Peds Case 25- 2M/o W Apnea

Front 1

Normal vital signs for a 2-month-old are:

neuro exam:

Back 1

RR: 23-39 breaths/minute
HR: 120-180 beats/minute (mean 150)
B/P: 90% at100/65, 50% at 85/50
Pulse oximetry: >95% saturation in room air

Two-month-old infants can fix and follow easily with their eyes and exhibit a meaningful smile to voices. They have a strong suck and are beginning to coo.

They lie flexed at the hips with good tone and move all 4 extremities well. They lack good head control when held upright and cannot roll over because of the persistence of the asymmetric tonic neck reflex. When prone, they can raise their heads from side to side.

Front 2

Infant colic

Back 2

syndrome of crying several hours a day, usually in the evening, more than 5 nights a week.
During episodes of crying, the baby is difficult to console.
etiology unknown
crying starts after 2 weeks of age, peaks at 6 weeks and gradually lessens by 3 or 4 months.
eats normally and has normal growth.
crying can create feelings of rejection, frustration and anxiety in caregivers.

Front 3

ALTEs: Apparent Life Threatening Events in infants

Back 3

replaced "near-miss SIDS" (sudden infant death syndrome) in the late 1980s.
not a diagnosis, but a description of an event.
apnea or change in breathing pattern, color change (cyanosis, pallor, erythema, plethora), change in muscle tone (usually limpness), and possibly choking or gagging.
Recovery occurs only after stimulation or resuscitation. incidence 0.05 to 1%

Front 4

CNS causes of ALTE

Back 4

Seizures
CNS bleeding, infection (e.g., meningitis, encephalitis), or structural abnormalities, metabolic disorders, electrolyte abnormalities, genetic syndromes or epilepsy.

Breath-holding spells
0.1-5% of healthy children from age 6 months to 6 years.
occurs during expiration and is reflexive in nature.
starts to cry and then suddenly falls silent in the expiratory phase of respiration. followed by a color change. Spells pallid (acyanotic) or cyanotic.
Pallid spells assc w injury such as fall
cyanotic spells with anger.
resolve spontaneously, or the child lose consciousness. rarely spell proceed to seizure or asystole.

Increased intracranial pressure
infant’s CNS respiratory center is sensitive to any event that causes increased intracranial pressure: a bleed, trauma, tumor or infection

Front 5

GI causes of ALTE

Back 5

Gastroesophageal reflux
blamed for apnea, but true correlation not been proven.
some say apnea occurs first; leads to hypoxia resulting in relaxation of the lower esophageal sphincter
others believe reflux of infant’s stomach contents may cause choking, gagging, color changes and laryngospasm resulting in apnea.

Swallowing abnormalities or tracheoesophaeal fistula
chronic history of coughing or difficulty with feeds

Front 6

systemic causes of ALTE

Back 6

Infection:
systemic sepsis= apnea, pallor, tachycardia, tachypnea, fever or hypothermia, decreased feeding or change in tone.
Common etiologies: Group B strep, pneumococcus and E. coli. Listeria (causing meningitis) and Herpes Simplex Virus (causing encephalitis) less than 1 month of age.

Metabolic disorders:
inborn errors of metabolism ddx for young infant with apnea, ALTE, or altered mental status despite NBS

Intoxication: Ingestions of medications and other toxins can result in respiratory depression, cardiac arrhythmias, or seizures.

Infant Botulism: Exposure to botulinum toxin (in soil or in honey) can lead to hypotonia, constipation, paralysis, and respiratory failure – usually in infants under one year of age. Environmental exposures, such as carbon monoxide, can lead to mental status changes, hypoxia and respiratory distress.

Front 7

Cardiac causes of ALTE

Back 7

Arrhythmia:
bradycardia secondary to congenital heart block or long QT syndrome is at risk for apnea.
SVT (supraventricular tachycardia) is a more common arrhythmia in infants, but it is an unlikely cause of apnea.

Congenital Heart Disease, particularly ductal-dependent lesions may present with acute decompensation in the first few weeks of life.
unrepaired Tetralogy of Fallot may have acute episodes of cyanosis (“Tet” spells) associated with a drop in pulmonary blood flow.

Front 8

Pulmonary causes of ALTE

Back 8

Respiratory infections:
most common respiratory cause of apnea is respiratory syncytial virus (RSV) infection. Premature infants and infants younger than 2 months are at highest risk for apnea with RSV.
Pertussis can also cause apnea and ALTEs, especially in infants.
Other lower respiratory infections (e.g., viral and bacterial pneumonias) may also cause apnea or ALTE.

Front 9

SIDS vs ALTE

Back 9

5% of SIDS deaths have a prior ALTE episode there are several significant differences between ALTEs and SIDS:

>80% of SIDS deaths occur between midnight and 6AM,
82% of ALTE episodes occur between 8AM and 8PM.

52% of ALTEs occur while awake,
83% of SIDS occur while asleep

Interventions to prevent SIDS (ie supine sleeping which has greatly decreased the rate of SIDS deaths in the United States) have not resulted in a decreased incidence of ALTEs

Front 10

age range for breath-holding spells

Back 10

6 months to 6 years

Front 11

Periodic breathing

Back 11

alternating pattern of rapid breathing followed by brief (3-5 second) pauses. It is viewed as a normal respiratory pattern in the newborn period and is not associated with cyanosis or altered mental status

Front 12

thought process (elimination of categories)

Back 12

Jeremy’s normal vital signs and lack of fever or hypothermia make respiratory infection, sepsis, and meningitis relatively unlikely. The history of colic (excessive crying) could be related to gastroesophageal reflux, but reflux would not cause abnormal neurological findings. A transient arrhythmia could have caused Jeremy’s apnea – but should not cause persistent alteration in mental status. Jeremy’s history of colic and Terry’s perception that he has been a difficult baby may contribute to an already stressful home environment. The family’s difficult social situation and Jeremy's abnormal neurological status raise suspicion for a closed-head injury.

Front 13

Congenital Dermal Melanocytoses, Mongolian Spots,

Back 13

flat birthmarks that can sometimes be confused with bruising.
most common in babies with darker skin pigmentation, but can be seen in up to 10% of Caucasian infants as well.
Most often found in the sacral/buttocks areas, but can also occur on the arms, legs, back or flanks.
present at or very soon after birth
usually fade over several months and, unlike bruises, should not change appearance over a short period of time.

Front 14

GCS

Back 14

any score above 13 represents mild or no neurological compromise. If an infant scores below 8, he is severely impaired and in coma.

Front 15

Subdural hematomas

Back 15

result from head trauma, either accidental or non-accidental.
Shaken Baby Syndrome, in which case they may be associated with retinal hemorrhages. I
bridging vessels tear when the infant is shaken, or shaken and thrown, achieving an extreme rotational cranial acceleration force to the brain and diffuse axonal injury to the neurons.

Accidental trauma, such as motor vehicle accidents, can cause subdural hematomas.
known but uncommon complication of delivery, especially in vacuum extraction or forceps deliveries. These all resolve within 4-6 weeks after birth.

Subdural hematomas do not occur as a result of CPR or seizures and do not occur from short falls (e.g falls from a height of less than 4 feet).

Front 16

Shaken baby synd

Back 16

10-12% of all deaths among children who are victims of child abuse. The mortality rate of victims of shaken baby syndrome is as high as 25%, and morbidity is 20-40% with poor outcomes related to neurological injury. The injury is the result of violent shaking or shaking and throwing (leading to blunt trauma to the head). Victims of shaken baby syndrome often have no other signs of physical abuse.