Pediatric Apnea Clinical Presentation

Updated: Feb 13, 2018
  • Author: Joshua A Rocker, MD; Chief Editor: Kirsten A Bechtel, MD  more...
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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.


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 latter 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):


See the list below:

  • 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.
  • One recent study has shown that in utero exposure to nicotine smoke has a negative effect on the chemoreceptors responsible for respiratory drive and may increase the risk of insufficient response to respiratory challenges during sleep. [18] This was confirmed when patients with ALTE and suspected apnea were found to have less spontaneous arousals during sleep, especially when exposed to second-hand smoke. [19]
  • Apnea may be the presenting symptom for sepsis (serious bacterial infection [SBI]), cardiac arrhythmia, and seizures. The incidence of SBI presenting with ALTE has been shown to be 0-3%. [20, 21]
  • 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 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

See the list below:

  • 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. Reflux has been shown to be the second most common cause of ALTE; idiopathic is the first. [22, 23]
    • 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. Most recently, 10-11% of patients with recurrent ALTE were found to have epilepsy. [24]
    • 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)
  • 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.