Pediatric Apnea Follow-up

  • Author: Joshua A Rocker, MD; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Aug 25, 2010
 

Further Inpatient Care

All children who experienced true apnea should be admitted for monitoring and further evaluation. Most children who have had a true apparent life-threatening event (ALTE) should be admitted for treatment of their underlying medical problem or for diagnostic evaluation.

The diagnostic evaluation of the child with ALTE usually includes a multichannel study. The infant is observed for an extended period while monitors (eg, EEG, ECG, esophageal pH probe, chest movement monitor, and nasal-airflow monitor) record data. Such monitoring requires some expertise and is probably best conducted in a pediatric center.

Treatment of sleep apnea in children includes both surgical and medical approaches. When adenoid and tonsillar hypertrophy accompany the OSA, adenotonsillectomy (surgical removal of adenoids and tonsils) is the treatment of choice. For those that are not suitable candidates for surgery or have symptoms despite surgery, the most effective treatment in both adults and children, is continuous positive airway pressure (CPAP). One study has shown that warm humidified air delivered through an open nasal cannula actually decreased the occurrence of sleep apnea episodes in children with OSA.[17]

For more information on pediatric sleep apnea, please refer to the eMedicine Pediatrics article Sleep Apnea.

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Further Outpatient Care

Children may be safely discharged for further outpatient care if one of the following conditions exist:

  • The history is consistent with a breath holding spell and the physical examination findings are normal.
  • The history is consistent with periodic breathing and the physical examination findings are normal.
  • The history suggests an isolated choking episode from either GERD or overfeeding and the physical examination findings are normal. The patient also then feeds normally in the ED.
  • The history is consistent with a simple febrile seizure and the physical examination findings are normal.
  • An unequivocal problem with a home monitor occurred.

When choking is suspected in an infant who feeds aggressively, the parents should be instructed to frequently interrupt feeding and to burp the infant more often than before.

If obstructive sleep apnea (OSA) is diagnosed, the patient should have a sleep study and follow up with an otolaryngologist.

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Transfer

Most infants who have a true apneic event should be evaluated at a facility with diverse faculty and expertise in the diagnostic evaluation of such events.

The team that is transporting the infant should be capable of monitoring and, if necessary, resuscitating an infant. If available, a pediatric transport team is preferred.

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Complications

Because the etiologies are so variable, the complication relate to the specific cause of the apnea. These are mostly addressed in Mortality/Morbidity.

One complication that is often ignored is the psychological impact of home monitoring on the family.

  • Monitoring places a tremendous amount of pressure on the caretakers. Families deal with these pressures in many ways.
  • Some parents eventually stop using the monitor, whereas others become dependent on it.
  • Some families experience renewed fears when they are told that their child no longer requires home monitoring.
  • Many of these stressors may be manifested in the ED.
  • Parents of a child for whom home monitor is being discontinued may present to the ED with a complaint of frequent alarms to try to continue monitoring.
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Prognosis

The prognosis is case specific. If the underlying etiology for the apnea is treated, most of the pathologies have good outcomes.

In general, as the child matures, the cause of the apparent life-threatening event (ALTE) is diagnosed and treated or spontaneously resolves. If the apnea is determined to be idiopathic, the prognosis is generally excellent.

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Patient Education

  • Parents of infants who are discharged should be instructed to return if more episodes occur, if episodes become associated with color change, or if new and/or worrisome findings (eg, fever, lethargy, frequent vomiting) develop.
  • Infants who have had a choking episode should receive feeding instructions as described above.
  • Families of monitored infants should be reminded to maintain current CPR training.
  • For excellent patient education resources, visit eMedicine's Children's Health Center. Also, see eMedicine's patient education article Sudden Infant Death Syndrome (SIDS).
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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; Director of Education for Pediatrics Emergency Medicine Fellowship, Pediatrics Emergency Medicine, Cohen's Children Medical Center of New York

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  Pediatric Emergency Medicine Fellow, Cohen Children's Medical Center of New York, 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.

Specialty Editor Board

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.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

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.

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.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Elizabeth B Jones, MD, Brent R King, MD, and Isaac Grate Jr, MD, to the development and writing of this article.

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