Section 12 Considerations Unique to Childhood

Questions

A Nervous New Mother

A first-time mother leaves the hospital with her newborn daughter. Her own mother had given her an old copy of Dr. Spock’s Baby and Child Care, which she read cover to cover before giving birth. One of the Dr. Spock’s topics was sleep apnea, and she was concerned about whether her newborn might have this condition. When the baby is a month old she calls to ask about her child’s sleep.

1 She has heard conflicting information about what position her baby should sleep in. What is your advice?

A The baby should sleep on left or right side to lessen the probability of obstructing her upper airway.

B The baby should sleep on her stomach (face down) to lessen the impact of possible aspiration.

C The baby should sleep on her back because this has been shown to reduce the prevalence of sudden infant death syndrome (SIDS).

D The position that the sleeps in does not matter.

2 The mother has noted that her baby sometimes stops breathing for 2 or 3 seconds, and she is concerned that her daughter might die from SIDS. During apneas the baby’s chest and abdomen are not moving. What should she be told about these breathing pauses?

A Episodes of apnea as described are statistically a risk for SIDS and home monitoring is indicated.

B The key distinction is length of the pauses; any duration longer than 10 seconds is critical.

C Central apneas longer than 20 seconds are abnormal and generally require investigation.

D Duration is not as important as whether there is a Cheyne-Stokes variation (waxing and waning respirations because the pause), which would suggest cardiovascular disease. She should check the baby’s breathing pattern before each pause.

3 The mother is not reassured by this information and requests that her baby be monitored for possible SIDS. What does the literature recommend about use of home monitoring to prevent SIDS?

A Monitoring of respiratory movements alone has been shown to prevent SIDS.

B Continuous monitoring of an electrocardiogram alone has been shown to prevent SIDS.

C Monitoring of SaO₂ has been shown to prevent SIDS.

D Home apnea monitoring does not reduce the risk of SIDS.

4 The mother asks about disadvantages of the baby sleeping on her back (supine). What should she be told?

A There are no negative effects of sleeping supine.

B Sleeping supine can result in some negative skeletal changes.

C The risk of aspiration is increased with sleeping supine.

D Sleeping supine increases the risk of asthma.

Panic

A father goes in to check on his 3-month-old baby boy sleeping in his crib. He notices the child is apparently not breathing and the father goes into a panic. He turns on the light and sees the child is blue, screams to his wife to call 911, then lifts the baby. His son feels like a rag doll with no muscle tone. He rocks the baby and yells at him to breathe. Within a minute the baby has awakened and is crying, and muscle tone and normal color have apparently returned. Within 5 minutes the ambulance arrives and the emergency squad is examining the baby. Their only finding is that the abdomen is slightly distended. The electrocardiogram shows no rhythm abnormality.

5 The father, still highly anxious, asks the ambulance staff whether the baby should be taken to the hospital.

A The baby should not be taken to the hospital since the problem has resolved. No additional follow-up is needed.

B The baby should be taken to the emergency department to make sure that long QT syndrome is not present. Then, if the EKG is normal, the baby can be sent home with an apnea monitor.

C The baby should be admitted to the hospital and the problem investigated.

D Because the abdomen is slightly distended the family should make an appointment with the pediatrician.

6 The baby is taken to the emergency department, where the distended abdomen is confirmed, and he is admitted for further investigation and SaO₂ monitoring. The pediatrician is not concerned with any of the blood tests. Continuous oximetry finds that the SaO₂ hovers around 94 ±2%. Arterial blood gases revealed PaO₂ = 82 mm Hg, PaCO₂ = 51 mm Hg. What should be done next?

A Discharge the baby and reassure the parents.

B Discharge the baby and arrange for 6 months of home SaO₂ monitoring.

C Schedule comprehensive polysomnography

D Discharge the baby with treatment for gastroesophageal reflux.

7 There is concern that this child might have congenital central hypoventilation syndrome (CCHS). Which of the following is not characteristic of CCHS?

A CCHS typically manifests after 3 to 4 years of age.

B Most cases are due to de novo mutations in the PHOX2B gene.

C Late diagnosis can result in cognitive deficits.

D Affected children have blunted ventilatory responses to hypoxia and hypercapnia.

My 2-Year-Old Won’t Sleep Alone

A couple is seeking help with their 24-month-old daughter’s sleep problem. The child has been a poor sleeper from birth and will not fall asleep when alone. The parents had her sleep in their bed from about 4 months of age, when nocturnal crying started to interfere with their own sleep. Attempts to let her fall asleep in her own room have been unsuccessful. By contrast, she falls asleep quickly in her parents’ bed. When in her crib alone, she screams as if in fear. If she does fall asleep and then awakens, which can be any time during the night, she cries and seems confused. The child moves at times when she sleeps, and this is now keeping both parents awake at night. Examination of the child is entirely normal, and she has no features that suggest daytime sleepiness. There is no family history of sleep disorders.

8 The clinician evaluating the child is considering the possibility of confusional arousals and will explore this diagnosis by asking several questions. Which of the following is not characteristic of confusional arousals in children?

A They occur in the first third of the night.

B There are stereotypical movements in each episode.

C A family history of similar parasomnias commonly exists.

D The child typically has amnesia of the event.

9 What is the most likely diagnosis of this child’s sleep problems?

A Sleep terrors

B Behavioral insomnia of childhood: limit-setting type

C Behavioral insomnia of childhood: sleep-onset association type

D Primary insomnia

10 What is the most appropriate approach to this problem?

A Reassure the parents that the child will grow out of the problem and that no specific treatment is required.

B A cautious trial of methylphenidate because the child might have attention-deficit/hyperactivity disorder.

C A trial of chloral hydrate, which is a safe hypnotic in children

D Behavioral treatment

Answers

1 C. The baby should sleep on her back. Although the mechanisms causing SIDS are not understood, epidemiologic studies have shown that having the baby sleep on the back and reducing exposure to tobacco smoke reduce the risk of SIDS. One hypothesis is that infants sleeping prone might asphyxiate when the upper airway is obstructed by soft pillows or bed clothes, and not arouse in response. Or they might arouse but be too weak to change their head position. The current recommendations include having the child sleep on a firm sleeping surface, avoiding soft objects in the crib, not bed sharing, and not overheating the infant Adams et al, 2009

2 C. Brief breathing pauses are common in newborns. Central apneas are generally not a problem unless they are longer than 20 seconds or are associated with cyanosis, pallor, bradycardia, or hypotonia. ICSD2, p 49

3 D. Published data have not shown that home apnea monitoring reduces SIDS, so home apnea monitoring would not be recommended for this infant. Adams et al, 2009

4 B. The back sleeping position has increased the incidence of flattening of the back of the head (deformational plagiocephaly). The flattening can be prevented or treated by encouraging supervised “tummy time”; while awake, infants should spend as much time as possible on their stomachs. Adams et al, 2009

5 C. The baby should be taken to the hospital for probable admission because the etiology of the event has not been ascertained. This baby had what is called an apparent life-threatening event (ALTE). There is some controversy about the acute and long-term management of ALTE. All cases should be evaluated in the emergency department. From there, recommendations are divided between hospital admission if abnormalities are found versus releasing the baby on home monitoring if ED evaluation is negative. One series reported the following findings in children presenting to an ED with ALTE: gastroesophageal reflux, 26%; pertussis, 9%; seizures, 9%; urinary tract infection, factitious illness, brain tumor, atrial tachycardia, patent ductus arteriosus, and opioid-related apnea account for smaller percentages. No etiology could be determined in 23%. Sleep breathing abnormality was actually a rare finding. It is generally recommended that ALTE babies be admitted to the hospital for 1 to 3 days of cardiorespiratory monitoring and the following investigations: complete blood count, measurement of CRP and glucose levels, arterial blood gases, and urinalysis. If no abnormality is found to explain the ALTE, home apnea monitoring is not recommended, because it has not been shown to reduce sudden infant death. Davies et al, 2002; Wijers et al, 2009

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