A 3-week-old girl is evaluated in the neonatal intensive care unit due to apnea. The patient was born at 26 weeks gestation with a birth weight of 820 g (1 lb 13 oz). She had mild respiratory distress syndrome initially and has been breathing comfortably on high-flow nasal cannula at 21% FiO₂. Enteral breast milk feeds have been started. The patient received ampicillin and gentamicin empirically until cultures were sterile at 48 hours. On day of life 3, she began having episodes of apnea, with 25-30 seconds without respiratory effort and subsequent bradycardia and desaturations. These episodes have occurred intermittently for the past several weeks. The patient recovers spontaneously or with brief stimulation. In between the episodes, she is well-appearing and has normal vital signs. The anterior fontanel is slightly sunken and soft. Lungs are clear to auscultation. The abdomen is soft and bowel sounds are normal. Ultrasound of the head on day of life 10 is normal. Which of the following is the best next step in management of this patient's condition?

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Explanation: 11ec25c8_d6fa_f2e8_bc81_0b853e815384_MD0003_00 This well-appearing preterm infant with episodes of apnea, bradycardia, and desaturation most likely has apnea of prematurity (AoP). AoP is characterized by intermittent cessation of respiratory effort for >20 seconds due to immature central respiratory centers in the pons and medulla. The condition occurs more frequently with increasing prematurity, affecting virtually all infants <28 weeks gestation. Classic presentation is on day 2-3 of life in an infant that is well-appearing between apnea episodes. Diagnosis is clinical, and no additional testing is indicated in a patient with characteristic findings (as seen here). Evaluation for other causes of apnea is reserved for the following situations: New, sudden-onset apnea after first few days of life Severe manifestations of apnea (eg, requiring resuscitation) Ill-appearing with abnormal physical examination findings between episodes Symptoms persist longer than expected (ie, beyond term) (Choice A) Chest CT scan is used to evaluate complex pulmonary disease, such as evolving bronchopulmonary dysplasia or congenital lung malformations. This infant has a normal lung examination and normal breathing pattern between episodes, making chest CT low yield. (Choice C) Intraventricular hemorrhage can present with nonspecific findings and cause apnea. However, almost all intraventricular hemorrhages in preterm infants occur before age 7 days, and this infant had a normal head ultrasound at age 10 days (after the onset of apneic episodes), making a repeat ultrasound of the head unnecessary. (Choice D) Infants with sepsis (eg, bacteremia or meningitis) can present with apnea but are typically ill-appearing between episodes and deteriorate clinically if antibiotics are not started promptly. This infant has had a stable clinical course for several weeks and has a normal physical examination, making sepsis unlikely. (Choice E) Rarely, subclinical seizures can present as apneic episodes. However, this infant has a normal physical examination, normal ultrasound of the head, and no abnormal motor activity, making seizures unlikely. Educational objective: Apnea of prematurity is caused by immature respiratory centers in the pons and medulla and affects virtually all preterm infants <28 weeks gestation. Diagnosis is clinical, and no additional testing is required in a well-appearing infant with a classic presentation in the first few days of life. References: Apnea of prematurity. (http://www.ncbi.nlm.nih.gov/pubmed/26628729)

A 3-Week-Old Girl Is Evaluated in the Neonatal Intensive Care