Two major treatment modalities are recommended for infants who have experienced an ALTE or are at risk for SIDS. Xanthine derivatives such as caffeine and theophylline are used frequently in treating apnea of prematurity because of their central excitatory effect. Their use is associated with the normalization of the respiratory pattern in over 80 percent of such children. Their efficacy in the prevention of SIDS is unclear. A pragmatic approach to the use of theophylline would be to limit it to infants with abnormal pneumograms. Reversal of these abnormalities with theophylline would be an indication for its use. Theophylline is given at 6 mg/kg per day, and a serum level of 5 to 15 mg/mL should be maintained.
Home apnea monitoring is the second modality that can be offered. Three groups have been defined in a National Institutes of Health Consensus Statement in 1986 as being candidates for home monitoring.33 Group 1 consists of term infants with unexplained apnea of infancy, usually manifested by a life-threatening episode and/or abnormal pneumogram. The absence of an abnormal pneumogram does not preclude home monitoring. The second group consists of preterm infants who have continued to manifest apnea beyond term (i.e., after 40 weeks postconception). The third group consists of subsequent siblings of two or more SIDS victims, but not of one SIDS victim. Twins of SIDS victims were reported in the past to have a 20-fold increase in their risk for SIDS. More recent studies suggest their chance is the same as for nontwin siblings. Additional candidates for home monitoring include infants with bronchopulmonary dysplasia, especially if oxygen dependent, and infants who require tracheostomy for airway support.
Home-monitoring devices usually measure chest wall movement and heart rate. The detection of bradycardia is particularly important in infants with an obstructive component because chest wall movement is not diminished with obstructive apnea. Parents must be instructed in equipment maintenance, interpretation of the alarm, and cardiopulmonary resuscitation. Home monitoring does not mean simply supplying a family with a mechanical device. It involves the development of a medical team to support the family, interpret any episodes of apnea, and decide when home monitoring can be discontinued. Technicians who are available 24 h a day to maintain the equipment are also required.
Emergency physicians are frequently consulted about monitor alarms. Infants are brought to the emergency department because of alarm triggering. Physicians must be able to differentiate a false alarm from a true episode. The need for vigorous stimulation or mouth-to-mouth resuscitation again suggests a serious episode. If there is concern about equipment malfunction, technical assistance should be obtained from the monitoring company.
The use of home monitors has increased dramatically in recent years. The estimated cost of monitoring (including initial assessment) ranges from $3000 to $5000 per infant, with monthly rental and maintenance costs ranging from $150 to $300. Although parental anxiety is frequently reduced, the reduction in the incidence of subsequent SIDS in monitored infants is questioned. Reports have shown a mortality rate of as high as 50 percent among infants on home monitoring. In many cases, technical errors and parental noncompliance contributed to the infant's demise. Some infants, however, simply failed to respond to aggressive cardiopulmonary resuscitation.
The decision to discontinue monitoring is usually made by an infant's primary physician. In general, most infants remain on a monitor for 6 to 8 months. Criteria for discontinuing the monitor include 2 to 3 months with no episodes requiring stimulation or resuscitation, 3 months without apnea of 20 s or longer, no apnea associated with an upper respiratory infection or immunization, and an improvement in any neurologic problem for which the monitoring was instituted (e.g., apnea associated with seizures).
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