A 2-week-old girl is evaluated in the neonatal intensive care unit. The patient was born at 26 weeks gestation weighing 820 g (1 lb 13 oz). She had mild respiratory distress syndrome at birth and received ampicillin and gentamicin empirically until cultures were sterile at 48 hours. Enteral breast milk feeds have been started and well tolerated. On day of life 3, the patient began having episodes of apnea characterized by 25-30 seconds without respiratory effort and subsequent bradycardia and desaturations. These episodes have occurred intermittently since onset. The patient recovers spontaneously or with brief stimulation. Between episodes, she is well-appearing and has normal vital signs; she continues to breathe comfortably on high-flow nasal cannula at 21% FiO2. The anterior fontanelle is soft and flat. Lungs are clear to auscultation. The abdomen is soft and bowel sounds are normal. Ultrasound of the head is normal. Which of the following is the best next step in management of this patient's apneic episodes?
Apnea of prematurity | |
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Clinical features |
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Treatment/prognosis |
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IVH = intraventricular hemorrhage. | |
This well-appearing preterm infant with episodes of apnea, bradycardia, and desaturation most likely has apnea of prematurity (AoP). AoP is characterized by intermittent cessation of respiratory effort for >20 seconds due to immature central respiratory centers in the pons and medulla. The condition occurs more frequently with increasing prematurity, affecting virtually all infants born <28 weeks gestation.
Apneic episodes typically begin on day of life 2 or 3 and usually recur over subsequent weeks to months, as in this patient. Infants are well-appearing between episodes. The diagnosis is clinical, and no additional testing is indicated in a patient with characteristic findings. Evaluation for other causes of apnea is reserved for the following situations:
For frequent, prolonged spells associated with bradycardia or hypoxia, treatment includes caffeine (which stimulates the respiratory center) and/or noninvasive respiratory support (eg, high-flow nasal cannula).
(Choice A) Premature infants are at risk for necrotizing enterocolitis (ischemic necrosis of intestinal mucosa), which is often diagnosed by abdominal x-ray. The presentation may include apneic episodes, but progressive gastrointestinal findings (eg, feeding intolerance, abdominal distension, bloody stools) or hemodynamic instability would be expected. In contrast, this patient is well-appearing and has been tolerating enteral feeds.
(Choice B) CT scan of the chest is used to evaluate complex pulmonary disease, such as evolving bronchopulmonary dysplasia or congenital lung malformations. This infant has a normal lung examination and normal breathing pattern between episodes, making CT scan low yield.
(Choice D) Infants with sepsis can present with apnea but are typically ill-appearing between episodes and deteriorate clinically if antibiotics are not started promptly. This infant has had a stable clinical course for weeks and has a normal physical examination, making sepsis unlikely.
(Choice E) Rarely, subclinical seizures can present as apneic episodes. However, this infant has a normal physical examination, normal ultrasound of the head, and no abnormal motor activity, making seizures less likely than AoP.
Educational objective:
Apnea of prematurity is caused by immature respiratory centers in the pons and medulla and affects virtually all preterm infants born <28 weeks gestation. Diagnosis is clinical, and no additional testing is required in a well-appearing infant with a classic presentation in the first few days of life.