Note: Always assess gestational age as accurately as possible. See appendix: Ballard Scoring Assessment.
APNOEA, NEONATAL
P28.3
DESCRIPTION
A neonate presenting with episodes of cessation of breathing.
Apnoea episodes in a previously asymptomatic well neonate may be the first indication of a serious underlying disease.
Apnoea episodes in an already unwell neonate indicate deterioration in the condition of the neonate.
DIAGNOSTIC CRITERIA
- Cessation of respiration for longer than 20 seconds, with/without cyanosis, pallor or bradycardia.
- Cessation of respiration for less than 20 seconds with cyanosis, pallor and/or bradycardia.
Central apnoea
Causes include:
- IRDS
- prematurity
- hypoxia/hypercarbia
- sepsis
- acidosis
- meningitis
- temperature disturbances
- hypotension
- pneumonia
- intraventricular haemorrhage
- patent ductus arteriosus
- hypoglycaemia
- hypermagnesaemia
- atypical convulsions
- anaemia
- rough or excessive handling
- medicines (sedatives, anticonvulsants, analgesics).
Obstructive apnoea
Neonates are obligatory “nose breathers”. Obstruction of the nares make neonates prone to apnoea.
Causes of obstructive apnoea include:
- choanal atresia,
- gastro-oesophageal reflux,
- micrognathia,
- macroglossia,
- secretions (milk, meconium, blood, mucus) lodged in the upper airway, and
- neck flexion or extension.
Reflex apnoea or vagally mediated apnoea
Is due to:
- endotracheal intubation,
- passage of a nasogastric tube,
- gastro-oesophageal reflux,
- overfeeding, and
- suction of the pharynx or stomach.
Mixed apnoea
Apnoea caused by a combination of the above causes.
GENERAL AND SUPPORTIVE MEASURES
For all forms of neonatal apnoea:
- Identify and treat the underlying cause.
- Frequent gentle physical stimulation e.g. rubbing of soles of feet.
- Nurse preterm neonates in the prone position.
- Maintain ambient temperature at the lower range of neutral thermal environment.
- Maintain axillary temperature or anterior abdominal wall temperature at 36.2–36.8°C.
- Maintain haematocrit at 40%.
- Maintain nasal CPAP of 4 cm water. (Nasal CPAP – not for central apnoea except for apnoea of prematurity.)
- Monitor vital signs and parameters relating to the underlying cause.
MEDICINE TREATMENT
To maintain oxygen/haemoglobin saturation of 90-94% or an oxygen tension in the blood at 60–80 mmHg:
- Oxygen via nasal cannula, headbox, or mask.
Only for apnoea of prematurity (not term infants):
- Caffeine base, (anhydrous), oral/IV (dose expressed as caffeine base)
- Loading dose: 10–12.5 mg/kg.
- Maintenance dose: 2.5–5 mg/kg/24 hours. Start maintenance dose 24 hours after the loading dose.
(Caffeine citrate 20mg = caffeine base 10 mg)
OR
- Aminophyline, IV/oral.
- Loading dose: 8 mg/kg. (If IV infusion, administer over 30 minutes).
- Maintenance dose: 1.5–3 mg/kg/dose 8 hourly. Start maintenance dose 8 hours after loading dose.
Maintain aminophylline blood levels at 10–12 mcg/mL.
If neonate responds favourably to caffeine/aminophyline continue until neonate is apnoea free for 7 days.
REFERRAL
- Recurrent life-threatening episodes of apnoea, not responding to adequate treatment and requiring ventilation.