Pediatric Apnea Clinical Presentation

Updated: Sep 28, 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- (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.)


  • 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?


  • 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). [22]   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?


  • 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?


  • 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?


  • 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. [23]
  • 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.

  • 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. [24]

Neck examination

  • Nuchal rigidity is a sign of meningitis, but only approximately 15% of all newborns with bacterial meningitis will exhibit this finding. [25]

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


  • 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.


  • 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.


  • 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):



  • Gastroesophageal reflux ( GER): Apnea due to reflux often may be a mixed apnea with both central and obstructive tendencies. In older patients with GER, apnea is most likely a result from laryngospasm. GER occurs in more than two-thirds of all infants. [26]  It has been noted to cause apnea and hypoxia related to obstruction, laryngospasm and aspiration. Before BRUE, GER was considered to be the most common identifiable etiology of ALTE second only to idiopathic, attributed in 20% to 54% of all patients. [27]
  • A choking episode might have been possible.


Increased intracranial pressure: such as the case in congenital hydrocephalus. On exam you would notice a large head circumference, as well as a fixed downward gaze (sundowning) of the eyes.

  • Idiopathic apnea – previously the leading cause of ALTE - The usual cause of apnea is unknown but often presumed to be immaturity of the respiratory center, with a weak respiratory response to hypercapnia.
  • 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. In past studies, 10-11% of patients with recurrent ALTE were found to have epilepsy. [28]
  • 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 pediatric apnea cases, the patient has no history of drug exposure. The examining physician should ask about the mother's use of medications, 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.

    See the list below:

    • 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. [29]  This was confirmed when patients with suspected apnea were found to have less spontaneous arousals during sleep, especially when exposed to second-hand smoke. [29]
  • In older infants, breath holding spells may cause apnea. A breath holding spell is usually triggered by an inciting event, namely frustration, surprise, anger or fear. The infant usually cries, followed by a pause, and then becomes pale or blue. Occasionally, a breath holding spell can lead to loss of consciousness and the infant will become limp. Breath holding spells are self-limiting and do not put the infant in danger. There is no treatment for a breath holding spell- because it is self limited and benign. Supportive care is all that is needed. However, there needs to be significant education and reassurance given to the family. Breath holding spells can begin as early as 6 months of age, and are usually outgrown by mid-childhood. [27]  


  • Upper/lower respiratory infection either due to RSV, or other infections ( pertussis, influenza, human metapneumovirus, rhinovirus, or other respiratory pathogens) is the second most used discharge diagnosis for patients who initially present with apnea or suspected BRUE. [27] ]
  • Aspiration pneumonia may cause apnea of a mixed or obstructive picture and may have a GI, neurological, or a respiratory etiology.


  • Upper/lower Apnea may be the presenting symptom for sepsis, or a serious bacterial infection (SBI). Previous studies have shown that the incidence of SBI presenting with ALTE is approximately 0-3%. [30, 31]


  • 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 presenting with BRUE, who ultimately has a cardiac cause, is less likely than others to present with primary apnea alone.
  • Congenital heart disease may present with cyanosis, hypoxia, and/or seizure.
  • The 5  T s of pediatric cardiac congenital malformations are as follows:

    See the list below:

    • Tetralogy of Fallot
    • Transposition of the great vessels
    • Truncus arteriosus
    • Total anomalous pulmonary venous return
    • Tricuspid atresia

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 physical abuse, Munchausen syndrome by proxy, and aborted infanticide.
  • Abuse should be considered when infants do not appear well on arrival. Careful physical examination should be performed to look for physical signs of abuse. Some of these physical exam findings include but are not limited to: retinal or subconjunctival hemorrhages, unexplained facial injuries such as a torn frenulum in the non ambulatory child, bruising in non ambulatory infants or bruising in unusual locations such as behind the ear or neck, under the chin, on the torso or buttocks, unexplained human bite marks, or unexplained burns.
  • Munchausen syndrome by proxy may be suspected in the infant who has an atypical history relating to the apnea, 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 true apnea, but more commonly technical errors such as worn or faulty leads, improper placement of leads, a damaged monitor, failure to adjust the limits of the alarm to account for a decreasing normal pulse and respiratory rate as the infant ages, or non compliance with monitoring. [23]