eMedicine Specialties > Emergency Medicine > Pediatric

Pediatrics, Apnea

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
Jeffrey Israel, MD,, Chief Resident Physician, Department of Pediatrics, Schneider Children's Hospital, North Shore, Long Island Jewish Health System

Updated: Oct 7, 2009

Introduction

Background

Apnea is defined by the cessation of respiratory airflow. The length of time necessary to be qualified as a true apneic event has changed dramatically over the last few decades: 2 minutes in 1956;¹ 1 minute in 1959;² 30 seconds in 1970,³ and 20 seconds or shorter if associated with bradycardia or cyanosis in 1978.⁴ The reduction of the duration in the definition of apnea reveals doctors’ desire to intervene early enough to avoid systemic consequences.

The 3 main categories of apnea are central, obstructive, and mixed. Central apnea is a result of inadequate medullary responsiveness and thus no or poor muscle coordination for breathing. Obstructive apnea is when there is an obstruction of the airway passages and therefore poor to no air exchange. Often times with obstructive apnea, there is a vigorous inspiratory effort but it is ineffective. Mixed apnea refers to an episode where combinations of both central and obstructive forces are involved.

Infant apnea is defined by the American Academy of Pediatrics as "an unexplained episode of cessation of breathing for 20 seconds or longer, or a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked hypotonia."⁵ Apnea is more common in preterm infants. Apnea of prematurityrequires a specific assessment and treatment and is not discussed in full in this article. Apnea is rare among full-term healthy infants and, if present, usually indicates an underlying pathology.

The ED physician may not experience many patients with pure apneic events but more likely will have an infant's caregiver come in and report that his or her child appeared to stop breathing, changed color, or became limp. This is an apparent life-threatening event (ALTE).

ALTE was defined by the 1986 National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring as follows:

"An episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking or gagging. In some cases, the observer fears that the infant has died. Previously used terminology, such as 'aborted crib death' or 'near miss SIDS' should be abandoned as it implies a, possibly, misleading close association between this type of spell and SIDS."

ALTE is not a diagnosis. It is the description of an event or a presenting complaint. The potential underlying diagnoses run the spectrum from benign to extremely serious. The challenge with the assessment of the patient who experienced an ALTE lies in scrutinizing the patient's history to discern first, if the event was in fact a true episode of apnea, cyanosis, or tone change, and to then use the physical examination findings and various diagnostic studies, if needed, to deduce the reason the event took place.

Apnea is a symptom that has large possibility of etiologies. In this article, some of the major etiologies of apneic events that an emergency medicine physician will encounter are discussed, namely, apnea of prematurity; ALTE; obstructive sleep apnea; and miscellaneous forms of apnea that are toxin mediated, secondary to head trauma, or caused by infections.

Pathophysiology

Apnea refers to a cessation of respiratory airflow and has 3 major types.

Central apnea

Central apnea occurs when there is a lack of respiratory effort due to either a cessation of output from the central respiratory centers or the inability of the efferent peripheral nerves and respiratory muscles required for oxygenation and ventilation to receive or process the signals from the brain. This can be due to immaturity of the system, as seen in certain premature infants, who have a decreased response to hypercapnia (increased carbon dioxide levels). Patients with central apnea have no respiratory effort; this can be seen by a lack of chest wall movement, and no breath sounds will be appreciated on auscultation.⁶
 
Another cause of central apnea is head trauma, as it may interfere with the afferent and efferent signals of the central respiratory center. Head trauma may be the result of abuse and must always be considered in the apneic pediatric patient without an obvious cause. Toxin-mediated apnea is another form of central apnea, as it may cause central nervous system depression and decrease the respiratory drive.

Obstructive apnea

Obstructive apnea, as the name suggests, results from attempts to breathe through an occluded airway. Obstructive sleep apnea (OSA) is the most common form of obstructive apnea in children. Obstructive sleep apnea is on the sleep-disordered breathing (SDB) spectrum. The sleep-disordered breathing spectrum includes snoring, obstructive hypoventilation, and, at its extreme, obstructive sleep apnea. Obstructive sleep apnea results from a number of factors, including the patient having smaller airway patency (may be congenital but also includes adenoid and tonsillar hypertrophy) coupled with a decreased neuromuscular tone of the pharyngeal dilator muscles during sleep.

Additional conditions may put an individual at risk for obstructive sleep apnea and include mucopolysaccharidosis, craniofacial anomalies, and obesity. Other causes of obstructive apnea are an aspirated foreign body and vocal cord paralysis.

Mixed apnea

Mixed apnea has characteristics of both central apnea and obstructive apnea. Examples can include a patient with a partial obstructive apnea (due to adenotonsillar hypertrophy) who has undergone sedation (causing central apnea), or a premature infant with central apnea who has an obstruction due to nasal congestion brought on by a viral illness. Gastroesophageal reflux is thought to cause this mixed picture as regurgitated gastric contents may occlude the airway and block laryngeal chemoreceptors to send signals for dilation to the brain.

Frequency

United States

An inverse relationship is found with apnea of prematurity for both birth weight and gestational age. Because the technology in the area of NICU care is increasing, the number of infants who are surviving ultra-premature births is expanding and therefore the number of children experiencing apnea of prematurity is also growing.

The true incidence of apparent life-threatening event (ALTE) is actually unknown, but it may account for 2.3% of hospitalized children, and between 0.5% and 0.6% of all newborns.⁷

Obstructive sleep apnea (OSA) has been previously shown to occur in almost 2% of the pediatric population, but that number is rapidly increasing secondary to the explosive incidence of obesity in the United States and is thought to be closer to 5-10%. In older pediatric textbooks, the classic picture of a patient with obstructive sleep apnea was of a patient who was thin and may have even been evaluated for failure to thrive. However, currently, the typical patient with obstructive sleep apnea is significantly overweight.

One study has shown that the incidence of apnea can range from 1.2-23.8% in hospitalized infants with respiratory syncytial virus (RSV) bronchiolitis; however, the populations in the studies included premature and neuromuscularly impaired infants.⁸

International

The worldwide incidence of ALTE is unknown. One report from Sweden places the incidence of apnea during the first 4 days of life at 0.35 case per 1,000 population.⁹

Mortality/Morbidity

As discussed in Pathophysiology, there are different types of apnea, and each has its own unique set of possible causes. The outcome may vary significantly from one cause to another.

Apnea of prematurity frequently persists beyond term gestation in infants delivered at prior to 28 weeks' gestational age. These persistent apnea events may contribute to prolonged hospitalization and mortality. Clearly, if a premature infant with apnea is not taken care of in an appropriate medical setting, the morbidity and mortality can be significant.

• Perhaps the most important question regarding patients who have had an ALTE is the degree to which they are associated with sudden infant death syndrome (SIDS).
  • Recent studies have shown that 4-13% of SIDS cases had a history of apnea.
  • However, multiple studies fail to demonstrate a link between ALTE and SIDS.
    • The dramatic reduction of SIDS with the advent of the Back to Sleep program initiated by the American Academy of Pediatrics (AAP) in 1994, which has parents putting children to sleep supine, has not been associated with an appreciable reduction in the incidence of ALTE.^10,11
    • More than 80% of SIDS cases occur between midnight and 6 am,⁶ while more than 80% of ALTEs occur between 8 am and 8 pm.¹²
    • In a recent study with the single largest ALTE cohort with extensive follow up, it was demonstrated that, for patients who present with ALTE and appear well upon presentation, 1 in 9 will subsequently suffer from child abuse, and 1 in 20 will develop an adverse neurological outcome (it is important to note that most of these patients did present again within 1 month of the original incident).¹³
• Among the various outcomes, psychological morbidity certainly occurs. Many children who experience an ALTE are ultimately given a home monitoring device. The period of monitoring may last a year or more. This monitoring can be stressful for the families because a family member must be relied on to respond to monitor alarms at all times.
• Untreated obstructive sleep apnea can result in failure to thrive, cor pulmonale, and loss of intellectual quotient.
• Apnea from miscellaneous sources, such an overwhelming sepsis, various infectious agents (RSV, influenza, pertussis, human metapneumovirus), toxic agents, or trauma, all carry very significant morbidity and mortality rates.

Sex

Most studies do not show a gender difference in the incidence of apnea of prematurity.

For ALTEs, the male-to-female ratio is variable, but, in some studies, it has been as high as 2:1.

Sleep-disordered breathing continuum, of which OSA is on, appears to have a male predilection.

Age

The risk for apnea of prematurity is clearly linked to a younger gestational age at birth as well as lower birth weights. Almost all infants born less than 28 weeks’ gestation suffer from apnea. For infants born at 30-31 weeks, the risk is approximately 50%, and, for those born at 32-33 weeks, the risk is about 14%. The risk for those born at 34-35 weeks is 7%.¹⁴

The typical infant presenting after an ALTE is 8-14 weeks. Approximately 7% of these infants were born prematurely.

OSA can occur at any age; however, its incidence is bimodal. It has its first peak at age 2-6 years and then again later in adulthood.

Infections such as bronchiolitis, classically caused by RSV but also influenza and human metapneumovirus, can cause apnea. Acquiring the respiratory illness at a younger age, younger than 3 months, puts the patient at much higher risk for apnea.

Clinical

History

A detailed history is essential to establish the severity of the apnea episode and to suggest a specific diagnosis.

• When taking a history, determining how long the actual event lasted may be difficult. Most physicians are familiar with the phenomenon of time expansion in which frightening events seem to last far longer than what actually occurred.
• The physician may be more successful at determining the timeframe of the incident by asking many details step by step during the history. Repeatedly asking, "what happened next?" may force the person to recollect events in real time as opposed to perceived time. Additionally, using the ambulance record can be extremely helpful. Most ambulance reports will note the time the call came in and the time EMS arrived on the scene. From those times and the report by family and EMS workers, a crude timeframe of events usually can be constructed.

Before discussing the event that brought the patient to the ED, one has to ascertain a history of the child so as to put the event in a context. What is the age of the patient? Was the patient born prematurely? Is there anything in the patient's past medical history, namely, are there any congenital or genetic abnormalities, metabolic disturbances, cardiac conditions, immunodeficiencies, neurological conditions, or is there a history of gastroesophageal reflux disease (GERD)? Is the child on any medications and why? Does the child take any alternative or nonprescribed medications? If the child is still a newborn, learning about prenatal, maternal, and perinatal events is important. Additionally, the physician should find out if such an event has occurred before.

One must also ascertain information about environmental conditions. Where was the child? How was the child found? Who was watching the child? Were there any containers or medicines near the child? Is there anyone in the home who is sick? What time did the event occur? What time of year is it? Is there a combustible motor around?

When assessing the event, it may be best to go through it using a systems-based approach, as follows:

• Gastrointestinal (the most likely known cause for apparent life-threatening events [ALTEs])
  • What does the child eat? Has it been changed recently? If so, why? How soon after feeding did this event occur?
  • Did the patient spit up, vomit, or have food/drink come through his or her nose? Does the child cough during feeds?
  • Was there an arching of the back before and/or during the episode? (This movement is known as Sandifer's posturing and is associated with reflux in infants, but it must be further parsed out to differentiate from posturing from a seizure or acute brain injury.)
  • How much did the child eat? (Try to determine if there overfeeding and thus refluxing not secondary to malfunction of the lower esophageal sphincter but to simple overflow of the stomach.)
• Neurological
  • Was the child conscious? Was the child shaking? Was the shaking of the entire body or was it focal? (Focal seizures have a higher incidence of being associated with an anatomical/vascular abnormality than with a generalized seizure.)
  • Were there any odd physical movements during the event? What was the body tone of the child?
  • Was there cyanosis? Was there incontinence of the bowel or bladder?
  • Did the child's eyes roll back? Was there drooling or frothing at the mouth?
  • Did the child fall asleep immediately after the event (post-ictal)? How is the child now relative to his or her normal state of behavior? Did the child's behavior stop with stimulation or comforting?
  • Was any anesthesia given recently? (Premature infants who have had general anesthesia are at increased risk for ALTE for 2-4 months after the procedure for which it was given.)
• Cardiac
  • How has the child's energy been?
  • Has the child been gaining weight? Is their diaphoresis with feeding? (Feeding may be the most strenuous activity for the newborn, so it is much like a pseudo-stress test.)
  • Did this event occur during increased activity, or did it occur at rest?
  • Was there cyanosis? Was the cyanosis of the extremities, face, or more? (Acrocyanosis of the distal extremities may be a normal finding in a newborn?) Outside of the circumstances of the event, is there ever cyanosis?
  • Was the baby's heart beating fast? Did the child have a pulse? Was CPR given? If so, why?
• Infection
  • Did the child have a fever?
  • Did the child have rhinorrhea, a cough, or congestion?
  • Was there any vomiting or diarrhea?
  • Was the child breathing comfortably prior to the event?
• Metabolic
  • Though much in this section overlaps with other areas, namely, GI, cardiac, and neurological, the questions are repeated so that they are understood to have various interpretations.
  • What does the child eat? Has it been changed recently? If so, why? How has the child's energy been? Has the child been gaining weight? Was the child conscious? Was the child shaking? What was the body tone of the child? Was there cyanosis? Was the baby's heart beating fast? Did the child have a pulse? Was CPR given? If so, why?
• Behavioral
  • Was this episode part of a tantrum?
  • Did the child scream in frustration, pain, or anger and then hold his or her breath? Has this happened before?
• Patients with home monitors
  • In a number of cases, the monitor malfunctioned or was improperly used; however, full evaluation is still warranted. During observation in the ED, the infant should be connected to the home monitor and to one of the cardiorespiratory monitors in the ED for comparison.
    • Home monitoring devices are simple, single-channel machines that monitor the patient's heart rate and chest-wall movements. Compare the home monitor with the recordings on the equipment in the ED. Newer home monitors have an event-recording feature that allows the episode to be played back.
  • When asking about the event, ask about the child’s behavior and appearance, not just about the numbers on the monitor, to determine if they correlated clinically.
  • Healthy infants may have respiratory pauses as long as 20 seconds. If the episode lasted fewer than 20 seconds and was not associated with vomiting, abnormal movements, hypotonia, or color change, it may be normal.

Physical

As with any physical examination, especially in the emergency care setting, it must begin with the primary survey, ABCDs. This step is crucial in differentiating the sicker patients who may require immediate stabilization before taking the history. If the child is still having serious respiratory issues, poor perfusion, or a significantly abnormal Disposition (abnormal sensorium), taking control of the airway and obtaining intravenous access may be essential prior to continuing.

In greater than 50% of ALTE cases, the infant appears well, and the examination findings are normal. However, complete physical examination must proceed with the patient fully undressed. Infants who do not appear well may have a variety of serious disorders (see Differential Diagnosis below).

• Vital signs and temperature: All abnormalities must be investigated. If a cardiac abnormality is suggested in the history, 4 limb-blood pressures (BPs) and ECG may be warranted.
• Height and weight: Deviation from growth charts may suggest child abuse/neglect, congenital abnormalities, malabsorption, or inborn errors of metabolism.
• Head, eyes, ears, nose, and throat examination
  • Abnormal facial appearance, low set ears, micrognathia (undersized jaw), large tongue, and frontal bossing may suggest genetic or metabolic abnormalities.
  • A bulging fontanel suggests raised intracranial pressure.
  • Thorough palpation of the cranium should be performed to look for signs of trauma.
  • The physician must look for conjunctival hemorrhages, pupillary abnormalities, and, if possible, retinal hemorrhages (the later is not pathognomonic for shaken baby syndrome because there can be other known causes, namely glutamic aciduria, but nonetheless it is very highly suggestive of abuse).
  • Oronasal hemorrhage has been associated with trauma but not with benign causes of ALTE.
  • Rhinorrhea may be suggestive of an infectious etiology.
  • Examination of the tympanic membranes may reveal signs of trauma, hemotympanum, or an infection. Otitis media is a common cause of fever in a child, and thus a possible source for a febrile seizure.
  • If a finger sweep was performed because of gagging or choking, a thorough mouth/throat examination should be performed because a blind sweep is often associated with intra-oral trauma.
• Neck examination
  • Nuchal rigidity is a sign of meningitis, but only approximately a quarter of all newborns with meningitis will exhibit this finding.
  • The examiner should listen to the neck for stridor, which suggests laryngotracheomalacia.
• Chest examination
  • The examiner should listen for abnormal breath sounds and for heart murmurs or thrills.
  • Chest wall deformities or wide-spaced nipples may suggest genetic disorders.
  • The patient's respiratory pattern should be observed to identify an exaggerated periodic breathing pattern.
  • Retractions and grunting suggest lower-airway pathology.
  • Wheezing with stridor may be consistent with laryngotracheomalacia or bronchitis. Placing the child prone and observing if the sounds resolve is a quick and cheap method of diagnosing laryngotracheomalacia.
• Abdominal examination
  • Hepatomegaly or splenomegaly may be signs of hematological, metabolic, or congenital abnormalities.
  • Hyperactive bowel signs may indicate enteritis.
  • Hypoactive bowel signs may indicate metabolic abnormalities or sepsis.
• Musculoskeletal
  • Signs of rickets include (bow legged) or genu valgum (knocked kneed), craniotabes (soft cranium), costochondral swelling (rickety rosary), or fractures. Significantly low calcium level from rickets can cause seizure activity.
• Genital
  • Abnormal genitalia may reflect an endocrinological abnormality.
  • Any sign of trauma should be noted.
• Neurologic examination
  • Any abnormal neurologic findings should be noted.
  • Specifically, one should look for symmetrical reflexes that are normal in the newborn. Examples include Moro, rooting, grasp, Babinski, and suck reflex
  • There are age-specific reflexes that also expire at certain ages; those should be evaluated for their presence or absence.
  • Seizure activity, muscle rigidity, and abnormal eye movements are important indicators of a neurologic pathology.
  • A sleeping and difficult to arouse child may be a sign of a post-ictal child, a neurologically injured child, a serious infectious cause, or a severe metabolic derangement.
• Skin
  • Cyanosis represents poor perfusion or hypoxia.
  • Pallor represents poor perfusion or anemia.
  • Any signs of trauma should be noted.
  • Any sign of needle marks may indicate intravenous or intramuscular use of illicit drugs.
  • Any signs consistent with neurocutaneous disorders (congenital disorders of the ectoderm, which are associated with neurological and cutaneous pathology):
    • Port wine stain - Sturge-Weber
    • Café-au-lait spots – Neurofibromatosis
    • Ash-leaf spots, shagreen patch, sebaceous adenomas – Tuberous sclerosis

Causes

• Apnea of prematurity clearly implicates the immature neurological mechanism for breathing in the premature infant. However, it has been suggested that perinatal injury can also be implicated in the mechanism because these premature infants also have a higher incidence of hypoglycemia, electrolyte abnormalities, intracranial hemorrhage, seizures, thermal disturbances, systemic illnesses, and anatomical narrowing of the airways.
• Apnea may be the presenting symptom for sepsis (serious bacterial infection), cardiac arrhythmia, and seizures.
• Apnea can be a failure of the central nervous system in a severe head trauma, a toxic overdose, an infection such as botulism, or autoimmune causes like Guillain-Barré syndrome.
• Apnea is seen as a sequelae of certain infections (bronchiolitis and pertussis) in a more complicated mechanism than simple end-organ failure.
• ALTE or apnea can sometimes be confused with normal physiological occurrences. Examples include normal infant periodic breathing, acrocyanosis (where hands and feet may appear cyanotic), and breath holding spells.
• As mentioned above any pediatric healthcare worker must consider abuse or Munchausen syndrome by proxy when presented with an apneic child.
• The number one cause of an ALTE is idiopathic. However, that is determined only after other causes have been eliminated.

Causes by system

• Gastrointestinal
  • Gastroesophageal reflux (GER): Apnea due to reflux often may be a mixed apnea with both central and obstructive tendencies. In older patients with GER, ALTE is most likely a result from laryngospasm.
  • A choking episode might be possible.
• Neurological
  • Idiopathic apnea (most common): The usual cause of apnea is unknown but often presumed to be immaturity of the respiratory center, with a weak respiratory response to hypercapnia. Studies of cases followed up in apnea centers have shown increased respiratory pauses in patients compared with age-matched control subjects. However, these events were not apparently correlated with low levels of oxygen. Studies of hypercapnia in infants with known apnea have not demonstrated an abnormal response to carbon dioxide.
  • Seizure: Neonatal seizures are often different from those observed in older children thought due to the lack of full myelinization of the peripheral nerves. Although apnea may result from seizures, it is usually not the only symptom. Most patients with seizures also have abnormal movements or posturing, and lateralizing eye movements.
  • Head injury causing central apnea
  • Toxin-related central apnea: Certain drugs are known to cause respiratory depression (opiates, benzodiazepines, and barbiturates) and thus place the patient at risk for central apnea; however, in most cases, the patient has no history of drug exposure. The examining physician should ask about the mother's use of drugs, particularly if the infant is being breastfed. Carbon monoxide poisoning must also be considered because it is more likely to affect young infants (because of CO greater affinity for fetal hemoglobin) more than adults.
• Respiratory
  • Upper/lower respiratory infection either due to RSV, or other infections (pertussis, influenza, human metapneumovirus) is the second most used discharge diagnosis for patients with apnea/ALTE.
  • Aspiration pneumonia may cause apnea of a mixed or obstructive picture and may have a GI, neurological, or a respiratory etiology.
• Anatomical
  • Laryngomalacia or tracheomalacia: The cause is a thin, floppy upper airway and trachea, which are prone to collapse with the negative pressure of inspiration. This is a prime example of obstructive apnea due to anatomical causes. Infants with these conditions may also have stridorous breathing.
• Cardiac
  • Primary arrhythmia: Cardiac arrhythmias can cause central apnea by disrupting the perfusion of the brain and lungs. Infants with previous cardiac surgery or known congenital defects near the conducting system may have an arrhythmia. In most cases, the cause is obscure. The infant with a cardiac cause for ALTE is less likely than others to present with primary apnea.
  • Congenital heart disease may present with cyanosis, hypoxia, and/or seizure.
  • The 4 T s of pediatric cardiac congenital malformations are as follows:
    • Tetralogy of Fallot
    • Transposition of the great vessels
    • Truncus arteriosus
    • Total anomalous pulmonary venous return

Other potential causes

In an ill-appearing infant, apnea may have many potential causes, including the following:

• Infection (eg, sepsis, meningitis, bronchiolitis, infant botulism)
• Inborn error of metabolism
• Congenital adrenal hyperplasia
• Dehydration or renal tubular acidosis
• Child abuse, including aborted infanticide, Munchausen syndrome by proxy, and physical abuse
  • Abuse should be considered when infants do not appear well on arrival. Careful physical examination should be performed to look for other signs of abuse.
  • Munchausen syndrome by proxy may be suspected in the infant who has recurrent or bizarre ALTEs, particularly when the family has been to several EDs and/or physicians with the same complaint and when "no one can find the cause." A previous SIDS death in the family also increases the risk of Munchausen by proxy. Although not found in all cases, family dynamics may include a father who is somewhat distant or uninvolved and a mother (usually the perpetrator) who has a healthcare background and who seems to identify with members of the healthcare team.
  • Home monitor alarm: Causes may include worn or faulty leads, improper placement of leads, a damaged monitor, or failure to adjust the limits of the alarm to account for a decreasing normal pulse and respiratory rate as the infant ages.

Differential Diagnoses

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

Treatment

Prehospital Care

• Prehospital care first and foremost includes resuscitation, if necessary, and prompt monitored transport to an ED. 
• If the child is cyanotic or a pulse oxygen level is low but respiratory effort is present O₂ should be administered via a nonrebreather.
• If the infant has an apneic event during transport, prehospital personnel should first attempt simple manual stimulation of the infant with brisk rubbing along the patient's back, patting, and thumping the feet. If these maneuvers fail, resuscitation via bag valve mask should be initiated immediately and securing a laryngeal mask airway (LMA) or endotracheal tube (ETT) placement may be necessary if a long transport time is foreseen.
• If the patient is seizing, local protocols should be followed and oxygen administered.
• If the patient is lethargic, local protocols should be followed, but, if a glucose evaluation can be performed, it should be, and hypoglycemia treated if present. If not possible, dextrose should be given prophylactically.
• With the cyanotic child or a child with an abnormal cardiac rhythm, an AED should be placed or an ECG should be obtained. If the child is pulseless, CPR should be initiated and epinephrine given.

Emergency Department Care

• In the ED, all infants should receive cardiac and respiratory monitoring.
• Ill-appearing infants should be treated as needed on the basis of their clinical condition. Treatment may include resuscitation or aggressive antibiotic treatment of sepsis.
• Well-appearing infants may need no emergency treatment other than a careful history and physical examination and then some close observation.
• A feeding should be observed in the health care setting for poor feeding techniques as well as for infant feeding difficulties.

Consultations

The history, physical examination, and diagnostic workup determine which consultation may become necessary to evaluate the patient. These may include the following:

• Pediatric gastroenterologist
• Pediatric neurologist
• Pediatric cardiologist
• Pediatric endocrinologist
• Metabolic/genetics specialist
• Pediatric intensivist
• Neonatologist
• Sleep specialists
• Otolaryngologist

The patients who are on home monitoring should have a consultation with the service that placed them on the monitor. Most children with apnea receive follow-up care by a special apnea service.

• Such services may be helpful by providing important data about the patient's history. Also, they often facilitate contact with the company providing the monitoring service.
• In addition, the apnea service may be able to simplify the process of admission or transfer to a tertiary care pediatric facility.

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.

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].

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

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.

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.

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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