Pediatric Apnea Clinical Presentation

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 – (previously the most likely known cause for ALTEs, second only to idiopathic causes)

• 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 is 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 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?

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 or perioral region may be a normal finding in a newborn. It is often caused by vasomotor changes that result in peripheral vasoconstriction and increased tissue oxygen extraction and is a benign condition). ^[29]   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 here for the reader 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. However, epidemiologic studies have failed to show an effect of cardiorespiratory monitors in reducing the incidence of SIDS in infants presumed to be at risk. ^[16]

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 10 seconds. If the episode lasted fewer than 10 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. If the child is still having serious respiratory issues, poor perfusion, or a significantly abnormal “D” - disposition, or neurological state - such as abnormal sensorium or with obtundation/unconsciousness, taking control of the airway and obtaining intravenous access may be essential prior to continuing.

General examination

• 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, and may be consistent with an infection such as meningitis, or an acute intracranial bleed from accidental or non accidental trauma.
• Thorough palpation and visual inspection 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).
• 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 sometimes associated with intra-oral trauma. ^[30]

Neck examination

• Nuchal rigidity is a sign of meningitis, but only approximately 15% of all newborns with bacterial meningitis will exhibit this finding. ^[31]

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, cardiac, metabolic, or congenital abnormalities.
• Hypo- or hyperactive bowel signs may indicate enteritis, or a toxic ingestion

Musculoskeletal examination

• 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 examination

• 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, a toxic ingestion, or a severe metabolic derangement.

Skin examination

• Cyanosis may reflect poor perfusion or hypoxia, depending on the area. Cyanosis to the extremities is not always a concern.
• Pallor may represent poor perfusion or anemia, or temporary shunt of blood to other areas of the body.
• 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