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that a significant apneic episode has not occurred, the patient can be discharged
after appropriate counseling of the parents and arrangements for close follow-up.
The evaluation of a young child with apnea, however, rarely will be so
straightforward. If historical information indicates that significant apnea has
occurred, the infant can be at risk for a recurrence of this potentially lifethreatening event. An aggressive search for an underlying cause is necessary and
may include laboratory studies, lumbar puncture, chest radiograph, and EKG.
Hospital admission should be arranged for observation and further diagnostic
evaluation.
A significant apneic episode in the absence of systemic disease leaves the
emergency physician in a quandary. There may not be an explanation for the
event that satisfies the physician or the anxious parents. Thus, referral to an
available specialist or center may be required. There is considerable practice
variation in the inpatient evaluation and management of an ALTE. The approach
that is usually pursued is designed to identify known causes of primary apnea. It
generally includes in-hospital observation with monitoring, a chest radiograph,
and/or an EKG. More significant events warrant further evaluation. This may
include an evaluation of the CNS with an electroencephalogram (EEG), and in
some cases, a sleep study. Gastroesophageal reflux is often recognized clinically.
Barium swallow can help identify anatomic abnormalities but are not reliable for
the diagnosis of reflux. Esophageal probes to measure pH and intraluminal
impedance are rarely required, but can be utilized during hospitalization if the
diagnosis is unclear. An ultrasound can identify hydrocephalus or intraventricular
hemorrhage, though a CT or MRI would be indicated if inflicted head injury is
suspected. Home cardiorespiratory monitoring is beyond the scope of emergency
practice, but is not routinely recommended. It is for this reason the AAP
recommends utilizing BRUE guidelines to minimize practice variation.
In many instances, a thorough history and careful physical examination will
suggest that a significant apneic event has not occurred and that there is no
serious underlying illness. In this situation, the emergency physician should
reassure and educate the family before discharging the patient. The parents also
should be given specific instructions regarding indications for another emergent

ED visit and a close follow-up visit to a primary care provider.
Suggested Readings and Key References
Eichenwald EC; Committee on Fetus and Newborn, American Academy of
Pediatrics. Apnea of prematurity. Pediatrics 2016;137(1).