Gerald Liu, MD; Ehab Home apnea monitors— Molokhia, MD, MPH; Allen Perkins, MD, MPH Harvard Vanguard Medical when to discontinue use Associates, Braintree, Mass. (Dr. Liu); Department of Family Medicine, University of South Premature newborns are frequently discharged with a Alabama, Mobile (Drs. Molokhia and Perkins) home apnea monitor. The following guidance can help perkins@health. you to counsel parents in 3 common scenarios. southalabama.edu The authors reported no potential conflict of interest relevant to this article. ach year, more than one in every 100 infants are born PRACTICE at less than 32 weeks postmenstrual age.1 In industri- RECOMMENDATIONS alized countries, many of these infants are discharged ❯ Tell parents that home E from the neonatal intensive care unit (NICU) with home ap- apnea monitoring has not nea monitors,1 which alert caregivers to episodes of apnea and been shown to prevent sudden unexpected bradycardia, while also capturing and storing data surround- 2 death in infants. C ing significant events for later analysis. Evidence supporting the use of home apnea monitoring ❯ Consider discontinuing is sparse, and recommendations highlight the need to use home apnea monitoring for infants at risk for recurrent this technology sparingly and to discontinue use once it is 3 apnea at approximately no longer necessary (TABLE). Counseling parents is critical. 43 weeks postmenstrual It’s important to explain that home apnea monitoring can be age or after the cessation used to help reduce the likelihood that a child will die in his of extreme episodes. B or her sleep, but it affords users no “guarantees.” In addition, ❯ Educate parents about home apnea monitoring can adversely affect parents. Parents steps they can take to reduce who use home apnea monitoring for their infants have been their child’s risk of sudden shown to have higher stress scores, greater levels of fatigue, infant death syndrome, such and poorer health than parents of infants without home ap- as putting him to sleep on his nea monitors.4-8 back, breastfeeding him, and As a family physician, you are likely to encounter home refraining from sleeping in apnea monitoring in one of 3 scenarios: at the first visit after the same bed with him. A discharge by a premature infant who experienced apnea while Strength of recommendation (SOR) hospitalized, at a follow-up visit after discharge from the hos- A Good-quality patient-oriented pital by an infant who experienced an apparent life-threaten- evidence ing event (ALTE), and at a follow-up visit by an infant whose B Inconsistent or limited-quality patient-oriented evidence sibling had died from sudden infant death syndrome (SIDS). C Consensus, usual practice, This article presents case studies that illustrate each of these opinion, disease-oriented scenarios, and explains what to tell parents who ask about how evidence, case series long they should continue home apnea monitoring. CASE 1 u Apnea of prematurity Jacob is a newborn who is brought in to your clinic by his par- ents for an initial visit. The infant was born prematurely at 32 weeks and required a prolonged NICU stay. His mother says that Jacob spent 4 weeks there and was discharged home with JFPONLINE.COM VOL 64, NO 12 | DECEMBER 2015 | THE JOURNAL OF FAMILY PRACTICE 769 home apnea monitoring. On exam, the infant of home apnea monitoring in this popula- has a monitor attached via a chest band. Jacob tion be discontinued after approximately appears healthy and his exam is normal. The 43 weeks postmenstrual age or after the mother asks you how long her son should use cessation of extreme episodes, whichever the home monitor. comes last.3 In Jacob’s case, the monitoring should Pathologic apnea is a respiratory pause that be discontinued at approximately week 12 of lasts at least 20 seconds or is associated with life, or about age 3 months. cyanosis; abrupt, marked pallor or hypoto- nia; or bradycardia.2 Apnea of prematurity is CASE 2 u Apparent life-threatening event present in almost all infants born at <29 weeks Sarah is brought to your office after being postmenstrual age or who weigh <1000 g.9 It is hospitalized for an ALTE. Her mother reports found in 54% of infants born at 30 to 31 weeks, that she had witnessed her 13-day-old daugh- 15% born at 32 to 33 weeks, and 7% of infants ter not breathing for “about a minute.” Upon born at 34 to 35 weeks.10 realizing what was happening, she “blew into Apnea of prematurity is primarily due the baby’s face,” whereupon Sarah awakened. to an immature respiratory control system, The mother then called 911 and they went by which results in impaired breathing regula- ambulance to the emergency room. The new- tion, immature respiratory responses to hy- born was admitted for observation overnight Apnea of percapnia and hypoxia, and an exaggerated and received a thorough evaluation. She was prematurity is inhibitory response to stimulation of airway discharged with a home apnea monitor. not associated receptors.11-13 Although apnea of prematu- You review the work-up and find noth- with an rity usually resolves by 36 to 40 weeks post- ing worrisome. Sarah is in a car seat attached increased risk menstrual age, it often persists beyond 38 to to the apnea monitor with a chest strap. An of sudden infant 40 weeks in infants born before 28 weeks.10 examination of the child is normal. The moth- death syndrome. In these infants, by 43 to 44 weeks postmen- er asks you when they should stop using the strual age, the frequency of apneic episodes home monitor. decreases to that of full-term infants.14 The differences in long-term outcomes An ALTE is “an event that is frightening to of infants with apnea of prematurity vs in- the observer and ... is characterized by some fants without it are subtle, if present at all.14,15 combination of apnea (central or occasion- There does seem to be a correlation between ally obstructive), color change (usually cya- the number of days with apnea and poor out- notic or pallid but occasionally erythematous comes. Neurodevelopmental impairment or plethoric), marked change in muscle tone and death are more likely in neonates who (usually marked limpness), choking, or gag- experience a greater number of days with ap- ging.”2 ALTE is a descriptive term, and not a nea episodes.16,17 However, apnea of prema- definitive diagnosis. turity is not associated with an increased risk The true incidence of ALTE is unknown, of SIDS.18 but is reported to be 0.5% to 6%; most events According to the American Academy occur in children younger than age 1.19,20 The of Pediatrics (AAP), home apnea monitor- risk for ALTE is increased for premature in- ing may be warranted for premature infants fants, particularly those with respiratory syn- who are at high risk of recurrent episodes cytial virus or who had undergone general of apnea, bradycardia, and hypoxemia af- anesthesia; infants who feed rapidly, cough ter hospital discharge.3 While there is gen- frequently, or choke during feeding; and eral consensus that all infants born prior male infants.19,21 to 29 weeks meet this criterion, the use of The most common causes of ALTE (in home apnea monitors in older preterm in- descending order) are gastroesophageal re- fants varies significantly, and the decision flux, seizure disorder, and lower respiratory to initiate monitoring in these patients is tract infection.22 The etiology is unknown for made by the discharging physician.3 Once about half of patients with ALTE.23 initiated, the AAP recommends that the use Tell parents that if their infant experienc- 770 THE JOURNAL OF FAMILY PRACTICE | DECEMBER 2015 | VOL 64, NO 12 HOME APNEA MONITORS es an ALTE, they should seek medical atten- TABLE tion without delay. The fear is that failing to Home apnea monitoring: What the American respond to this concern will ultimately result 3 in a sudden unexpected infant death, specifi- Academy of Pediatrics recommends 24 cally as a result of SIDS. Home apnea monitoring should not be routinely prescribed to prevent SIDS is very rare, occurring in only 40 per sudden infant death syndrome (SIDS). 100,000 births. One analysis found that chil- Home apnea monitoring may be warranted for premature infants who are dren who die from SIDS and those who expe- at high risk of recurrent episodes of apnea, bradycardia, and hypoxemia rience ALTE have very similar histories and after hospital discharge. The use of home apnea monitoring in this population should be limited to approximately 43 weeks postmenstrual clinical factors.25 Approximately 7% of infants age or after the cessation of extreme episodes, whichever comes last. who die from SIDS have had an ALTE.2 Overall, the long-term prognosis for infants who have Home apnea monitoring may be warranted for infants who are technol- had an ALTE is very good, although it depends ogy dependent (tracheostomy, continuous positive airway pressure), have unstable airways, have rare medical conditions affecting regulation of 8,26-28 on seriousness of the underlying etiology. breathing, or have symptomatic chronic lung disease. Guidance on the effective use of home If home apnea monitoring is prescribed, the monitor should be efficacious apnea monitors in infants who experience in recognizing apnea and triggering its alarm for prolonged apnea and be an ALTE is sparse. Despite this, the Na- equipped to capture and store patterns surrounding significant events for tional Institutes of Health (NIH) Consensus later analysis. Statement on Infantile Apnea and Home Parents should be told that home apnea monitoring has not been proven Monitoring2 and the American Academy to prevent sudden unexpected deaths in infants.