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Key Features

Essentials of Diagnosis

  • Respiratory pause of sufficient duration to result in cyanosis or bradycardia

  • Most common in infants born before 34 weeks' gestation; onset before 2 weeks of age

  • Methylxanthines (eg, caffeine) provide effective treatment

General Considerations

  • Defined as a respiratory pause lasting more than 20 seconds—or any pause accompanied by cyanosis and bradycardia

  • Causes

    • Temperature instability—both cold and heat stress

    • Response to passage of a feeding tube

    • Gastroesophageal reflux

    • Hypoxemia

      • Pulmonary parenchymal disease

      • Patent ductus arteriosus

      • Anemia

    • Infection

    • Sepsis (viral or bacterial)

    • Necrotizing enterocolitis

    • Metabolic causes

      • Hypoglycemia

    • Intracranial hemorrhage

    • Posthemorrhagic hydrocephalus

    • Seizures

    • Drugs (eg, morphine)

    • Apnea of prematurity

Clinical Findings

  • Onset is typically during the first 2 weeks of life

  • Frequency of episodes gradually increases with time

  • Pathologic apnea should be suspected if episodes are sudden in onset, unusually frequent, or very severe

  • Apnea at birth or on the first day of life is unusual but can occur in the nonventilated preterm infant

  • In the full-term or late preterm infant, presentation at birth suggests neuromuscular abnormalities of an acute (asphyxia, birth trauma, or infection) or chronic (eg, congenital hypotonia or structural CNS lesion) nature


  • All infants—regardless of the severity and frequency of apnea—require a minimum screening evaluation, including

    • A general assessment of well-being (eg, tolerance of feedings, stable temperature, normal physical examination)

    • A check of the association of spells with feeding

    • Measurement of PaO2 or SaO2

    • Blood glucose

    • Hematocrit

    • Review of the drug history

  • Infants with severe apnea of sudden onset require more extensive evaluation for primary causes, especially infection


  • Any underlying cause should be treated

  • If the apnea is due simply to prematurity, symptomatic treatment is dictated by the frequency and severity of apneic spells

  • Spells frequent enough to interfere with other aspects of care (eg, feeding), or severe enough to cause cyanosis or bradycardia necessitating significant intervention or bag and mask ventilation require treatment

  • Caffeine citrate (20 mg/kg as loading dose and then 5–10 mg/kg/d) is the drug of choice

    • Side effects are generally mild and include tachycardia and occasional feeding intolerance

    • Target drug level is usually 10–20 μg/mL

  • Nasal continuous positive airway pressure (CPAP) is effective in some infants

  • Intubation and ventilation can eliminate apneic spells but carry the risks associated with endotracheal intubation.

  • Although many preterm infants are treated medically for possible reflux-associated apnea, there is little evidence to support this intervention; if suspected, a trial of continuous drip gastric or transpyloric feedings can be helpful as a diagnostic and therapeutic intervention



  • In most premature infants, apneic and bradycardiac spells cease by 34–36 weeks

  • Apneic and bradycardiac episodes in the nursery are not predictors of later SIDS, although the ...

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