eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Apnea: Follow-up

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

Follow-up

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.

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.

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.

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.

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.

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).

Miscellaneous

Medicolegal Pitfalls

  • In the patient who presents with true apnea with or without an associated seizure and with a poor history, abuse must be considered, especially if the child is still lethargic or with a decreased sensorium in the ED.
  • Erring on the side of admitting most infants with an apparent life-threatening event (ALTE) is better than not admitting a potentially ill patient.
    • Although the baby may appear well at the time of ED evaluation, he or she may have had a clinically significant episode.
    • Parents of all patients discharged from the ED should be given strict instructions to return if the infant's condition worsens.
  • All infants presenting for ALTEs should be monitored while in the ED.
    • Should transport be necessary, monitoring is required.
    • All infants transported for the evaluation and treatment of ALTEs should be transported by a team capable of infant resuscitation.
    • Ensuring an appropriate method of transport is the responsibility of the referring institution.
 
Acknowledgments

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.



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

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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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