Introduction.
Apnea is cessation of breath for more than 15 seconds with bradycardia and cyanosis.
There may also be hypotonia or pallor in
severe cases.
It is particularly common among very preterm infants with estimated gestational age of <32 weeks.
It may also occur among sick term babies.
Prematurity and immaturity of the central respiratory centre causes a separate entity known as “Apnea of Prematurity”.
Other causes include septicaemia,
pneumonia, necrotizing enterocolitis, gastro oesophageal reflux, congestive cardiac failure, meningitis, intra-cranial
haemorrhage, seizures, hypoglycaemia,
severe anaemia and urinary tract infection.
Management
The first step in the management of an apneic infant is to provide tactile stimulation such as flicking the sole of the feet.
If there is no response to tactile stimulation, the following steps are recommended:
- Resuscitation: airway clearance,
assisted breathing and circulation according to standard protocols. - 10% Dextrose-in-Water (4ml/kg) for the correction of blood glucose.
- Start any of the following depending on availability:
Methyl-xanthine.
- Caffeine citrate in a loading dose of 20mg/kg oral or slow intravenous and maintenance of 5mg/kg per 24 hours is the drug of choice.
Alternative drugs include aminophylline in a loading dose of 6mg/kg slow intravenous and maintenance of 2.5mg/kg 12-hourly.
Apnea monitor should be used if available or a pulse oximeter with an alarm system turned for hypoxaemia may be a good substitute.
If apnea persists, nasal Continuous
Positive Airway Pressure (CPAP) is
recommended at 4-5cm H₂O.
If apnea still persists with persisting cyanosis, intubation and subsequent commencement of Intermittent Positive Pressure Ventilation is recommended.
For preterm infants, the medications may be continued until the infant attains the post conceptional age of 33-34 weeks.
For other infants, medications may be continued till the infant no longer requires oxygen therapy or has been free of apnea for at least 5 days.
Nursing in the prone position with cessation of oral feeds may be helpful if apnea becomes recurrent and gastro-oesophageal reflux is highly suspected.