DISCHARGE PLANNING & FOLLOW UP (1)

A major issue in the management of infants with apnea is deciding when to stop administration of theophylline and whether or not the infant needs to be discharged on theophylline, a home monitor or both.

Discontinuing medications:- Consider stopping theophylline therapy when the apnea has resolved and the infant weighs between 1800 and 2000 g. If the infants remain asymptomatic following the discontinuation of theophylline therapy, the child may be discharged without further therapy.

Reinstituting medication:- If symptomatic apnea recurs after discontinuing therapy, theophylline therapy should be reinstituted and a decision made to discharge the infant on this medication or to keep the infant hospitalized longer. The use of home monitors in addition to theophylline therapy is controversial. Therapeutic theophylline levels are maintained until the child reaches 52 weeks of post conception age; then theophylline therapy is discontinued and pneumography is performed. If the pneumogram is normal, therapy can be stopped. If the pneumogram is abnormal, the infant needs to be restarted on theophylline and monitoring continued. Another attempt can be made to discontinue theophylline in 4 weeks

Home Monitors:- Preterm infants who continue to exhibit symptomatic apnea when they would otherwise be ready for hospital discharge should have their oxygenation carefully evaluated, because hypoxia can cause apnea in preterm infants, and relieving it may resolve the problem. Chronic lung disease is frequently associated with apnea in preterm infants, In the absence of any identified underlying cause, preterm infants who are still having clinically apparent episodes of apnea can be discharged on home apnea-bradycardia monitoring. If theophylline or caffeine reduces the frequency of these episodes, then these infants can be treated in addition to the home monitor. (13) Routine monitoring of asymptomatic preterm infants, as a group, is not warranted. An additional indication for home monitoring is a positive history of an apparent life- threatening event (ALTE) during the infant's hospital course.

SEQUELAE

Although the ultimate significance of apnea of prematurity for the long-term neurodevelopment of infants remains uncertain (14,3), prolonged apnea in association with falls in oxygen saturation must be considered an adverse event in view of the necessary decline in tissue oxygen delivery.

Apnea in premature infants can result in a failure of the mechanisms that protect cerebral blood flow resulting in ischemia and eventually leukomalacia. During apneic episodes, in an attempt to protect cerebral blood flow, cardiac output is diverted away from the mesenteric arteries resulting in intestinal ischemia and possibly necrotizing enterocolitis (15).

Also See "Frequently Asked Questions On Apnea"

REFERENCES

1. Thomas H. Pauly: Apnea & Periodic Breathing. In: Gomella TL (Ed) Clinical manual of Neonatology. Management, Procedures, On-call Problems, Diseases and Drugs. 3rd Edition, Stamford, Connecticut: Appleton & Lange, 1994, pp 413- 417.
2. Martin RJ, et al: Pathogenesis of apnea in preterm infants. J Pediatr 109:733- 741,1986.
3. Miller MJ, Martin RJ: Apnea of prematurity. Clinics in Perinatology 19:789- 808,1992.
4. Ruggins NR: Pathophysiology of apnea in preterm infants. Arch Dis Child 66:70- 73,1991.
5. Finer NN,Barrington KJ, Hayes BJ, Hugh A: Obstructive, mixed, and central apnea in the neonate: Physiologic correlates. The Journal of Pediatrics 121:943-950, 1992.
6. Stark AR: Apnea. In: Cloherty JP (ed) Manual of Neonatal Care. 3rd edn.,Boston: The Little, Brown Spiral Manual, 1991, pp 222-226.
7. National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring, Sept. 29 to Oct. 1, 1986. Pediatrics 79:292-299, 1987.
8. Peliowski A, Finer NN: A blinded, randomized, placebo-controlled trial to compare theophylline and doxapram for the treatment of apnea prematurity. The Journal of Pediatrics 116:648-653, 1990.
9. Greene MG: The Harriet Lane Handbook: a manual for pediatric house officers, ed 12, St. Louis, MO: Mosby-Year Book, Inc., 1991.
10. Young TE, Mangum OB: Neofax '94: A Manual of Drugs Used in Neonatal Care, 7th edition. Columbus, Ohio: Ross Products Division, Abbott Laboratories, USA, 1994.
11. Schmidt B. Methylxanthine therapy in premature infants: Sound practice, disaster, or fruitless byway J. Pediatr 135:526-528, 1999.
12. Hayakawa,F. J.Pediatr. 109:138, 1986.
13. Keens TG, Ward SLD: Apnea spells, sudden death, and the role of the apnea monitor. Pediatric Clinics of North America 40:897-911, 1993.
14. Koons AH, Mojica N, Jadeja N, Ostfeld B, Hiatt M, Hegyi T: Neurodevelopmental Outcome of infants with apnea of infancy. American Journal of Perinatology 10:208-211, 1993
15. Marchal F, Bairam A, Vert P: Neonatal Apnea and Apneic Syndromes. Clinics in Perinatology 14:509-529, 1987.