Postanesthesia Apnea in Former Preterm and Term Infants: A Qualitative Systematic Review and Meta-analysis

Former preterm and term infants are at risk for postanesthesia apnea, but the lack of uniform standards for monitoring and discharge criteria leads to inconsistent practice. The primary aim of this study was to identify major risk factors for postanesthesia apnea. This systematic review and meta-regression analysis used Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Agency for Healthcare Research and Quality guidelines. The literature search included English language case reports, case series, clinical studies, and clinical trials. Major databases were queried from inception to October 2025. A total of 6,191 articles underwent title and abstract screening, 491 underwent full-text screening, and 173 underwent detailed reviews. Data were extracted from 115 of 173 articles (98 studies, 17 case reports or series). Across studies (preterm or full term infants), the median incidence of apnea was 7.6% (range, 0 to 85%). Univariable meta-regression analysis (96 eligible articles) identified five significant predictors of apnea: gestational age, postmenstrual age at time of procedure, birth weight, procedure duration, and year of publication. Odds for apnea incidence decreased with later publication year, older gestational age at birth, older postmenstrual age at time of surgery, higher birth weight, and shorter procedure duration. A multivariable "best fitting model" (64 eligible articles) including publication year (1986 to 2025) and postmenstrual age (32 to 63 weeks) found a decrease in odds of apnea incidence with later publication year (odds ratio [OR], 0.936; CI, 0.91 to 0.964; P < 0.001) and higher postmenstrual age (OR, 0.889; CI, 0.828 to 0.954; P = 0.001). Recommended postanesthesia monitoring duration ranged from 6 to 24 h based on postmenstrual age. Meta-regression showed significantly lower apnea odds with neuraxial versus general anesthesia (OR, 0.236; CI, 0.094 to 0.592; P = 0.003). Postmenstrual age appears to be the strongest and most consistent risk factor for postanesthesia apnea; neuraxial anesthesia may reduce this risk. An individual participant data meta-analysis in a follow-up article will shed further light on the at-risk postmenstrual age threshold for increased risk and help refine monitoring recommendations for these vulnerable infants.