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 an outpatient sleep study and follow up with an otolaryngologist. If the episodes of OSA are very prolonged and significant, an EKG should be performed in the ED to rule out right heart strain or cor pulmonale.

Further Emergency Department Care

If it is determined that a patient had a low-risk brief resolved unexplained event, it is not recommended to perform any further testing other than testing for pertussis (if a respiratory infection is suspected) or an electrocardiogram. The infant should be monitored for 1-4 hours in the emergency department with continuous pulse oximetry and serial observations ensuring that vital signs, physical examination and symptomatology remain stable. The infant should be assessed for social risk factors of child abuse; and clinicians should offer resources for CPR training and education regarding brief resolved unexplained events.^[11]

Treatment of sleep apnea in children includes both surgical and medical approaches. When adenoid and tonsillar hypertrophy accompany the OSA, adenotonsillectomy (surgical removal of adenoids and tonsils) is the treatment of choice. For those that are not suitable candidates for surgery or have symptoms despite surgery, the most effective treatment in both adults and children, is continuous positive airway pressure (CPAP). One study has shown that warm humidified air delivered through an open nasal cannula actually decreased the occurrence of sleep apnea episodes in children with OSA.^[39]

For more information on pediatric sleep apnea, please refer to the Medscape Reference Pediatrics article Sleep Apnea.

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 unique pediatric 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.

Blystad W. Blood gas determinations on premature infants. III. Investigations on premature infants with recurrent attacks of apnea. Acta Paediatr. 1956 May. 45(3):211-21. [QxMD MEDLINE Link].
Miller HC, Behrle FC, Smull NW. Severe apnea and irregular respiratory rhythms among premature infants; a clinical and laboratory study. Pediatrics. 1959 Apr. 23(4):676-85. [QxMD MEDLINE Link].
Perlstein PH, Edwards NK, Sutherland JM. Apnea in premature infants and incubator-air-temperature changes. N Engl J Med. 1970 Feb 26. 282(9):461-6. [QxMD MEDLINE Link].
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.
Committee on Fetus and Newborn. American Academy of Pediatrics. Apnea, sudden infant death syndrome, and home monitoring. Pediatrics. 2003 Apr. 111(4 Pt 1):914-7. [QxMD MEDLINE Link].
Kondamudi NP, Virji M. Brief Resolved Unexplained Event (BRUE). 2018 Jan. [QxMD MEDLINE Link]. [Full Text].
Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. 2005 Apr. 115 (4):885-93. [QxMD MEDLINE Link].
Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016 May. 137 (5):[QxMD MEDLINE Link].
Fleming P, Blair P, Bacon C, et al. Sudden unexpected deaths in Infancy: the CESDI SUDI studies 1993-1996. Stationary Office. 2000.
Doshi A, Bernard-Stover L, Kuelbs C, Castillo E, Stucky E. Apparent life-threatening event admissions and gastroesophageal reflux disease: the value of hospitalization. Pediatr Emerg Care. 2012 Jan. 28(1):17-21. [QxMD MEDLINE Link].
McFarlin A. What to Do when Babies Turn Blue: Beyond the Basic Brief Resolved Unexplained Event. Emerg Med Clin North Am. 2018 May. 36 (2):335-347. [QxMD MEDLINE Link].
Anjos AM, Nunes ML. Prevalence of epilepsy and seizure disorders as causes of apparent life- threatening event (ALTE) in children admitted to a tertiary hospital. Arq Neuropsiquiatr. 2009 Sep. 67(3A):616-20. [QxMD MEDLINE Link].
Stéphan-Blanchard E, Chardon K, Léké A, et al. In utero exposure to smoking and peripheral chemoreceptor function in preterm neonates. Pediatrics. 2010 Mar. 125(3):e592-9. [QxMD MEDLINE Link].
Mittal MK, Shofer FS, Baren JM. Serious bacterial infections in infants who have experienced an apparent life-threatening event. Ann Emerg Med. 2009 Oct. 54(4):523-7. [QxMD MEDLINE Link].
Zuckerbraun NS, Zomorrodi A, Pitetti RD. Occurrence of serious bacterial infection in infants aged 60 days or younger with an apparent life-threatening event. Pediatr Emerg Care. 2009 Jan. 25(1):19-25. [QxMD MEDLINE Link].
Ward SL, Keens TG, Chan LS, Chipps BE, Carson SH, Deming DD, et al. Sudden infant death syndrome in infants evaluated by apnea programs in California. Pediatrics. 1986 Apr. 77 (4):451-8. [QxMD MEDLINE Link].
Brooks JG. Apparent life-threatening events and apnea of infancy. Clin Perinatol. 1992 Dec. 19(4):809-38. [QxMD MEDLINE Link].
Lumeng JC, Chervin RD. Epidemiology of pediatric obstructive sleep apnea. Proc Am Thorac Soc. 2008 Feb 15. 5 (2):242-52. [QxMD MEDLINE Link].
Rosen CL, Debaun MR, Strunk RC, Redline S, Seicean S, Craven DI, et al. Obstructive sleep apnea and sickle cell anemia. Pediatrics. 2014 Aug. 134(2):273-81. [QxMD MEDLINE Link]. [Full Text].
Ralston S, Hill V. Incidence of Apnea in Infants Hospitalized with Respiratory Syncytial Virus Bronchiolitis: A Systematic Review. J Pediatr. 2009 Jul 31. [QxMD MEDLINE Link].
Schroeder AR, Mansbach JM, Stevenson M, Macias CG, Fisher ES, Barcega B, et al. Apnea in children hospitalized with bronchiolitis. Pediatrics. 2013 Nov. 132 (5):e1194-201. [QxMD MEDLINE Link].
Ricart S, Rovira N, Garcia-Garcia JJ, Pumarola T, Pons M, Muñoz-Almagro C, et al. Frequency of apnea and respiratory viruses in infants with bronchiolitis. Pediatr Infect Dis J. 2014 Sep. 33 (9):988-90. [QxMD MEDLINE Link].
Genizi J, Pillar G, Ravid S, Shahar E. Apparent life-threatening events: neurological correlates and the mandatory work-up. J Child Neurol. 2008 Nov. 23(11):1305-7. [QxMD MEDLINE Link].
Chen VC, Yang YH, Kuo TY, Huang KY, Huang YC, Lee Y, et al. Increased Incidence of Obstructive Sleep Apnea in Hospitalized Children following Enterovirus Infection: A Nationwide Population-Based Cohort Study. Pediatr Infect Dis J. 2018 Jan 8. [QxMD MEDLINE Link].
Quintana-Gallego E, Carmona-Bernal C, Capote F, Sánchez-Armengol A, Botebol-Benhamou G, Polo-Padillo J, et al. Gender differences in obstructive sleep apnea syndrome: a clinical study of 1166 patients. Respir Med. 2004 Oct. 98 (10):984-9. [QxMD MEDLINE Link].
Henderson-Smart DJ. The effect of gestational age on the incidence and duration of recurrent apnoea in newborn babies. Aust Paediatr J. 1981 Dec. 17(4):273-6. [QxMD MEDLINE Link].
Schiller O, Levy I, Pollak U, Kadmon G, Nahum E, Schonfeld T. Central apnoeas in infants with bronchiolitis admitted to the paediatric intensive care unit. Acta Paediatr. 2011 Feb. 100(2):216-9. [QxMD MEDLINE Link].
Gozal D. Sleep-disordered breathing and school performance in children. Pediatrics. 1998 Sep. 102 (3 Pt 1):616-20. [QxMD MEDLINE Link].
Sasidharan P. An approach to diagnosis and management of cyanosis and tachypnea in term infants. Pediatr Clin North Am. 2004 Aug. 51 (4):999-1021, ix. [QxMD MEDLINE Link].
Hartrey R, Bingham RM. Pharyngeal trauma as a result of blind finger sweeps in the choking child. J Accid Emerg Med. 1995 Mar. 12 (1):52-4. [QxMD MEDLINE Link].
Pong A, Bradley JS. Bacterial meningitis and the newborn infant. Infect Dis Clin North Am. 1999 Sep. 13 (3):711-33, viii. [QxMD MEDLINE Link].
Wright JN. CNS Injuries in Abusive Head Trauma. AJR Am J Roentgenol. 2017 May. 208 (5):991-1001. [QxMD MEDLINE Link].
Wang S, Liao C, Liang S, Zhong D, Liu J, Li Z. Ultrasound findings of mild neonatal periventricular-intraventricular hemorrhage after different treatments. Int J Clin Exp Med. 2015. 8 (4):5085-93. [QxMD MEDLINE Link].
Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016 May. 137 (5):[QxMD MEDLINE Link].
[Guideline] Aziz K, Lee CHC, Escobedo MB, et al. Part 5: Neonatal Resuscitation 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2021 Jan. 147 (Suppl 1):[QxMD MEDLINE Link]. [Full Text].
Johnson PJ. Caffeine citrate therapy for apnea of prematurity. Neonatal Netw. 2011 Nov-Dec. 30(6):408-12. [QxMD MEDLINE Link].
Kumral A, Tuzun F, Yesilirmak DC, Duman N, Ozkan H. Genetic basis of apnoea of prematurity and caffeine treatment response: role of adenosine receptor polymorphisms: Genetic basis of apnoea of prematurity. Acta Paediatr. 2012 Mar 8. [QxMD MEDLINE Link].
Alansari K, Toaimah FH, Khalafalla H, El Tatawy LA, Davidson BL, Ahmed W. Caffeine for the Treatment of Apnea in Bronchiolitis: A Randomized Trial. J Pediatr. 2016 Oct. 177:204-211.e3. [QxMD MEDLINE Link].
McGinley B, Halbower A, Schwartz AR, Smith PL, Patil SP, Schneider H. Effect of a high-flow open nasal cannula system on obstructive sleep apnea in children. Pediatrics. 2009 Jul. 124(1):179-88. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

of 0

Author

Joshua A Rocker, MD Assistant Professor of Pediatrics and Emergency Medicine, Hofstra North Shore-LIJ School of Medicine; Associate Chief, Division of Pediatric Emergency Medicine, Director of Education for Pediatrics Emergency Medicine Fellowship, Cohen's Children Medical Center of New York

Joshua A Rocker, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Santina P Bruno, DO Fellow in Pediatric Emergency Medicine, Cohen Children's Medical Center, Northwell Health; Teaching Associate in Pediatrics, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell

Santina P Bruno, DO is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, 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.

Additional Contributors

Jeffrey Israel, MD Pediatric Emergency Medicine Fellow, Cohen Children's Medical Center of New York, North Shore-Long Island Jewish Health System

Jeffrey Israel, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference 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.

Pediatric Apnea Follow-up

Further Outpatient Care

Further Emergency Department Care

Transfer

References

Tables

Contributor Information and Disclosures

What would you like to print?