Pat Mathios,RN, MSNPediatric Pulmonary Educator

APNEA of Prematurity, SIDS and ALTE

Historical perspective

Objectives Define AOP, SIDS and ALTE Discuss treatments for AOP Describe the “triple-risk” theory for

SIDS Identify an evidenced based

intervention for prevention of SIDS Discuss the UAMC Apnea/CLD Clinic Discuss the indications for use of an

apnea monitor

APNEA—what is it?

Apnea is a nonspecific indicator of distress:

√Failure of a system√Early indicator of deterioration

Many causes of apnea can be diagnosed and treated.

Apnea of Infancy

Definition: “an unexplained episode of cessation of breathing for 20 seconds or longer, or a shorter respiratory pause associated with bradycardia, cyanosis, pallor, and/or marked hypotonia. The term ‘apnea of infancy’ generally refers to infants with a gestational age of 37 weeks or more at the onset of apnea.”American Academy of Pediatrics policy statementPEDIATIRCS Vol. 111, No. 4 April 2003

Definition of Apnea of Prematurity-AOP

Apnea of prematurity is cessation of breathing that lasts longer than 20 seconds and is associated with bradycardia (<100bpm), oxygen desaturation, pallor/cyanosis in an infant younger than 37weeks gestational age.American Academy of Pediatrics policy statementPEDIATRICS, Vol 111, No. 4 April 2003

Periodic breathing

Periodic breathing is not apnea.3 or more pauses for greater than 30

seconds duration with less than 20 seconds of respiration between pauses.

Thought to be benignPeriodic breathingApneaSIDS????Should not be considered linear eventsThey overlap, but one is not causative

to the next

Apnea of prematurity

Apnea and periodic breathing are common in premature infants after the first 24-48 hours of life.

Apnea only occurs during active sleepPremature infants sleep 80% of the time

full term infants 50%.

Chronic Lung Disease past & present

Surfactant

Annual deaths from RDS (respiratory distress syndrome) in the US decreased from 10-15,000 babies in the 1960’s to fewer than 1000 in 2002.

www.faseb.org/opar/break/. 2002

Types of Apnea

Central (40-45%)No respiratory effort, no nasal airflowDevelopmental phenomenon

Obstructive (10-15%)respiratory effort, no nasal airflow HRCaused by aspiration, laryngospasm or poor

airway control

Mixed (40-45%)Both obstructive and central

Factors contributing to respiratory effort

CNS immaturity- # of synaptic connectionssensitivity to CO2

activity of protective respiratory reflexes (conserve rather than breathe)

minute ventilation Diaphragmatic fatigue Soft complaint chest

Therefore AOP: Mixed apnea occurs frequently in premature

infants due to:√ Increased CNS immaturity (central apnea)-

blunted response to 02 and CO2√ Softer chest, weaker diaphragms (obstructive

apnea)√ Immature immune system -viruses, infections

(obstructive apnea)Usually resolves by 37 weeks PCA or persists

several weeks post term

Clinical conditions associated with Apnea

Intraventricular bleed-may see hypoventilation, apnea arrest

Subtle seizures Sepsis Congestive heart failure-due to

atelectasis WOB, fatigue Anemia Polycythemia

Other contributing factors to AOP Feeding problems:• Over distention• Aspiration• GER (gastroesphogeal reflux) with or w/o aspiration• Due to laryngospasm• Stimulations of irritant receptors in lower esophagus

Metabolic conditions• Hypoglycemia• Hypercalcemia• Hypernatremia

Other• Myelomeningocele/meningitis

Treatment of Apnea

Dependent on Etiology Least invasive-monitor, medication Treat underlying causes Non–pharmacologic vs pharmacologic

Treatment of Apnea

Mechanical CPAP/ ventilation CPAP markedly apneic episodes

with an obstructive component Improves patency of upper airways by

activation of dilator muscles by passive splinting

Treatment of apnea

METHYLXANTHINES:•May treat more severe AOP with methylxlanthines•Methylxanthines effects neurotransmitters and increase the transmission of impulses across nerves and synapses•Caffeine preferred over Theophylline•Caffeine more centrally active, not metabolized by liver-not all pharmacies carry•Caffeine- 2.5-5mg/kg/day once per day (therapeutic range 6-20mcg/ml-toxic >40)

Treatment of Apnea-pharmocologic

Oxygen via nasal cannula-can go home if no apnea or bradycardia for at least 5 days and parents room in.

DME will bring home oxygen Follow-up will be in the Apnea CLD

clinic in 2-4 weeks

Weaning Oxygen in the Outpatient setting Growing is important!-consider weight gain Any apnea events/viral illness Pulse ox on current setting Consider altitude where the baby lives Discontinue if good weight gain is pulse ox is

96+, Oxygen at night if pulse ox 93-95 with good

growth Pulse ox < 92 and RR and wt-keep 02

Keep oxygen in home for another 2-4 weeks and check weight gain

Treatment of apneaNon -pharmacologic

Tactile stimulation Neutral ambient temperature Address feeding issues Monitor Parent instruction

Apparetn Life Threatening Event-ALTE

Definition: “an episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic, pallid), marked change in muscle tone (usually marked limpness) choking or gagging”

American Academy of Pediatrics policy statementPediatrics Vol 111,No. 4 April 2003

ALTE-Apparent Life Threatening Event

Frigententing to the observer Combination of apnea Color change Marked change in muscle tone Over 37 weeks of PCA Usually awake

ALTE treatment condierations

History of event including feeding & sleeping history

Physical exam, VS, overheated? CBC, lytes, ABG, pulse ox, Blood and viral cultures CXR, Cranial US, Echocardiogram Ph probe, barium swallow Sleep study

Goals for Discharge to HomePrefer to discharge without monitor and/or methylxanthinesFor AOP:•No apneic episodes for 5 days•If dc on methylxanthines - in this community is with a monitor•May discharge with only monitor or only oxygen with follow up in Apnea/CLD clinicFor ALTE:•May discharge < 5days if work up negative and no events

Indications for Home Apnea monitoring (or not) Infants with BW < 1000grams Infants with continued apnea and bradycardia Infant requiring methylxanthines Infants with severe GER Infant with tracheostomies/or tech dependent Family peace of mind severe CLD with 02,

sibling of SIDS, non–repeating ALTE with no cause

American Academy of Pediatrics does not recommend apnea monitors to reduce the incidence of SIDS

Caregiver Monitor Training Essential!!!!!! Pulmonary consult required Case manager arranges with DME for

equipment Apnea nurse makes arrangement to teach

parents/ caregivers prior to discharge & nesting/rooming in

Documented in EHR that parents were successfully trained

Home Monitor Training Parents instructed about signs symptoms of

apnea and respiratory distress How to use the monitor and troubleshoot Infant CPR & infant choking (American Heart

Association Friends and Family program) Contacts to call for medical or equipment

concerns Support via phone call, clinic, community Event log-? Increase in alarms? Download

monitor.

Monitors Prescription from MD with setting parameters: Alarm RecordApnea: 20 seconds 15 secondsHR 60 for term 70 seconds 70 for preterm 80 secondsHR offChildproof on/offParents are the best monitor: use only when the

baby is not observed

Termination of Monitor use

Resolution of primary problem If off caffeine for 1-2 weeks and no

significant apnea No significant apnea or repeat ALTE

event for 1-2 months AAP states by 43 weeks PCA or

“cessation of extreme events” Parent comfort level

SIDS- Sudden Infant Death Syndrome

The sudden death of an infant younger than one year of age that remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the infant’s and family's clinical histories.

American Academy of Pediatrics , Pediatrics (1992) 1120-1126

SIDS statisitcs

Currently 0.5 (0.49) per 1000 live births

1.2 deaths per 1000 in 1992 Back to Sleep campaign in the US• 1994 endorsed side or supine• 1996 endorsed supine only

Understanding SIDS Leading cause of death in infants from

one month to one year of age Most deaths occur between 2-4 months

(99% before 6 months, 1% 6 months to a year)

Infants have a change in response to hypoxia at 6 months

Associated with sleep and little or no signs of suffering

Understanding SIDS

SIDS risk for an infant with AOP or had an ALTE is at no greater risk than the general population

Premature infants have a slightly greater risk as their gestational age decreases

The SIDS sibling/twin is not at greater risk than general population

Home monitoring if infants has NOT decreased the incidence of SIDS

SIDS ResearchSIDS is not entirely preventable, but the risk can be reduced:•Supine sleeping on a firm sleep surface covered with a fitted sheet•Keep soft objects, toys and loose bedding out of baby’s sleep area•Overheating is contributory•Smoking is contributory•Any breastfeeding is protective•Pacifier use is protective

Preventing SIDS

Sleeping in the same place every night is protective

Keep baby’s sleep area close to but separate from where you sleep and others sleep

Avoid products that claim to reduce the risks SIDS

Reduce the chance that flat spot will develop on the baby’s head by providing ‘tummy time”

Back to Sleep-Safe Sleeping

SIDS research

CHIME (Collaborative Home Infant Monitoring Evaluation)study indicates that normal infants can have apnea, bradycardia and desaturations into the 70’s-why do they recover and some infants die of SIDS-How do they arouse?

Research indicates that SIDS is more complex than a single abnormality in a single system

In conclusion

Questions??? References to follow or contact Pat

Mathios, Pediatric Pulmonary Nurse at VM #4-7133 for additional information

Thank you

ReferencesEunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)Back to Sleep campaignhttp://www.nichid.nih.gov/SIDS

American Academy of Pediatrics (AAP)http://www.aap.org/healthtopics/Sleep.cfm

References Willinger, M., James, L.S. & Catz, C (1991) Defining the

Sudden Infant Death Syndrome (SIDS): Deliberations of an expert panel convened by The National Institute of Child Health and Human Development. Pediatric Pathology 11(5) 677-684

Esani, N. Hodgman, J. E., Ehsani, N., Toke, H. (March 2008) Apparent Life Threatening Events and Sudden Infant Death Syndrome: Comparison of Risk Factors, Journal of Pediatrics Vol. 152, issue 3

Halbower, A.C., (August 2008),Pediatric Home Apnea Monitors, Chest, Vol. 134, issue 2.

Silvestri, J.M. (March 2009), Indications for Home Apnea Monitoring (or Not), Clinics in Perinatology, Vol.36 Issue 1

References Darnall. R.A., (March 2009), ALTE’s: Still a Puzzle after

all These Years, Journal of Pediatrics, Vol. 154. Issue 3 Eichenwald, E.C., Zupancic, J.A., Wen-Yang, M.,

Richardson, D.K., McCormick, M.C., Escobar, G.J., (January 2011) pediatrics, Vol. 127, No. 1

Adams, S.M. , Good, M.W., Defranco. G.M., Sudden Infant Death Syndrome, (May 2008) American Family Physician, Vol. 79, Issue 10

Ralston, S., and Hill, V. (November 2009) Incidence of Apnea in Infants Hospitalized with Respiratory Syncytial Virus Bronchiolitis, Journal of Pediatrics, Vol. 155, Issue 5

References Weese-Meyer, D.E., Berry-Kravis, E.M., Ceccherini, I.,

Keens, T.G., Loughmanee, D.A., Trang, H. on behalf of the American Thoracic Society (ATS) Congenital Central Hypoventilation Syndrome Subcommittee, (March 2010), American Journal of Respiratory and Critical Care Medicine, Vol. 181, No. 6 626-644

Task force on Sudden Infant Dear Syndrome, (online October 17, 2011) Pediatrics (American Academy of Pediatrics)

Sexton, S. and Natale, R. (April 2009) Risk and Benefits of Pacifiers, American Family Physician, Vol. 79, Issues 8

References Committee on Fetus and Newborn, American Academy of

Pediatrics Policy Statement, (April 2003) Apnea, Sudden Infant Death Syndrome, and Home Monitoring, Pediatrics, Vol. 111, No. 4

Federation of American Societies for Experimental Biology, Bubbles, Babies, and Biology: The Story of Surfactant, 2004