Apnea of Prematurity.

AAP Issues Guidance on Apnea of Prematurity. Pediatrics, January 2016, Eric C. Eichenwald, COMMITTEE 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