Apnoea of Prematurity

Why is this topic important?

Apnoea of prematurity is one of the commonest problems in preterm infants and a frequent MRCPCH neonatal topic. It is important because candidates must distinguish benign immaturity from serious causes such as sepsis, hypoglycaemia, seizures or respiratory deterioration.

Definition

Apnoea of prematurity is a pause in breathing in a preterm infant, usually due to immaturity of respiratory control.

It is commonly defined as:

Breathing pause lasting 20 seconds or more

Shorter pause associated with bradycardia, desaturation or colour change

Key MRCPCH Facts

Common in infants born before 34 weeks.
More common with lower gestational age.
Usually improves with maturation.
Caffeine citrate is first-line treatment.
Always exclude secondary causes before diagnosing apnoea of prematurity.

Pathophysiology

Preterm infants have immature respiratory control centres in the brainstem.

This causes:

Reduced respiratory drive
Poor response to carbon dioxide
Immature airway tone
Increased susceptibility to desaturation and bradycardia

Types of Apnoea

Central Apnoea

No respiratory effort.

Due to immature respiratory control.

Obstructive Apnoea

Respiratory effort is present but airflow is obstructed.

May be due to airway positioning or upper airway collapse.

Mixed Apnoea

Combination of central and obstructive components.

This is common in premature infants.

Causes and Differential Diagnosis

Before diagnosing apnoea of prematurity, consider:

Infection

Neonatal sepsis
Meningitis

Metabolic

Hypoglycaemia
Hypocalcaemia
Temperature instability

Respiratory

RDS
Pneumonia
Chronic lung disease

Neurological

Seizures
IVH

Cardiovascular

PDA
Arrhythmia

Gastrointestinal

Significant reflux is sometimes considered, but reflux is often over-attributed as a cause.

Clinical Features

Pause in breathing
Desaturation
Bradycardia
Colour change
Reduced tone
Need for stimulation

Investigations

Bedside

Oxygen saturation monitoring
Heart rate monitoring
Temperature
Blood glucose

If Unwell or New Apnoea

Septic screen
Blood gas
FBC and CRP
Blood culture
Consider lumbar puncture if clinically indicated

If Neurological Concern

Cranial ultrasound
EEG or aEEG if seizures suspected

Management

Immediate Management

Assess airway, breathing and circulation.
Gentle stimulation.
Correct positioning.
Oxygen if needed.

Treat Underlying Cause

If apnoea is due to sepsis, hypoglycaemia, anaemia or other pathology, treat the cause.

Caffeine Citrate

Caffeine is the standard treatment for apnoea of prematurity.

Benefits:

Stimulates respiratory drive
Reduces apnoea frequency
Reduces need for ventilation

Respiratory Support

If frequent or severe episodes:

CPAP
High-flow oxygen
Mechanical ventilation if severe

Complications

Prolonged hospital stay
Feeding delay
Need for respiratory support
Parental anxiety

Common Exam Traps

Trap 1

Do not diagnose apnoea of prematurity without excluding sepsis and hypoglycaemia.

Trap 2

A new increase in apnoea frequency may be a sign of infection.

Trap 3

Caffeine is treatment; antibiotics are not unless infection is suspected.

Trap 4

Apnoea is more common with lower gestation.

One Minute Revision

Preterm baby + apnoea + bradycardia = think apnoea of prematurity.
Always exclude sepsis, hypoglycaemia and seizures.
Caffeine citrate is first-line treatment.
CPAP may be needed if frequent or severe episodes.

Suggested References

NICE Guideline: Specialist neonatal respiratory care for babies born preterm
BNF for Children: Caffeine citrate
RCPCH Guidance
Nelson Textbook of Pediatrics
Rennie & Roberton’s Textbook of Neonatology

Disclaimer

These notes are intended for MRCPCH revision and educational purposes only. They do not replace local, national or institutional guidelines. Clinical decisions should always be based on current guidance, senior advice and individual patient circumstances.

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