Pediatric Apnea Follow-up

Updated: Sep 28, 2018
  • Author: Joshua A Rocker, MD; Chief Editor: Kirsten A Bechtel, MD  more...
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Follow-up

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.

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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. [27]

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. [38]

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

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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.

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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.
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Prognosis

The prognosis is case specific.

In general, as the child matures, the cause of the suspected brief resolved unexplained event (BRUE) is diagnosed and treated or spontaneously resolves. If the apnea is determined to be idiopathic, the prognosis is generally excellent.

Patient Education

See the list below:

  • 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.
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Patient Education

See the list below:

  • 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 patient education resources, see the Children's Health Center, as well as Sudden Infant Death Syndrome (SIDS).

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