Apnea in Premature Infants

Premature infants, particularly those born more than seven weeks early (before 32 weeks of pregnancy), often have apnea. Having apnea means your baby has pauses in his/her breathing pattern (apnea spells). Apnea is the stopping of breathing for 20 seconds or longer. It may be shorter if associated with a heart rate drop (usually below 80 beats per minute), color change (blue or pale) or a drop in the amount of oxygen in the blood (oxygen saturation).

Apnea may happen only once a day or many times a day. The more immature the baby is, the more frequent the apnea spells. As the baby matures, he/she usually outgrows the apnea.

 What is normal?

All infants stop breathing for a brief period of time. Extensive studies recently show that most infants maintain their oxygen levels at normal levels if they take a breath at least every 20 seconds. Some premature infants may not be able to wait this long.

 What is not normal?

  • When pauses between breaths are longer than 20 seconds
  • When pauses are less than 20 seconds but are associated with a drop in heart rate or a color change (blue or pale)

 Types of apnea

  • Central Apnea
    The premature baby's brain is not yet programmed for nonstop breathing, so the baby sometimes stops breathing. Apnea caused by an immature brain is called central apnea. The premature baby outgrows central apnea as the brain matures.
  • Obstructive Apnea
    Premature infants have another kind of apnea spell called obstructive apnea. This kind of apnea occurs when their fragile airway is blocked. The block may be caused by mucous, or the baby may be in a position that kinks the airway. Suctioning the airway or changing the baby's position usually relieves the problem. Again, growth and strengthening of the tissues in the airway often solve this problem.

Most premature babies have both kinds of apnea.

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 Treatments

The treatment for apnea is designed to protect the baby while we wait for him/her to outgrow the problem.

1. Stimulation

When the monitor alarm sounds, the nurse goes to the baby and observes. The nurse determines whether the baby is breathing, what the heart rate is, and whether the baby's skin has changed color. Many times the baby starts breathing again by himself/herself and does not need any help.
If the baby is not breathing, his/her back, arms or legs are rubbed. The baby's head may be turned to a different side or he/she may be turned over. This kind of stimulation is continued until the baby is clearly trying to breathe again. If the baby remains pale or bluish, oxygen may be given. Occasionally the baby may be given some breaths with a bag filled with oxygen to help him/her start breathing again.

2. Medications

Several medications can stimulate the part of the brain that controls breathing and can reduce the number of apnea spells. Aminophylline and theophylline are the most commonly used drugs. They can be given directly into the veins (intravenously, or IV) or by mouth. Caffeine can also be very effective and is given by IV or by mouth.
Side effects from the medications are usually mild. They include fast heart rate, throwing up and irritability. The levels of medication in the blood can be measured and the dosage adjusted to get just the right level and avoid most side effects.
The baby keeps getting medication until he/she has outgrown the apnea.

3. Monitors

Although not a treatment, premature and sick infants are more likely to have apnea. Because premature and sick newborn babies are likely to have apnea, all premature babies admitted to Children's Healthcare of Atlanta have a monitor attached to them that continuously measures heart rate and respiratory (breathing) rate. If the baby stops breathing for too long or his/her heart rate drops too low, the monitor sounds an alarm to alert the staff. A nurse then immediately checks the baby to see if he/she needs help.
Many alarms are false because the monitor did not measure the breathing or heart rate correctly. Sometimes the monitor leads come off the skin, causing an alarm to sound. Someone must check the baby and determine if it is a false alarm.
Spells are recorded to track how the baby is doing.

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 Discharge from the hospital

The decisions for discharge from the hospital may be different for each baby, but here are some general guidelines:

  • Families of babies with apnea are encouraged to train in infant cardiopulmonary resuscitation (CPR) before the baby is discharged.
  • If a baby has never been on medication for apnea, he/she is ready for discharge after not having apnea for seven days.
    - If a baby has been on medication for apnea but has not had apnea for seven days, he/she may be sent home with a prescription for theophylline or caffeine.
  • If a baby on medication is apnea free but not ready to go home for other reasons, the theophylline or caffeine may be stopped and the baby will be observed for apnea for five to seven days.
  • If a baby is still having apnea spells, even on medication, the doctor may recommend home monitoring to allow earlier discharge from the hospital. The family will be taught how to use a monitor at home. These monitors are similar to the monitors used in the hospital and will sound an alarm if the baby's breathing or heart rate changes.

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 Long-term outcome

Apnea caused by prematurity is not a cause of SIDS (Sudden Infant Death Syndrome, or crib death). Babies who have had apnea of prematurity are not necessarily at a higher risk for SIDS. Your baby's physician makes decisions for home monitoring based on how the baby is outgrowing his/her apnea spells, not to protect him/her from SIDS.
All babies outgrow apnea caused by prematurity, although some may take longer than others. Most babies stop having apnea by one month after their due date (44 weeks after conception).

Apnea is one of the more frightening problems premature babies can have, but rest assured, they do outgrow it.