vary substantially among NICUs. Evidence linking later discontinuation of pulse oximetry with a later postmenstrual age at recorded last apnea and longer length of stay suggest "oximetry may detect events that cardiorespiratory monitoring does not," the authors observe.

Impedance monitoring, which detects small changes in electrical impedance as air enters and leaves the lungs and as the blood volume changes in the thoracic cavity, is subject to artifacts caused by body movement or cardiac activity. It is also unable to detect obstructive apnea and thus is a potentially misleading measure.

Routine home monitoring for infants with resolved apnea of prematurity after discharge is not supported by the current evidence, although it may be prescribed for a subset of preterm infants with prolonged, recurrent, or extreme apnea. If such monitoring is prescribed, "it can be discontinued in most infants after 43 weeks [postmenstrual age] unless indicated by other significant medical conditions," the authors say.

Options for pharmacologic therapy include the methylxanthines theophylline and caffeine, which may help reduce the frequency of events in infants with central apnea. Of these, caffeine citrate is preferred because it has a long half-life, is well tolerated, and does not require drug-level monitoring, the authors write. Although no trials to data have addressed timing of xanthine cessation, "timely discontinuation is advised to avoid unnecessary delays in discharge," they say. A possible approach might be a trial of discontinuing therapy after an apnea-free period, they suggest.

In conjunction with pharmacological therapy, nasal continuous positive airway pressure at pressures of 4 to 6 cm H2O can reduce the frequency and severity of apnea in preterm infants.

The report also highlights the following clinical implications:

  • Gastroesophageal reflux is not associated with apnea of prematurity; thus, treatment for it for the purpose of reducing apnea events is not supported.

  • Discharge should not be delayed by the occurrence of brief, isolated bradycardic episodes that resolve spontaneously or feeding-related events that resolve with interruption of feeding, which are common in convalescent preterm infants.

  • An apnea event-free period of 5 to 7 days is commonly used to assess discharge readiness; however, infants born at less than 26 weeks' gestation may require a longer period, depending on the nature and severity of their apnea events.

  • Clinically unsuspected events of uncertain significance that are identified by examination of archived monitoring data do not predict subsequent outcomes, including recurrent clinical apnea or sudden infant death syndrome.

For consistency and clinical staff guidance, individual neonatal intensive care units should develop policies and procedures for the assessment, intervention, documentation, and predischarge duration of apnea, bradycardia, and desaturation events, the authors emphasize.

All authors have filed conflict-of-interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the AAP Board of Directors.

Pediatrics. Published online December 1, 2015. Full text

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