The onset of AOP is typically within the first 48 hours of life although it can take up to a week to manifest. Typically, a lower GA is correlated to a lengthier duration of this condition.

Bradycardia occurs in the different subtypes of apnea, especially in infants with longer episodes of the disorder. Moreover, this phenomenon is observed in 75% of apneic events that continue for more than 20 s where is it is seen in 10% of spells that last 10s to 14s. Typically, the drop in the heart rate is more than 30% from the baseline.

Additionally, one study discovered that oxygen desaturation precedes bradycardia although the latter recovers first [5]. Bradycardia may occur without desaturation as well.

Physical exam

Neonates with apnea demonstrate notable findings such as absent wall movement, cyanosis, and hypotonia [1]. The patient is typically gasping for air during these episodes. Additionally, auscultation of the lungs yields no breath sounds [8].

• Collapse

  In addition, we found that the primary site of OSA is not necessarily the same as the collapsible conduit site. [jcsm.aasm.org]

  Abstract Obstructive sleep apnoea syndrome (OSAS) is a common clinical condition in which the throat narrows or collapses repeatedly during sleep, causing obstructive sleep apnoea events. [ncbi.nlm.nih.gov]

  The pharynx collapses from negative pressure generated during inspiration, because the muscles responsible for keeping the airway open, the genioglossus and geniohyoid are too weak in the premature infant. [uichildrens.org]

  […] otorhinolaryngology, Faculty of medicine ,Benha University, Egypt 3Department of Cardiology, Faculty of medicine, Benha University, Egypt Abstract Introduction: Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive partial and total collapse [zumj.journals.ekb.eg]

  It prevents collapse of the lower throat and pulls the tongue muscles forward, thereby opening the obstructed airway. [centralarkansasentclinic.com]

• Fatigue

  Sleep apnea most commonly causes excessive fatigue and often creates a loud snoring reflex. [prima-care.com]

  Some complications include: Fatigue. The repeated awakenings associated with sleep apnea make normal, restorative sleep impossible. People with central sleep apnea often experience severe fatigue, daytime drowsiness and irritability. [mayoclinic.org]

  Lack of Concentration — The mental fatigue of sleep deprivation can make daily activities more challenging than they should be. [tmjtexas.com]

  On the other hand, hypothyroidism can be associated with OSA [6], and some symptoms, such as daytime sleepiness, fatigue, and lethargy, overlap for both diseases. [apfmj.biomedcentral.com]

  Whether you feel groggy and fatigued on a full night’s rest or you wake yourself up with your snoring, you probably wonder what’s wrong. People often leap immediately to worst case scenarios and think they have sleep apnea. [compcare.us]

• Excessive Daytime Sleepiness

  Sleep apnea is a serious condition that can lead to consequences such as work related or automobile accidents due to excessive daytime sleepiness. [tmjtexas.com]

  Excessive daytime sleepiness is a burden for the majority of patients. [ncbi.nlm.nih.gov]

  daytime sleepiness (hypersomnia) Difficulty paying attention while awake Irritability What To Expect From A Sleep Study To better understand your sleep problem, we will ask you about your sleep habits and about your personal routine and habits. [compcare.us]

  Of the 63 patients asked, 62 (98%) snored and 59 (95%) experienced excessive daytime sleepiness. [jamanetwork.com]

  […] symptoms (excessive daytime sleepiness) and already treated and controlled hypertension in the present model might explain these findings. [primarycare.imedpub.com]

• Hypoxemia

  We postulated that since exogenous opiates modify respiration and the ventilatory response to hypercapnia and hypoxemia (19), the endogenous opiate-like compounds might modify the respiratory response to neonatal asphyxia. [nature.com]

  CLINICAL PEARL Transient hypoxemia and acidosis are well tolerated by the normal newborn. However, prolonged hypoxemia and acidosis lead to depressed hemodynamics, persistent pulmonary hypertension, and poor ventilatory drive. II. [aneskey.com]

  […] newborn 770.84 - Respiratory failure of newborn 770.85 - Aspiration of postnatal stomach contents without respiratory symptoms 770.86 - Aspiration of postnatal stomach contents with respiratory symptoms 770.87 - Respiratory arrest of newborn 770.88 - Hypoxemia [emedcodes.com]

  However, shorter episodes of apnea, and even periodic breathing, may be accompanied by bradycardia or hypoxemia. [doi.org]

• Resistant Hypertension

  Characterization of resistant hypertension: association between resistant hypertension, aldosterone, and persistent intravascular volume expansion. [thieme-connect.com]

  The investigators' laboratory identified primary aldosteronism (PA) as a common cause of treatment resistance with a prevalence of 20% among subjects with resistant hypertension. [clinicaltrials.gov]

  Overall, 25 out of 187 (13.4%) resistant hypertension patients with PA had snoring. There was no difference in the prevalence of resistant hypertension between the groups. [nature.com]

  Clinical characteristics of patients with resistant hypertension: the RESIST-POL study.J Hum Hypertens. 2013; 27:678–685. doi: 10.1038/jhh.2013.32CrossrefMedlineGoogle Scholar 3. [ahajournals.org]

• Tachypnea

  Pulmonary aspergilloma Pulmonary edema Pulmonary function tests Pulmonary nocardiosis Rapid shallow breathing Respiratory acidosis Respiratory alkalosis Rheumatoid lung disease Solitary pulmonary nodule Swan-Ganz - right heart catheterization Transient tachypnea [icdlist.com]

  […] respiratory symptoms 770.18 Other fetal and newborn aspiration with respiratory symptoms 770.2 Interstitial emphysema and related conditions 770.3 Pulmonary hemorrhage 770.4 Primary atelectasis 770.5 Other and unspecified atelectasis 770.6 Transitory tachypnea [healthprovidersdata.com]

  He required continuous positive airway pressure (CPAP) support initially for transient tachypnea but subsequently could not be weaned off as he had recurrent apneas. There was no significant antenatal history. [indianpediatrics.net]

  […] oxygenation from congestive heart failure and pulmonary edema (PDA, coarctation, etc.), or from shunting (cyanotic heart disease) Pulmonary - Impairment of oxygenation and ventilation from lung disease (surfactant deficiency disease, pneumonia, transient tachypnea [uichildrens.org]

• Respiratory Disorders

  This definition was written in the context of Respiratory disorders of newborns [workplacetesting.com]

  Subscription RequiredOriginal Articles Abstract Study Objectives: Obstructive sleep apnea (OSA) is a respiratory disorder caused by the obstruction of the upper airway during sleep. [jcsm.aasm.org]

  ICD-10-CM Codes › P00-P96 Certain conditions originating in the perinatal period › P19-P29 Respiratory and cardiovascular disorders specific to the perinatal period › P28- Other respiratory conditions originating in the perinatal period › Primary sleep [icd10data.com]

  According to the International Classification of Sleep Disorders (CIDS-2) [5], OSAS is mentioned in the category of "sleep-related respiratory disorders". This category is one of eight that describe such disorders. [medcraveonline.com]

  Chapter 18 Differential Diagnosis of Neonatal Pulmonary Disorders See Table 18-1. [clinicalgate.com]

• Abnormal Breathing

  Historical note and terminology The term "central sleep apnea" was coined by Gastaut and his collaborators in their report on the abnormal breathing patterns observed in a subtype of so-called "Pickwickian patients," morbidly obese subjects with somnolence [medlink.com]

  Sleep disturbances produced by abnormal breathing patterns are termed sleep-disordered breathing (SDB). Snoring, sleep apnea and other sleep-related breathing disorders represent the most common sleep disorders seen in the outpatient setting. [entmds.net]

  Symptoms Common signs and symptoms of central sleep apnea include: Observed episodes of stopped breathing or abnormal breathing patterns during sleep Abrupt awakenings accompanied by shortness of breath Shortness of breath that's relieved by sitting up [mayoclinic.org]

• Vomiting

  […] newborns, primary apnea) Pulmonology (pulmonary arterial hypertension, cystic fibrosis, asthma, acute respiratory distress syndrome) Anesthesia and intensive care (general and regional anesthesia, opiate overdose, pain control, postoperative nausea and vomiting [providens.org]

  List infant behaviors that should cause a nurse to suspect prenatal drug exposure. appear hungry, but suck & swallow poorly coordinated; hyperactive, increased muscle tone; regurgitation, vomiting, & diarrhea; signs typical of hypoglycemia but normal [studystack.com]

  Rapid IV pushes have been associated with SUDDEN DEATH from CARDIAC ARRHYTHMIAS Major side effects - tachycardia, vomiting, feeding intolerance, jitteriness and seizures. [uichildrens.org]

  There was no history of fever, cough, chest retraction, difficulty in breathing, seizure, vomiting, jaundice, or abdominal distention. [comprped.com]

  ◼Pain areas : in the abdomen, lower back, or pelvis ◼Groin : uterine contraction, vaginal bleeding, or vaginal discharge◼Gastrointestinal : nausea or vomiting Also ◼common : cramping, fatigue, or irregular uterine bleeding, fever. [tibahlebait.com]

• Nausea

  […] premature newborns, primary apnea) Pulmonology (pulmonary arterial hypertension, cystic fibrosis, asthma, acute respiratory distress syndrome) Anesthesia and intensive care (general and regional anesthesia, opiate overdose, pain control, postoperative nausea [providens.org]

  ◼Pain areas : in the abdomen, lower back, or pelvis ◼Groin : uterine contraction, vaginal bleeding, or vaginal discharge◼Gastrointestinal : nausea or vomiting Also ◼common : cramping, fatigue, or irregular uterine bleeding, fever. [tibahlebait.com]

• Constipation

  AND UCL COMMENCE PREPARATIONS FOR PHASE I CLINICAL STUDIES IN ALZHEIMER’S DISEASE FOR NOVEL ANTI-TAU ANTIBODY E2814 DISCOVERED THROUGH JOINT RESEARCH November 29, 2018 MOVICOL® Launched in Japan The First Polyethylene Glycol Preparation for Chronic Constipation [eisai.com]

• Hypertension

  Secondary hypertension: Obstructive sleep apnea. [thieme-connect.com]

  Hypertension was more frequently seen in patients with OSAS than in patients without OSAS and hypertension frequency increased in parallel to the severity of OSAS .The goal of uvulopalatopharyngoplasty (UPPP) in the treatment of obstructive sleep apnea [zumj.journals.ekb.eg]

  Hypertension, 42, 1067-1074. http://dx.doi.org/10.1161/01.HYP.0000101686.98973.A3 [5] Brostrom, A., Sunnergren, O., Nilsen, P., et al. (2013) Gender differences in respiratory disturbance, sleep and daytime sleepiness in hypertensive patients with different [scirp.org]

  Mancia G, Fagard R, Narkiewicz K, et al.. 2013 ESH/ESC guidelines for the management of arterial hypertension: the task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology [ahajournals.org]

  Those with common secondary hypertensive conditions such as renal artery stenosis, renal parenchymal hypertension, Cushing’s syndrome, and pheochromocytoma were excluded. [nature.com]

• Cyanosis

  The infant usually gasps or demonstrates labored breathing and/or cyanosis. Generally, the risk of AOP is inversely related to the GA. Note that brief pauses lasting 5 to 10 seconds are normal in the preterm neonate. [symptoma.com]

  He was admitted to UH approximately after one year already due to complaints of physical load intolerance, growth retardation, increased swelling, perioral cyanosis, and secondary erythrocytosis in complete blood count. [lsmuni.lt]

  Gauda, MD Reviewed 10/2018 Apnea of infancy An unexplained episode of cessation of breathing for 20 seconds or longer or a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked ... [5minuteconsult.com]

  Respiratory pauses of >20 seconds or if associated with bradycardia and cyanosis are labelled as apneas [1]. Apnea is a grave sign in term neonates and could result from sepsis, meningitis or severe brainstem dysfunction in hypoxic neonates. [indianpediatrics.net]

  Klein, MD Peer Review Status: Internally Peer Reviewed Definition Apnea is a "pause in breathing of longer than 10 to 15 seconds, often associated with bradycardia, cyanosis, or both." (Martin et al). [uichildrens.org]

• Restless Legs Syndrome

  Behavioral problems (bedtime struggles, night wakings) Behavioral and cognitive problems that may be worsened by sleep apnea, such as ADHD Upper airway resistance syndrome Restless leg syndrome Rhythmic movement disorders (periodic limb movement disorder [stanfordchildrens.org]

  Regarding common sleep disorders, it is estimated that in the United States, chronic insomnia affects 30 million individuals, while obstructive sleep apnea syndrome affects 8 million; and restless legs syndrome affects 6 million. [aastweb.org]

  Leg Syndrome Sleep Apnea secondary to Sinusitis Sleep Apnea secondary to Seizure Disorders (e.g., Epilepsy) Sleep Apnea secondary to Stenosis Sleep Apnea secondary to Stroke Sleep Apnea secondary to Temporomandibular Joint Syndrome (TMJ) Sleep Apnea [vaclaimsinsider.com]

  Among the patients referred for suspicion of OSA, the diagnosis was confirmed in 81%, while 78% received CPAP and restless leg syndrome was detected in 18%. [breathe.ersjournals.com]

• Abnormal Behavior

  Sleep disorders involve any difficulties related to sleeping, including difficulty falling or staying asleep, falling asleep at inappropriate times, excessive total sleep time, or abnormal behaviors associated with sleep. [orlassociates.com]

  Polysomnographic testing measures physiologic changes, including staging sleep, respiratory abnormalities, cardiac arrhythmias, body movements, arousal from sleep and abnormal behaviors in sleep to be identified. [rchsd.org]

• Behavior Disorder

  The American Journal of Psychiatry, 148, 564-577. [25] Frick, P.J., Kamphaus, R.W., Lahey, B., Loeber, R., Christ, M.A.G. and Hart, E.L. (1991) Academic underachievement and the disruptive behavior disorders. [scirp.org]

• Insomnia

  Baehr}, year={2000} } A lthough several studies document psychological disturbance in various sleep disorders, most existing work concerns insomnia, probably because psychological deviations are presumed to have no particular etiologic role in disorders [semanticscholar.org]

  loud snoring (more prominent in obstructive sleep apnea), intermittent pauses in breathing, abrupt awakenings accompanied by shortness of breath (may indicate central sleep apnea), awakening with a dry mouth or sore throat, a morning headache, and insomnia [fortherecordmag.com]

  Sleep Medicine, 11, 987-998. doi:10.1016/j.sleep.2010.04.019 [10] Roth, T. and Roehrs, T. (2003) Insomnia: Epidemiology, characteristics, and consequences. [scirp.org]

  The Minimal Insomnia Symptoms Scale (three items) was used to measure difficulties initiating sleep, difficulties maintaining sleep, and difficulties with non-restorative sleep [15]. [tandfonline.com]

  Symptoms Of Sleep Apnea Loud snoring Episodes in which you stop breathing during sleep — which would be reported by another person Gasping for air during sleep Awakening with a dry mouth Morning headache Difficulty staying asleep (insomnia) Excessive [compcare.us]

• Somnolence

  Historical note and terminology The term "central sleep apnea" was coined by Gastaut and his collaborators in their report on the abnormal breathing patterns observed in a subtype of so-called "Pickwickian patients," morbidly obese subjects with somnolence [medlink.com]

  Obstructive sleep apnea was quantified using the Berlin questionnaire which apart from the demographic data, it included three categories (10 questions) designed to illicit information regarding snoring (category 1), daytime somnolence (category 2) and [hsj.gr]

  In the current paradigm of care, the primary care provider is in the best position to identify patients with symptoms of OSA, such as snoring, excessive daytime somnolence, and pauses in breathing. [jcsm.aasm.org]

  Case report A 58 year old short obese man, with a snoring habit and daytime somnolence, had a history of hypertension and an episode of stroke one year ago. He had smoked one packet of cigarettes daily for more than 30 years. [jcp.bmj.com]

  […] systolic, and diastolic BP, all of which translated into a reduction in the frequency of pre-HTN and masked HTN. 63 In patients with coronary artery disease and OSA, CPAP treatment led to an effective reduction in diastolic BP and improvements in daytime somnolence [ahajournals.org]

• Intracranial Hemorrhage

  IVH=intraventricular hemorrhage. Central nervous system problems, particularly intracranial hemorrhage, can precipitate apnea in the preterm infant. Asphyxia, including transient birth depression, may cause either episodic or prolonged apnea. [doi.org]

  intracranial hemorrhage, neonatal seizures, perinatal asphyxia, or other pathology which could lead to increased intracranial pressure Cardiovascular - Impairment of oxygenation from congestive heart failure and pulmonary edema (PDA, coarctation, etc [uichildrens.org]

  Cranial injuries: caput succedaneum, subconjunctival hemorrhage, cephalohematoma, subgaleal hemorrhage, skull fractures, intracranial hemorrhage, cerebral edema Spinal injuries: spinal cord transection Peripheral nerve injuries: brachial palsy (Erb–Duchenne [clinicalgate.com]

  Recurrent apnea can lead to respiratory failure, pulmonary hemorrhage, abnormal heart and lung function, intracranial hemorrhage, abnormal nervous system development, and even sudden death [3, 4]. [hindawi.com]

• Lethargy

  On the other hand, hypothyroidism can be associated with OSA [6], and some symptoms, such as daytime sleepiness, fatigue, and lethargy, overlap for both diseases. [apfmj.biomedcentral.com]

  Asymptomatisch, bovenste luchtweginfectie, lethargie, voedingsproblemen en apneu, bronchiolitis, pneumonie en sepsis. Deze richtlijn is door het LOI vastgesteld op 6 november 2012. [lci.rivm.nl]

The NICU staff should obtain the antenatal history, examine the patient, and order the relevant studies. Additionally, all premature neonates should be monitored closely especially in terms of the cardiac, respiratory, and neurologic status.

Physical exam

Observation of the neonate's vital signs is a key component of the exam. The patient should be placed on a cardiorespiratory monitor, which allows the NICU staff to detect apnea and measure the blood pressure. The patient's heart rate and blood pressure will exhibit findings that are indicative of reflex. Additionally, a pulse oximeter is used to obtain the oxygen saturation levels, which reflects the degree and the duration of apnea.

Additionally, the clinicians should monitor the neonate's breathing patterns, oxygen levels, and heart rate during feeding, awake and sleep times and in the prone and supine positions.

Laboratory tests

Infectious causes are investigated with a complete blood count (CBC), and blood, urine, and cerebrospinal fluid cultures. An electrolyte panel including glucose and mineral levels helps evaluate stressful events, metabolic conditions, or long-term hypoventilation. Also, metabolic diseases should be excluded with plasma and urine organic acid concentration as well as ammonia and amino acid measurements.

Imaging

Neonates with wheezing and/or regurgitation should have chest radiography to assess the lower airway status. A milk scan may also be beneficial [9]. Patients featuring difficulties with swallowing or display anomalies such as tracheoesophageal fistula should undergo a barium swallow study. Finally, infants suspected to have pyloric stenosis or motility dysfunction warrant an abdominal ultrasound and gastric-emptying study.

• Hypercapnia

  We postulated that since exogenous opiates modify respiration and the ventilatory response to hypercapnia and hypoxemia (19), the endogenous opiate-like compounds might modify the respiratory response to neonatal asphyxia. [nature.com]

  The direct consequences of the collapse are intermittent hypoxia and hypercapnia, recurrent arousals and increase in respiratory efforts, leading to secondary sympathetic activation, oxidative stress and systemic inflammation. [ncbi.nlm.nih.gov]

  Secondary effects[edit] The conditions of hypoxia and hypercapnia, whether caused by apnea or not, trigger additional effects on the body. [en.wikipedia.org]

The treatment of neonates with primary apnea takes into consideration the GA in addition to other factors related to the cause of the premature birth and the measurements of heart rate, oxygen saturation, and physical exam. The delivery room and NICU should be equipped with trained personnel who are able to resuscitate apneic infants according to the neonatal resuscitation program (NRP) algorithm.

Medication

Caffeine and other methylxanthines such as theophylline and aminophylline improve apnea by stimulating the respiratory drive [3] and central nervous system. Preterm neonates receive caffeine or theophylline until they reach a GA of 34 to 35 weeks. Specifically, caffeine is administered orally or intravenously at a dose of 20 mg/kg, which is subsequently followed by a maintenance dose of 5 mg/kg daily [10]. The IV form of theophylline is aminophylline [11], which is given at a loading dose of 5–6 mg/kg and a daily maintenance with 2 to 6 mg/kg split into several doses [12].

Assisted ventilation

Another important component in the treatment of these patients is continuous positive airway pressure (CPAP), which is delivered at 4 to 6 cm H2O to prevent atelectasis of the alveoli and pharyngeal collapse. Another option is the nasal intermittent positive pressure ventilation (NIPPV).

Other

Further interventions include the particular positioning of the newborn while in the NICU. The prone position is effective in decreasing the frequency apneic episodes [13] as it provides chest wall stability and reduces thoracoabdominal asynchrony [14].

Home monitoring

From the cardiopulmonary standpoint, patients with AOP remain in hospital until they achieve resolution of apneic episodes. Moreover, discharge criteria typically include a 3 to 10 day period of no events while on continuous monitoring. Additionally, all infants must pass the car seat test prior to discharge.

Patients who experience these episodes that resolve without intervention may be eligible for home monitoring. These newborns are sent home with a cardiorespiratory monitor and possibly oral caffeine.

Education for parents and caretakers is paramount. They should learn how to utilize the monitor, understand when to intervene and how to perform cardiopulmonary resuscitation (CPR).

Apnea usually resolves in newborns as they reach 37 weeks of GA.

Initially, there can be a rise int he stroke volume, leading to systemic blood pressure and cerebral hypoperfusion that may eventually lead to brain injury.While severe cases of apnea may impact the neural development of the infant, the possible coexistence of other factors or conditions may impact this as well. Hence, no clear relationship has been established between apnea and long-term neurodevelopmental outcomes [7].

AOP, the most prevalent type of primary apnea, is idiopathic although experts indicate that this condition reflects the immature management of respiratory control in preterm infants. Specifically, an underdeveloped respiratory drive and an imbalance between the parasympathetic and sympathetic tones are factors that contribute to the development of AOP.

Additionally, primary apnea may occur secondary to disorders emerging from prematurity. There may be a genetic predisposition as well according to studies that have observed a familial association.

The incidence of AOP occurs more frequently in preterm neonates born at lower GAs. For example, almost all newborns born less that 29 weeks or weigh below 1,000 grams have AOP [2], in comparison to 55% of newborns with a GA of 30 to 31weeks and 7% at GA of 34 to 35 weeks [3].

There are 3 subtypes of apnea, which are central (10% to 25% of cases), obstructive (10% to 25% of cases), and mixed (at least half of all cases) [4]. They vary in terms of pathophysiology and clinical picture.

Central apnea is characterized by the absence of respiratory effort secondary to a failure in the central respiratory centers to stimulate afferent peripheral nerves and produce stimulation of the respiratory muscles. This lack of communication between the brain and respiratory muscles in response to hypercapnia is observed in premature neonates due to immaturity. Note that there are secondary causes such head trauma and toxin-induced apnea but these are beyond the scope this topic.

Patients with obstructive apnea develop this due to a partial or complete occlusion of the airway while the mixed subtype features elements of both central and obstructive apnea.

Neurologic effects

Preterm infants with AOP exhibit episodes of oxygen desaturation and possibly reflex bradycardia, which are two variables that promote changes in the cerebral hemodynamics. For example, shortly after hypoxemia, the heart rate falls and the stroke volume increases [5]. However, this is not sustained in prolonged episodes of apnea and bradycardia, which are characterized by systemic hypotension and cerebral hypoperfusion [6]. These mechanisms may lead to hypoxic brain injury [6].

One of the main approaches to preventing poor outcomes in the discharged infant is by proper placement of the infant in the supine position [13] with the head centered and the neck kept neutrally.

Apnea refers to an interruption of respiratory airflow or a cessation of airflow. Apnea is usually classified as central, obstructive, or mixed according to the underlying pathophysiology. The most common type of primary apnea is known as apnea of prematurity (AOP), which usually occurs in an infant born prior to 37 weeks of gestational age (GA). Specifically, the definition of AOP [1] is a pause in breathing that is 1) greater than 20 seconds or 2) accompanied by oxygen desaturation with or without bradycardia.

The clinical picture manifests early in the neonatal period, usually within the first 2 days. The infant usually gasps or demonstrates labored breathing and/or cyanosis. Generally, the risk of AOP is inversely related to the GA. Note that brief pauses lasting 5 to 10 seconds are normal in the preterm neonate.

All newborns undergo full physical exams immediately after birth. High-risk infants such as those who are born preterm are placed in the neonatal intensive care unit (NICU) where they are monitored carefully in terms of their cardiopulmonary status and other important elements such as feeding, weight gain, etc. The medical team should also ascertain the antenatal and family history. All causes of apnea should be investigated and hence pertinent laboratory and imaging studies should be obtained as well.

Patients with AOP are treated with caffeine or other methylxanthines to increase the respiratory drive and the diaphragm contractility [1]. Additionally, assisted ventilation is also usually required in these patients to help to achieve the above goals.

While the long-term consequences of apnea are not understood, this condition may hinder neurological development and produce unfavorable outcomes although the exact relationship has not been fully elucidated.

The most common form of primary apnea is referred to as apnea of prematurity. As the name suggests, this occurs in babies born prematurely, which is before 37 weeks of gestational age. These patients do not have any other condition or disorder that lead to apnea, and therefore it is presumed the apneic episodes develop due to the immaturity of the central nervous system, obstruction of the airways, or a combination of both.

Specifically, the criteria of apnea are:

• A pause in breathing that lasts more than 20 seconds or
• Shorter pause that is accompanied with a low oxygen saturation and/or bradycardia (slow heartbeat)

The apneic episodes start in the first week, especially in the first 2 days of the newborn's life. The following features are usually seen:

• Gasping for breath
• Bluish discoloration of the skin
• Weak muscle tone
• No movement of the chest
• No breath sounds

The obstetric and neonatal teams should be prepared when babies are born preterm. The medical personnel should be trained in performing CPR in order to resuscitate babies experiencing difficulty with breathing.

Preterm neonates are admitted to the neonatal intensive care unit (NICU) where they are placed on heart and oxygen monitors to monitor their breathing, heart rate, blood pressure, and respiratory rate. Additionally, the medical staff will observe the infant's breathing patterns while feeding, sleeping, and other times.

A series of blood tests, possibly chest X-rays and other imaging tests are performed to rule out other disease or causes of apnea.

The main goal is to stimulate breathing, which can be achieved by:

• Treatment with caffeine
• Assisted ventilation

Also, the positioning of the neonate is very important. While in the NICU, the baby should sleep on his/her belly. However, once discharged at home, the patient should lay on his/her back, with the head kept midline and in a neutral position.

Babies are observed carefully and closely. If they have not had any episodes with breathing trouble for a certain period of time, they may be discharged. The neonates should have close follow-up appointments with the doctor. Also, parents should be educated on signs of breathing trouble and when to seek immediate medical care.

The prognosis is good as most cases resolve as the newborn reaches 37 weeks of gestational age.

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3. Martin RJ, Abu Shaweesh JM, Baird TM. Apnoea of prematurity. Paediatr Respir Rev. 2004;5(Suppl 1):S377–S382.
4. Stokowski LA. A primer on Apnea of prematurity. Advances in Neonatal Care. 2005;5(3):155–170.
5. Poets CF. Apnea of prematurity: what can observational studies tell us about pathophysiology? Sleep Medicine. 2010;11(7):701–707.
6. Pilcher G, Urlesberger B, Muller W. Impact of bradycardia on cerebral oxygenation and cerebral blood volume during apnoea in preterm infants. Physiol Meas. 2003;24(3):671–680.
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