eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Apnea: Differential Diagnoses & Workup

Author: Joshua A Rocker, MD, Assistant Professor of Pediatrics and Emergency Medicine, Albert Einstein College of Medicine; Attending Physician and Director of Education for Pediatrics Emergency Medicine Fellowship, Pediatrics Emergency Medicine, Schneider Children's Hospital
Coauthor(s): Jeffrey Israel, MD,, Chief Resident Physician, Department of Pediatrics, Schneider Children's Hospital, North Shore, Long Island Jewish Health System
Contributor Information and Disclosures

Updated: Oct 7, 2009

Differential Diagnoses

Apparent Life-Threatening Events
Munchausen Syndrome
Aspiration Syndromes
Munchausen Syndrome by Proxy
Asthma
Obstructive Sleep Apnea Syndrome
Bacteremia
Parainfluenza Virus Infections
Botulism
Pediatrics, Bacteremia and Sepsis
Bronchiolitis
Pediatrics, Bronchiolitis
Bronchopulmonary Dysplasia
Pediatrics, Status Epilepticus
Child Abuse & Neglect, Physical Abuse
Pediatrics, Sudden Infant Death Syndrome
Croup
Pertussis
Guillain-Barre Syndrome in Childhood
Pneumonia
Head Trauma
Prematurity
Heart Failure, Congestive
Sepsis
Hypoglycemia
Status Asthmaticus
Influenza
Supraventricular Tachycardia, Wolff-Parkinson-White Syndrome
Laryngomalacia
Toxicity, Carbon Monoxide
Meningitis, Aseptic
Toxicity, Opioids
Meningitis, Bacterial

Other Problems to Be Considered

Well child, anxious mother (diagnosis of exclusion)

Workup

Laboratory Studies

If the infant is truly afebrile and appears well, laboratory results are likely to be within the reference ranges. In a recent study, 49% of patients with apparent life-threatening event (ALTE) had positive findings on history and physical that were confirmed by subsequent testing. Twenty-one percent were diagnosed by history and physical alone with no help from other tests, and 14% were diagnosed by positive tests performed after a noncontributory history and physical examination.15

  • If the infant does not appear well, the following studies should be considered:
    • Rapid bedside glucose testing, as a decreased glucose level may indicate sepsis or a metabolic derangement. Hypoglycemia can be treated quickly, and if untreated, its consequences can be severely damaging. Therefore, early diagnosis is essential.
    • Complete blood count with differential
    • Blood culture
    • Complete metabolic panel: The combination of hyperkalemia and hyponatremia may be the first suggestion of congenital adrenal hyperplasia in the male infant.
    • Arterial blood gas (ABG) or venous blood gas (VBG) measurement
    • Lumbar puncture with culture
    • Urinalysis and urine culture via catheter to obtain the cleanest specimen
  • Additional studies may include the following:
    • Viral respiratory panel to look for common causes of bronchiolitis such as RSV or influenza.
    • The tests listed above help in identifying unexplained metabolic acidosis, potential sepsis, or unexplained anemia.
    • When the clinical presentation warrants, tests of the carboxyhemoglobin and methemoglobin level and screening for certain toxins (eg, opiates, benzodiazepines, barbiturates, marijuana, toxic alcohols, botulism) should be considered.
    • If the infant has a history of central apnea, he or she may have received theophylline or caffeine, which stimulates the central respiratory centers. Therefore, one would want to know the drug levels.

Imaging Studies

  • In most cases, no imaging studies are needed.
  • In those cases in which raised intracranial pressure or intracranial injury is suspected, CT scanning of the head is indicated.
  • In premature infants, CT of the head may reveal interventricular and periventricular hemorrhages.
  • When child abuse is seriously considered, a skeletal survey should be performed.
  • Chest radiography should be performed in the presence of increased respiratory rate, abnormal findings on lung examination, or heart murmur.

Other Tests

  • A neurologist may request an EEG.
  • Likewise, many infants will be admitted or transferred for a multichannel sleep study (see Further Inpatient Care).
  • ECG to assess for cardiac arrhythmias or cor pulmonale
  • If congenital adrenal hypoplasia is being considered, cortisol and thyroid levels
  • pH probe for evaluation of reflux
  • Fiberoptic evaluation of the larynx

More on Pediatrics, Apnea

Overview: Pediatrics, Apnea
Differential Diagnoses & Workup: Pediatrics, Apnea
Treatment & Medication: Pediatrics, Apnea
Follow-up: Pediatrics, Apnea
References
Further Reading
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References

  1. Blystad W. Blood gas determinations on premature infants. III. Investigations on premature infants with recurrent attacks of apnea. Acta Paediatr. May 1956;45(3):211-21. [Medline].

  2. Miller HC, Behrle FC, Smull NW. Severe apnea and irregular respiratory rhythms among premature infants; a clinical and laboratory study. Pediatrics. Apr 1959;23(4):676-85. [Medline].

  3. Perlstein PH, Edwards NK, Sutherland JM. Apnea in premature infants and incubator-air-temperature changes. N Engl J Med. Feb 26 1970;282(9):461-6. [Medline].

  4. Nelson NM. Members of task force on prolonged apnea. Reports of the task force on prolonged apnea of the American Academy of Pediatrics. Pediatrics. 1978;61:651-652.

  5. Committee on Fetus and Newborn. American Academy of Pediatrics. Apnea, sudden infant death syndrome, and home monitoring. Pediatrics. Apr 2003;111(4 Pt 1):914-7. [Medline].

  6. Fleming P, Blair P, Bacon C, et al. Sudden unexpected deaths in Infancy: the CESDI SUDI studies 1993-1996. Stationary Office. 2000.

  7. Brooks JG. Apparent life-threatening events and apnea of infancy. Clin Perinatol. Dec 1992;19(4):809-38. [Medline].

  8. Ralston S, Hill V. Incidence of Apnea in Infants Hospitalized with Respiratory Syncytial Virus Bronchiolitis: A Systematic Review. J Pediatr. Jul 31 2009;[Medline].

  9. Genizi J, Pillar G, Ravid S, Shahar E. Apparent life-threatening events: neurological correlates and the mandatory work-up. J Child Neurol. Nov 2008;23(11):1305-7. [Medline].

  10. Dewolfe CC. Apparent life-threatening event: a review. Pediatr Clin North Am. Aug 2005;52(4):1127-46, ix. [Medline].

  11. Kiechl-Kohlendorfer U, Hof D, Peglow UP, Traweger-Ravanelli B, Kiechl S. Epidemiology of apparent life threatening events. Arch Dis Child. Mar 2005;90(3):297-300. [Medline].

  12. Kahn A, Groswasser J, Rebuffat E, et al. Sleep and cardiorespiratory characteristics of infant victims of sudden death: a prospective case-control study. Sleep. Aug 1992;15(4):287-92. [Medline].

  13. Bonkowsky JL, Guenther E, Filloux FM, Srivastava R. Death, child abuse, and adverse neurological outcome of infants after an apparent life-threatening event. Pediatrics. Jul 2008;122(1):125-31. [Medline].

  14. Henderson-Smart DJ. The effect of gestational age on the incidence and duration of recurrent apnoea in newborn babies. Aust Paediatr J. Dec 1981;17(4):273-6. [Medline].

  15. Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. Apr 2005;115(4):885-93. [Medline].

  16. [Guideline] Atwood CW Jr, McCrory D, Garcia JG, Abman SH, Ahearn GS. Pulmonary artery hypertension and sleep-disordered breathing: ACCP evidence-based clinical practice guidelines. Chest. Jul 2004;126(1 Suppl):72S-77S. [Medline].

  17. Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted?. Pediatrics. Apr 2007;119(4):679-83. [Medline].

  18. De Piero AD, Teach SJ, Chamberlain JM. ED evaluation of infants after an apparent life-threatening event. Am J Emerg Med. Mar 2004;22(2):83-6. [Medline].

  19. Edner A, Wennborg M, Alm B, Lagercrantz H. Why do ALTE infants not die in SIDS?. Acta Paediatr. Feb 2007;96(2):191-4. [Medline].

  20. Gray C, Davies F, Molyneux E. Apparent life-threatening events presenting to a pediatric emergency department. Pediatr Emerg Care. Jun 1999;15(3):195-9. [Medline].

  21. Hewertson J, Poets CF, Samuels MP, Boyd SG, Neville BG, Southall DP. Epileptic seizure-induced hypoxemia in infants with apparent life-threatening events. Pediatrics. Aug 1994;94(2 Pt 1):148-56. [Medline].

  22. Hunt CE, Hufford DR, Bourguignon C, Oess MA. Home documented monitoring of cardiorespiratory pattern and oxygen saturation in healthy infants. Pediatr Res. Feb 1996;39(2):216-22. [Medline].

  23. Keens TG, Ward SL. Apnea spells, sudden death, and the role of the apnea monitor. Pediatr Clin North Am. Oct 1993;40(5):897-911. [Medline].

  24. [Guideline] Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr. Practice parameters for the treatment of snoring and Obstructive Sleep Apnea with oral appliances: an update for 2005. Sleep. Feb 1 2006;29(2):240-3. [Medline].

  25. McGovern MC, Smith MB. Causes of apparent life threatening events in infants: a systematic review. Arch Dis Child. Nov 2004;89(11):1043-8. [Medline].

  26. [Guideline] Morgenthaler TI, Kapen S, Lee-Chiong T, Alessi C, Boehlecke B, Brown T. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep. Aug 1 2006;29(8):1031-5. [Medline].

  27. Southall DP, Plunkett MC, Banks MW, Falkov AF, Samuels MP. Covert video recordings of life-threatening child abuse: lessons for child protection. Pediatrics. Nov 1997;100(5):735-60. [Medline].

  28. Spitzer AR, Gibson E. Home monitoring. Clin Perinatol. Dec 1992;19(4):907-26. [Medline].

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Further Reading

Clinical guidelines

Atwood CW Jr, McCrory D, Garcia JG, Abman SH, Ahearn GS. Pulmonary artery hypertension and sleep-disordered breathing: ACCP evidence-based clinical practice guidelines. Chest 2004 Jul;126(1 Suppl):72S-77S.

Kushida CA, Morgenthaler TI, Littner MR, Alessi CA, Bailey D, Coleman J Jr, Friedman L, Hirshkowitz M, Kapen S, Kramer M, Lee-Chiong T, Owens J, Pancer JP. Practice parameters for the treatment of snoring and obstructive sleep apnea with oral appliances: an update for 2005. Sleep 2006 Feb 1;29(2):240-3.

Morgenthaler TI, Kapen S, Lee-Chiong T, Alessi C, Boehlecke B, Brown T, Coleman J, Friedman L, Kapur V, Owens J, Pancer J, Swick T, Standards of Practice Committee, American Academy of Sleep Medicine. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep 2006 Aug 1;29(8):1031-5.

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Keywords

pediatric sleep apnea, sleep apnea symptoms, sleep apnea causes, sleep apnea treatment, obstructive sleep apnea, sudden infant death syndrome, SIDS, sleep apnea in children, apparent life-threatening event, ATLE

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Contributor Information and Disclosures

Author

Joshua A Rocker, MD, Assistant Professor of Pediatrics and Emergency Medicine, Albert Einstein College of Medicine; Attending Physician and Director of Education for Pediatrics Emergency Medicine Fellowship, Pediatrics Emergency Medicine, Schneider Children's Hospital
Joshua A Rocker, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey Israel, MD,, Chief Resident Physician, Department of Pediatrics, Schneider Children's Hospital, North Shore, Long Island Jewish Health System
Jeffrey Israel, MD, is a member of the following medical societies: American Academy of Pediatrics and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Kirsten A Bechtel, MD, Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital
Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, 
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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