Apneas represent another important group of respiratory/ventilation dysfunctions in newborns (apart from perinatal asphyxia and respiratory distress syndrome). They are generally defined as a cessation of breathing movements and air flow for more than 20 seconds, thus often being accompanied by desaturation and bradycardia.
Division of apneas
- central
→ prematurity
→ injury to respiratory control centre in medulla oblongata and pons (brainstem) - peripheral
→ airway obstruction (muscle hypotonia, meconium) - mixed
→ central and peripheral features
Mixed apneas are typical and highly frequent in preterm infants => apnea of prematurity (AOP). Special attention is given to recurrent apneas that endanger a newborn by severe and/or prolonged desaturations/bradycardia, thus causing hypoxic injury and cerebral reperfusion damage.
DIAGNOSIS
Causes of Apnea
- seizures (especially in term infants)
- apnea of prematurity
- congenital upper airway defects (orofacial cleft, stenosis, atresia)
- congenital pulmonary (lower) airway malformation (CPAM)
- respiratory distress syndrome (RDS)
- neurologic issues (PIVH, HIE, meningitis)
- sepsis (EOS, LOS)
- gastro-esophageal reflux (GER)
- anemia
- circulation issues (PDA – rare cause of apneas)
- disturbed homeostasis (hypothermia, hyperthermia, hypoxemia, hypoglycemia, hyponatremia, hypocalcemia)
- inherited metabolic disorders
- medication (phenobarbital, opioids)
- inappropriate handling and positioning
THERAPY
General
- Appropriate handling and positioning
- Upper airways suctioning
- Elevated position (GER)
- Slow infusion of enteral feeds or continuous enteral feeding (GER)
- Oxygen (maintain normoxemic oxygenation)
Specific
- Caffein citrate
- Ventilation support (CPAP or mechanical ventilation)
Caffein citrate (PEYONA®)
→ stimulates respiratory control centre in the brainstem
→ prevention from apnea of prematurity
→ Loading dose: 20 mg/kg i.v. (30 minute infusion)
→ Maintenance dose: 5-10 mg/kg/day i.v./p.o. (given once daily and titrated as per clinical effect)
→ Adverse effect: tachycardia
REFERENCES
① Koch G, Datta AN, Jost K, Schulzke SM, van den Anker J, Pfister M. Caffeine Citrate Dosing Adjustments to Assure Stable Caffeine Concentrations in Preterm Neonates. J Pediatr. 2017 Dec;191:50-56.e1. doi: 10.1016/j.jpeds.2017.08.064
② Sweet DG, Carnielli V, Greisen G, et al. European Consensus Guidelines on the Management of Respiratory Distress Syndrome – 2019 Update. Neonatology. 2019;115(4):432-450. doi:10.1159/000499361