Neonatal apnoea: recognition, causes and management
Apnoea is cessation of breathing for about 20 seconds or a shorter pause associated with bradycardia, cyanosis, pallor or marked hypotonia. Apnoea of prematurity reflects immature respiratory control, but apnoea in any newborn may signal sepsis, hypoglycaemia, seizures, airway obstruction, respiratory disease, anaemia, temperature disturbance or neurological injury.
Treat the event immediately, then search for an underlying cause—“apnoea of prematurity” is a diagnosis of exclusion.
Types and clinical patterns
- Central: absent respiratory effort and airflow.
- Obstructive: respiratory effort continues but airflow is blocked.
- Mixed: central pause followed by obstruction or the reverse; common in preterm infants.
- Periodic breathing: brief pauses separated by regular breaths, usually without colour change or bradycardia; distinguish from pathological apnoea.
Immediate response
- Call for help, assess airway, breathing, heart rate, colour, oxygen saturation and perfusion.
- Position head neutrally, ensure airway patency and provide gentle tactile stimulation.
- If breathing does not resume promptly or bradycardia/cyanosis persists, begin positive-pressure ventilation with a correctly fitted mask.
- Escalate to CPAP, intubation and resuscitation protocol when ventilation is ineffective or recurrent.
- Check bedside glucose and temperature immediately; treat abnormalities.
Causes to exclude
| Cause | Clues | Evaluation/response |
|---|---|---|
| Apnoea of prematurity | Preterm, recurrent, otherwise stable, often mixed | Monitor, stimulation, caffeine and respiratory support |
| Sepsis/meningitis | Temperature instability, poor feeding, lethargy, perfusion change | Cultures and prompt antibiotics when indicated |
| Hypoglycaemia/electrolyte disorder | Jitteriness, seizures, poor feeding, instability | Immediate glucose/electrolyte testing and correction |
| Respiratory disease | Grunting, retractions, oxygen need, abnormal gases | Respiratory support and chest evaluation |
| Seizure/neurological injury | Abnormal movements, tone, consciousness or birth asphyxia | Glucose, calcium, EEG and neurological assessment |
| Airway obstruction/aspiration | Choking, secretions, stridor, positional events | Airway assessment, feeding review and imaging when indicated |
Assessment and investigations
- Document duration, colour change, heart rate, oxygen saturation, respiratory effort, context (feed/sleep/handling), intervention and recovery.
- Review gestation, birth history, maternal drugs, infection risks, feeding and previous events.
- Check glucose, temperature, blood gas, electrolytes, calcium, haemoglobin and sepsis tests according to presentation.
- Consider chest radiograph, ECG, cranial ultrasound/MRI, EEG, airway assessment or reflux/aspiration evaluation when clinically indicated.
- Continuous cardiorespiratory and saturation monitoring is required for recurrent or significant events.
Apnoea of prematurity management
Supportive measures
Maintain neutral airway position, minimise handling, avoid excessive neck flexion, prevent hypothermia, treat infection, optimise oxygenation and provide safe feeding. Review medications and anaemia.
Caffeine
Caffeine citrate is standard therapy for clinically significant apnoea of prematurity. Use the current weight-based loading/maintenance regimen and monitor heart rate, feeding, seizures and response under neonatal protocol.
CPAP/non-invasive support
Use CPAP or other non-invasive support for recurrent apnoea, obstruction or oxygen/ventilation need. Check interface, pressure, gastric distension, nasal injury and work of breathing.
Mechanical ventilation
Intubate and ventilate for persistent apnoea with bradycardia, failure of non-invasive support, severe respiratory disease or inability to protect the airway.
Feeding and discharge
Pause oral feeds during severe or recurrent events, assess suck–swallow–breathe coordination and use expressed milk by a safe route. Before discharge, the infant should be clinically stable, maintaining temperature and feeding, with no significant untreated apnoea/bradycardia/desaturation for the unit’s protocol-defined observation period. Educate caregivers about safe sleep, CPR response where available and urgent return for colour change, pauses, poor feeding or lethargy. Home monitors are not a substitute for diagnosis and follow-up.
References
- SlideShare: Neonatal apnoea.
- AAP review: Apnoea of prematurity.
- Current neonatal resuscitation and local neonatal-unit protocols.
