Apnea of Prematurity

Presentation

• Premature infant (common < 34 weeks gestation)
• Pause in breathing > 20 seconds
• OR pause < 20 seconds accompanied by bradycardia (< 100 bpm) or oxygen desaturation
• Exclude other causes (sepsis, IVH, NEC, hypoglycemia) before diagnosing 'Apnea of Prematurity'

Treatment & Management

• Tactile stimulation for acute events
• Pharmacologic therapy: Caffeine Citrate (loading dose 20 mg/kg, maintenance 5-10 mg/kg/day)
• Respiratory support: Nasal CPAP to stent airway open (treats mixed/obstructive apnea components)
• Maintain appropriate head positioning (sniffing position) to avoid airway obstruction

Discharge Criteria

• Caffeine typically discontinued between 33-34 weeks PMA (postmenstrual age) if symptom-free
• Requires a completely spell-free observation period (typically 5 to 7 days) completely OFF caffeine and positive pressure
• Assess for car seat tolerance (prevent obstructive position issues)

Advanced Respiratory & Ventilator Protocol

• Surfactant dosing (Poractant alfa): 2.5 mL/kg (200 mg/kg) initial dose, administer via INSURE or LISA method to minimize mechanical trauma.
• High-Frequency Oscillatory Ventilation (HFOV) starting parameters: MAP 1-2 cmH2O above conventional ventilation, Amplitude adjusted to achieve visible chest wiggle.
• Target SpO2 explicitly strictly to 90-95% for infants < 32 weeks to prevent Retinopathy of Prematurity.
• Provide aggressive tracheobronchial suctioning ONLY when clinically indicated by coarse breath sounds or desaturations, not routinely.
• Permissive hypercapnia: Allow PaCO2 up to 55-60 mmHg if pH remains > 7.25 to prevent barotrauma.

Standardized Discharge & Follow-Up Criteria

• Adequate weight gain explicitly > 15-30g/day over a continuous 3-5 day period.
• Maintenance of temperature in an open crib with standard clothing for 48 hours.
• Successful completion of the 90-120 minute Infant Car Seat Challenge.
• Caregiver successfully completed CPR training, rooming-in, and independent medication administration.
• Referrals placed for High-Risk Infant Follow-Up Clinic, Early Intervention (PT/OT), and appropriate sub-specialists.

Diagnostic & Management Algorithm

• Apnea of Prematurity Management: [START] Apnea > 20s or with bradycardia -> [ACTION] Tactile stimulation -> [DECISION] Recurrent? -> [YES] Caffeine Citrate load -> [NO] Monitor -> [DECISION] Refractory? -> [YES] CPAP/NIPPV

References

1. Zhao J, Gonzalez F, Mu D. Apnea of prematurity: from cause to treatment. Eur J Pediatr.
2. Rhein LM, Dobson NR, Darnoko R. Apnea of Prematurity and Neurodevelopmental Outcomes. Pediatrics.