Apnoea, Neonatal
Description Diagnostic criteria General and supportive measures Medicine treatment Referral ICD-10 code: 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 t
Description
Diagnostic criteria
General and supportive measures
Medicine treatment
Referral
ICD-10 code: 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 (heart rate < 100 bpm).
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, and
- medicines (sedatives, anticonvulsants, analgesics).
Obstructive apnoea
Neonates are obligatory ‘nose breathers’. Obstruction of the nares makes 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 skin temperature at 36.2–36.8°C.
- Maintain haematocrit at 30%.
- Maintain nasal CPAP of 4–6 cmH2O. (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 90–95% or an oxygen tension in the blood at 60–80 mmHg:
- Oxygen via nasal cannula or mask.
Only for apnoea of prematurity (not term infants):
- Caffeine citrate, oral/IV:
- Oral route strongly recommended (formulation can be extemporaneously compounded).
- Loading dose: 20 mg/kg.
- Maintenance dose: 5 mg/kg/24 hours. Start maintenance dose 24 hours after the loading dose. (Caffeine citrate 20 mg = caffeine base 10 mg.)
OR
(if caffeine not available)
- Aminophylline, 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 μg/mL.
If neonate responds favourably to caffeine/aminophylline, continue until neonate is apnoea free for 7 days.
REFERRAL
- Recurrent life-threatening episodes of apnoea, not responding to adequate treatment and requiring ventilation.
Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition
Chapter 19: Prematurity And Neonatal Conditions, 19.3 Prematurity/Preterm Neonate, 19.3.4 Apnoea, Neonatal