Apnea of Prematurity.

AAP Issues Guidance on Apnea of Prematurity. Pediatrics, January 2016, Eric C. EichenwaldCOMMITTEE ON FETUS AND NEWBORN, From the American Academy of Pediatrics, Clinical Report

Abstract

 

Apnea of pre­ma­tu­ri­ty is one of the most com­mon diag­noses in the NICU. Despite the fre­quen­cy of apnea of pre­ma­tu­ri­ty, it is unknown whether recur­rent apnea, brady­car­dia, and hypox­emia in preterm infants are harm­ful. Research into the devel­op­ment of res­pi­ra­to­ry con­trol in imma­ture ani­mals and preterm infants has facil­i­tat­ed our under­stand­ing of the patho­gen­e­sis and treat­ment of apnea of pre­ma­tu­ri­ty. How­ev­er, the lack of con­sis­tent def­i­n­i­tions, mon­i­tor­ing prac­tices, and con­sen­sus about clin­i­cal sig­nif­i­cance leads to sig­nif­i­cant vari­a­tion in prac­tice. The pur­pose of this clin­i­cal report is to review the evi­dence basis for the def­i­n­i­tion, epi­demi­ol­o­gy, and treat­ment of apnea of pre­ma­tu­ri­ty as well as dis­charge rec­om­men­da­tions for preterm infants diag­nosed with recur­rent apne­ic events.

Clinical Implications

  1. Apnea of prematurity reflects immaturity of respiratory control. It generally resolves by 36 to 37 weeks’ PMA in infants born at ≥28 weeks’ gestation.

  2. Infants born at <28 weeks’ gestation may have apnea that persists to or beyond term gestation.

  3. Individual NICUs are encouraged to develop policies for cardiorespiratory monitoring for infants considered at risk of apnea of prematurity.

  4. Initial low heart rate alarms are most commonly set at 100 beats per minute. Lower settings for convalescent preterm infants older than 33 to 34 weeks’ PMA may be reasonable.

  5. Caffeine citrate is a safe and effective treatment of apnea of prematurity when administered at a 20-mg/kg loading dose and 5 to 10 mg/kg per day maintenance. Monitoring routine serum caffeine levels usually is not contributory to management. A trial off caffeine may be considered when an infant has been free of clinically significant apnea/bradycardia events off positive pressure for 5 to 7 days or at 33 to 34 weeks’ PMA, whichever comes first.

  6. Evidence suggests that GER is not associated with apnea of prematurity, and treatment of presumed or proven GER solely for the reduction in apnea events is not supported by currently available evidence.

  7. Brief, isolated bradycardic episodes that spontaneously resolve and feeding-related events that resolve with interruption of feeding are common in convalescent preterm infants and generally need not delay discharge.

  8. Individual units are encouraged to develop policies and procedures for caregiver assessment, intervention, and documentation of apnea/bradycardia/desaturation events as well as the duration of the period of observation before discharge.

  9. A clinically significant apnea event–free period before discharge of 5 to 7 days is commonly used, although a longer period may be suitable for infants born at less than 26 weeks’ gestation. The specific event-free period may need to be individualized for some infants depending on the gestational age at birth and the nature and severity of recorded events.

  10. Interrogation of electronically archived monitoring data may reveal clinically unsuspected events of uncertain significance. Such events do not predict subsequent outcomes, including recurrent clinical apnea or SIDS