Apnea and Bradycardia of Prematurity Discharge Considerations
Yvette Pugh, MS CRNP NNP-BC
Apnea of prematurity (AOP) is a developmental condition that reflects physiologic immaturity of respiratory control and affects most infants born at less than 37 weeks' gestational age (Patrinos, 2020; Kesavan & Parga, 2017). Apnea occurs in almost all babies born before 28 weeks' gestational age, and the frequency of symptoms is inversely proportional to the postmenstrual age (PMA) (Chandrasekharan, Rawat, Reynolds, Phillips, & Lakshminrusimha, 2017; Eichenwald, 2016; Kesavan & Parga, 2017). Apnea of prematurity is one of the most common diagnoses in the neonatal intensive care unit and contributes to prolonged hospital stays (Eichenwald, 2016; Kesavan & Parga, 2017). Management practices regarding discharge decisions vary widely among neonatologists, but most practitioners include a 5- to 10-day apnea/bradycardia free period before sending a premature infant home without a monitor. The purpose of the following discussion is to present information regarding discharge considerations to assist with discharge planning and the transition to home for babies affected by AOP.
Although there is no consensus on the definition of apnea of prematurity, the American Academy of Pediatrics (AAP) defines it as a cessation of breathing for 15–20 seconds or longer accompanied by bradycardia (< 100 beats per minute), a decrease in oxygen saturation < 85%, or pallor, not associated with feeding (Eichenwald, 2016; Kesavan & Parga, 2017; Patrinos, 2020).
Apnea traditionally is classified as either obstructive, central, or mixed (Kesavan & Parga, 2017):
- Obstructive apnea may occur when the infant's neck is hyperflexed or, conversely, hyperextended. It also may occur because of low pharyngeal muscle tone or inflammation of the soft tissues, which can block the flow of air through the pharynx and vocal cords.
- Central apnea occurs when there is a lack of respiratory effort. This may result from central nervous system immaturity or from the effects of medications or illness.
- Many episodes of apnea of prematurity may start as either obstructive or central but then involve elements of both, becoming mixed in nature.
Apnea is a developmental disorder, rather than pathophysiologic, that resolves with increasing maturity (Kesavan & Parga, 2017; Patrinos, 2020). Apnea occurs in almost all babies born before 28 weeks' gestational age, and the frequency of symptoms is inversely proportional to the postmenstrual age (PMA) (Darnall, Kattwinkel, Nattie & Robinson, 1997; Eichenwald, 2016). Episodes of apnea and bradycardia often cease by 37 weeks' PMA, but infants born before 28 weeks' gestation have been found to have apneic and bradycardic events that last up to 44 weeks' PMA (Centene, 2019, Darnell et al., 1997; Eichenwald, 2106; Kesavan & Parga, 2017).
Interventions for AOP include positional, pharmacologic, and ventilator techniques (Kesava & Parga, 2017). Methylxanthine therapy, usually theophylline or caffeine, has been the main pharmacologic treatment for AOP (Kesavan & Parga, 2017; Martin, 2019; Optum 2018; Patrinos, 2020). However, caffeine citrate has emerged as the primary treatment due to its daily dosing, broader therapeutic range, longer half-life, and good safety profile (Kesavan & Parga, 2017; Patrinos, 2020). Caffeine is recommended for all infants born before 28 weeks' gestation with some recommendations for caffeine for all infants born at 29–32 weeks' gestation because most of these infants will experience AOP (Kesavan & Parga, 2017). There are no clear guidelines for the discontinuation of treatment, but most providers discontinue treatment at 33–34 weeks' PMA if there have been no events for 7 days (Kesavan & Parga, 2017).
AOP Monitor Watch Studies
Several studies have been conducted to provide discharge recommendations for preterm infants who have experienced apneic, bradycardic, and desaturation events. In one 1997 study, Darnall and colleagues attempted to define a minimal and safe observation period between the last event and discharge. In the study, 36% of infants born at or before 28 weeks' gestation experienced apnea beyond 40 weeks PMA, compared with only 2.4% of infants born after 28 weeks' gestation (Darnall et al., 1997). Of the infants who required an apnea-free period prior to discharge, 86% of the infants required a period of 5 or more days, with 75% requiring a 5- to 7-day observation period (Darnall et al., 1997). Thirty percent of the infants with a 5- to 7-day observation period required stimulation, and 60% of the infants with a 2- to 4-day observation period required stimulation (Darnall et al., 1997). Presumably, the timeframe of 5 to days provides an appropriate margin of safety, decreasing the probability that an event will occur at home (Darnall et al., 1997).
One study by Lorch and colleagues reported a 95% success rate threshold of 9 days for infants born at 27–28 weeks' gestation and 13 days for infants born before 26 weeks' gestation (Lorch, Srinivasan, Escobar, 2011). A study by Chandrasekharan and colleagues showed a decreased period of observation prior to discharge after the implementation of a monitor watch protocol as opposed to the observation period prior to discharge before implementation of a protocol (Chandrasekharan et al., 2017). In addition, implementation of a protocol for an apnea-free observation period did not prolong the length of stay but effectively reduced interprovider variability and readmission rates (Chandrasekharan et al., 2017).
In general, complete cessation of apneic/bradycardic/desaturation events is required for a period prior to discharge (Chandrasekharan et al., 2017; Eichenwald, 2016; Kesavan & Parga, 2017). Most providers include an event-free period prior to discharge for at least 5–10 days after discontinuation of caffeine therapy (Centene, 2019; Chandrasekharan et al., 2017; Darnall et al., 1997; Eichenwald, 2016; Martin, 2019). Depending on the severity, feeding-related events are not included in the monitor watch. The event-free period may be extended for infants at a younger gestational age (i.e., < 26 weeks) (Optum, 2018). As set forth by the AAP and Committee on Fetus and Newborn, individual units are encouraged to develop policies and procedures for caregiver assessment, intervention, and documentation of apnea/bradycardia/desaturation events as well as the duration of the period of observation prior to discharge (Chandrasekharan et al., 2017).
- Centene Corporation. (2019). Clinical policy: NICU apnea and bradycardia guidelines. Reference Number: CP.MP.82. https://www.azcompletehealth.com/content/dam/centene/policies/clinical-policies/CP.MP.82.pdf
- Chandrasekharan, P., Rawat, M., Reynolds, A. M., Phillips, K., & Lakshminrusimha, S. (2017). Apnea, bradycardia and desaturation spells in premature infants: Impact of a protocol for the duration of 'spell-free' observation on interprovider variability and readmission rates. Journal of Perinatology, 38:86-91. doi: 10.1038/jp.2017.174
- Darnall, R. A., Kattwinkel, J., Nattie, C., & Robinson, M. (1997). Margin of safety for discharge after apnea in preterm infants. Pediatrics, 100(5):795-801. doi: 10.1542/peds.100.5.795
- Eichenwald, E. C., and AAP Committee on Fetus and Newborn. (2016). Apnea of prematurity. Pediatrics, 137(1):e20153757. doi: 10.1542/peds.2015-3757
- Kesavan, K. & Parga, J. (2017). Apnea of prematurity: Current practices and future directions. NeoReviews, 18(3):e149. https://doi.org/10.1542/neo.18-3-e149
- Lorch, S. A, Srinivasan, L., Escobar, G. J. (2011). Epidemiology of apnea and bradycardia resolution in premature infants. Pediatrics. 128(2). www.pediatrics.org/cgi/content/full/128/2/e366
- Martin, R. (2019). Management of apnea of prematurity. UpToDate. Accessed October 26, 2019. https://www.uptodate.com/contents/management-of-apnea-of-prematurity
- Optum. (2018). Clinical performance guideline; Neonatal resource services: Apnea and bradycardia [Medical Necessity Guideline].
- Patrinos, M. E. (2020). Neonatal apnea and the foundation of respiratory control. In: R. Martin, A. Fanaroff, & M. Walsh (Eds.), Fanaroff and Martin's neonatal-perinatal medicine (11th ed., pp. 1234–1235, 1239). Saunders.