Apnoea of prematurity — clinical case

Case summary

This extremely preterm infant presents with a change in her apnoea pattern at one week of age — more frequent, more severe events, with the added features of mild hypothermia and increased gastric residuals. The key clinical insight is that new or worsening apnoea after a stable period is a sentinel for late-onset sepsis or necrotising enterocolitis, not simply immaturity that has outgrown its caffeine dose. [2]

Initial assessment and investigations

The first priority is to treat and to investigate in parallel. Confirm the events on the cardiorespiratory and SpO2 traces, then perform a full examination looking for temperature instability, abdominal distension or tenderness, perfusion, and tone. Given the hypothermia and gastric residuals, the working diagnosis is late-onset sepsis with possible necrotising enterocolitis. [2]

The investigation panel includes a blood culture, full blood count with differential, and CRP; a capillary blood gas and glucose; electrolytes and calcium; and a chest and abdominal X-ray. A cranial ultrasound is reasonable given the gestational age and the change in neurological pattern. [2]

Management

Begin broad-spectrum antibiotics immediately after taking cultures. Continue caffeine citrate, which the infant is already receiving at 5 mg/kg per day; if the level is therapeutic and the cause is sepsis rather than inadequate dosing, increasing the dose will not solve the problem. Caffeine citrate is dosed as a 20 mg/kg load followed by 5 to 10 mg/kg once daily. [1]

Add non-invasive respiratory support — nasal continuous positive airway pressure or nasal intermittent positive-pressure ventilation — to splint the airway and reduce the obstructive burden while the infection is treated. Reserve doxapram for refractory apnoea only, given its thinner evidence base. [2]

Disposition and counselling

Once the infection is treated and the apnoea settles, the infant can be weaned back to her baseline support. Counsel the family that apnoea of prematurity usually resolves by 36 weeks postmenstrual age, with resolution by 43 to 44 weeks in the extremely preterm, and that it is not a risk factor for sudden infant death syndrome. Discharge will require an apnoea-free interval, stable feeding, and adequate growth, typically around 34 to 36 weeks postmenstrual age; home cardiorespiratory monitoring is not routinely indicated. [3]