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A 3-Month-Old Infant With Recurrent Apparent Life-Threatening Events in a Car SeatInfant With Life-Threatening Events in a Car Seat FREE TO VIEW

Lourdes M. DelRosso, MD
Author and Funding Information

From The Children’s Hospital of Philadelphia; and The University of Pennsylvania, Philadelphia, PA.

CORRESPONDENCE TO: Lourdes M. DelRosso, MD, The Children’s Hospital of Philadelphia and The University of Pennsylvania, 34th St and Civic Center Blvd, Philadelphia, PA 19104; e-mail: lourdesdelrosso@me.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(4):e152-e155. doi:10.1378/chest.14-1595
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A 3-month-old infant was brought to clinic for evaluation of recurrent apparent life-threatening events (ALTEs). Two ALTE episodes occurred while the infant was sleeping in a safety car seat. The first one occurred when he was 4 weeks old. His mother noticed that he was not breathing; he appeared limp with full body cyanosis. His mother picked him up from the car seat, and he started breathing spontaneously and without any sign of distress. His skin color returned to normal. He was evaluated at the ED where the physical examination was normal. He was hospitalized 1 day for observation. During this time, workup, including ECG and chest radiograph, was normal. The parents were instructed on cardiorespiratory resuscitation and recommended to change car seats. The infant was discharged with an apnea monitor. He wore the apnea monitor while in the car seat. A second similar episode occurred at 10 weeks of age for which he was seen at the ED and referred to our clinic for further evaluation. Neither episode was related to feeding.

Figures in this Article

Further history revealed that at 8 weeks of age he started spitting up sporadically after feedings. He was never breastfed. The spitting episodes increased in frequency. Currently, he spits after each feeding. There is no projectile emesis. Currently, the infant sleeps in a bassinet. He does not snore and does not have witnessed breathing pauses.

He was born at 39 weeks without perinatal complications. His birth weight was 3.04 kg. Length was 48 cm. The mother, 31 years of age, gravida 2 para 2, had a history of lupus and took hydroxychloroquine and methylprednisolone during pregnancy. She received prenatal care.

There is no other past medical history. He does not take any medications. Both mother and father smoke.

Physical examination revealed a well-appearing infant except for weight, length, and head circumference below the fifth percentile. Milestones were appropriate for age; airway examination revealed 1+ tonsils. The remainder of the cardiopulmonary and neurologic examination was normal.

Review from the home apnea monitor recording did not show any apneic episodes or periods of bradycardia. Further investigations revealed an unremarkable chest radiograph. Nasopharyngeal laryngoscopy revealed posterior cricoid and arytenoid edema. A fluoroscopic study of the upper GI tract showed mild gastroesophageal reflux (GER) to the mid-thoracic esophagus.

A nocturnal split polysomnogram (PSG) was performed with the infant allowed to sleep supine in the crib for 4 h and in the car seat for 4 h. He was not taking any medications prior to the sleep study. The PSG revealed markedly increased obstructive apnea hypopnea index (AHI) while sleeping in the car seat compared with sleeping in the crib (Table 1). Mixed apneas were not seen.

Table Graphic Jump Location
TABLE 1 ]  Split PSG Results-CO2?

C-AHI = central apnea hypopnea index; HR Min = lowest heart rate; NREM = nonrapid eye movement sleep (in min); O-AHI = obstructive apnea hypopnea index; PSG = polysomnogram; REM = rapid eye movement sleep (in min); Sao2 = oxyhemoglobin saturation; TST = total sleep time (in min).

What is the diagnosis?
Diagnosis: Worsened OSA in car seat

The National Institutes of Health defines apparent life-threatening event (ALTE) as an episode frightening to the observer and usually characterized by a combination of apnea, color change, change in muscle tone, choking, or gagging. An ALTE episode does not imply risk for sudden infant death syndrome. The incidence of ALTE is estimated to be 0.6 to 2.46 per 1,000 births. After medical evaluation, the cause of ALTE is never found in 50% of patients. Among the other 50%, GER, respiratory infection, and neurologic-related issues are the most common diagnosis found.

Causality between GER and ALTE is difficult to prove. Although GER is found in 30% of infants with ALTE, GER is also very common in normal infants. Some studies have shown a relationship between GER and obstructive apnea in infants presenting with ALTE. In some, GER preceded the apneic episodes while in others the apnea was followed by acid reflux. Furthermore, laryngospasm can occur with GER events.

Esophageal impedance and pH monitoring have been studied in infants with GER both in a car seat and in the recumbent position. Postprandial GER episodes were similar in both groups while respiratory events were significantly decreased in the car seat group. Nonacid GER was more common in the car seat group, but symptoms of GER were more common in the infants in recumbent position. These tests are of limited value in ALTE evaluation because causality could only be made if an infant is having regurgitation at the time of the ALTE, or if the ALTE is documented with a GER event during esophageal monitoring.

Other studies have explored the relationship between swallowing and breathing. Breathing briefly stops during deglutition, a protective mechanism against aspiration. It has been postulated that infants with ALTE have abnormal swallowing-respiratory coordination, leading to prolonged and more frequent respiratory pauses during deglutition. Feeding difficulties have been reported in patients with ALTE without GER symptoms.

Both ALTE and sudden infant death syndrome have been reported on infants in safety car seats. The American Academy of Pediatrics recommends premature newborns undergo the infant car seat challenge (ICSC) for 90 to 120 min to identify episodes of desaturation, apnea, or bradycardia. Newborns who fail the ICSC should be tested in a car bed. Lower weight at the time of ICSC testing has been associated with an increased risk of test failure.

Besides low weight, the contributing mechanism of ALTE in safety car seats could be postulated to be airway obstruction by passive pharyngeal collapse during inspiration secondary to cervical flexion. A recent study has demonstrated that tongue size in premature infants can also contribute to airway narrowing during cervical flexion in car seats.

Smoking by this patient’s parents can also be a contributor to the recurrent ALTE episodes. Infants with ALTE from mothers who smoke have been found to have more obstructive apneic events than infants from nonsmoking mothers.

Obstructive events in the patient were significantly increased while sleeping in the car seat (AHI, 9.4) when compared with sleeping in the crib (AHI, 1.9) (Fig 1). Although the association between OSA and ALTE is unclear, it is my opinion that sleeping in the car seat increased the obstructive AHI, possibly contributing to the ALTE episodes. Further investigations are needed to evaluate the relationship between OSA and ALTE. Other contributing factors to the ALTE episodes may include parental smoking and low weight.

Figure Jump LinkFigure 1 –  Hypnogram from split polysomnogram. Sleep prior to the line (blue arrow) is supine in the crib. Sleep after the line is in the car seat. A/H = apnea hypopnea; A/H type = apnea hypopnea type; CAP = capnography; REM = rapid eye movement sleep; SAO2 = oxyhemoglobin saturation.Grahic Jump Location

Although there is no consensus regarding the evaluation of infants presenting with ALTE, infants presenting with recurrent ALTE episodes are more likely to have an underlying condition and should be thoroughly investigated. Recurrent ALTE occurs in 10% to 20% of infants. Child abuse should be considered in the evaluation of recurrent ALTE.

Clinical Course

The patient was admitted to the hospital. Therapy for GER was initiated with omeprazole. He continued feedings with formula. His breathing was stable during hospitalization, and he gained weight. He was released home. The parents were counseled to continue omeprazole, to use the car seat while driving only, and to stop smoking. He remains stable without further ALTE.

  • 1. Low birth weight, position of the neck, maternal smoking, and tongue size can contribute to ALTE.

  • 2. Obstructive events can be worsened by flexion of the neck while sleeping in a car seat.

  • 3. Car seat polysomnography is an important diagnostic tool in infants who present with respiratory symptoms in the car seat.

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions: The author acknowledges Carole Marcus, MBBCh, for her advice with this manuscript. CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Arad-Cohen N, Cohen A, Tirosh E. The relationship between gastroesophageal reflux and apnea in infants. J Pediatr. 2000;137(3):321-326. [CrossRef] [PubMed]
 
Tonkin SL, Vogel SA, Bennet L, Gunn AJ. Apparently life threatening events in infant car safety seats. BMJ. 2006;333(7580):1205-1206. [CrossRef] [PubMed]
 
Côté A, Bairam A, Deschenes M, Hatzakis G. Sudden infant deaths in sitting devices. Arch Dis Child. 2008;93(5):384-389. [CrossRef] [PubMed]
 
Bass JL. The infant car seat challenge: determining and managing an “abnormal” result. Pediatrics. 2010;125(3):597-598. [CrossRef] [PubMed]
 
Franco P, Montemitro E, Scaillet S, et al. Fewer spontaneous arousals in infants with apparent life-threatening event. Sleep. 2011;34(6):733-743. [PubMed]
 
Fu LY, Moon RY. Apparent life-threatening events: an update. Pediatr Rev. 2012;33(8):361-368. [CrossRef] [PubMed]
 
Jung WJ, Yang HJ, Min TK, et al. The efficacy of the upright position on gastro-esophageal reflux and reflux-related respiratory symptoms in infants with chronic respiratory symptoms. Allergy Asthma Immunol Res. 2012;4(1):17-23. [CrossRef] [PubMed]
 
Tieder JS, Altman RL, Bonkowsky JL, et al. Management of apparent life-threatening events in infants: a systematic review. J Pediatr. 2013;163(1):94-99. [CrossRef] [PubMed]
 
Davis NL, Gregory ML, Rhein L. Test-retest reliability of the infant car-seat challenge. J Perinatol. 2014;34(1):54-58. [CrossRef] [PubMed]
 
Hasenstab KA, Jadcherla SR. Respiratory events in infants presenting with apparent life threatening events: is there an explanation from esophageal motility? J Pediatr. 2014;165(2):250. [CrossRef] [PubMed]
 
Tonkin SL, McIntosh C, Gunn AJ. Does tongue size contribute to risk of airway narrowing in preterm infants sitting in a car safety seat? Am J Perinatol. 2014;31(9):741-744. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Hypnogram from split polysomnogram. Sleep prior to the line (blue arrow) is supine in the crib. Sleep after the line is in the car seat. A/H = apnea hypopnea; A/H type = apnea hypopnea type; CAP = capnography; REM = rapid eye movement sleep; SAO2 = oxyhemoglobin saturation.Grahic Jump Location

Tables

Table Graphic Jump Location
TABLE 1 ]  Split PSG Results-CO2?

C-AHI = central apnea hypopnea index; HR Min = lowest heart rate; NREM = nonrapid eye movement sleep (in min); O-AHI = obstructive apnea hypopnea index; PSG = polysomnogram; REM = rapid eye movement sleep (in min); Sao2 = oxyhemoglobin saturation; TST = total sleep time (in min).

Suggested Readings

Arad-Cohen N, Cohen A, Tirosh E. The relationship between gastroesophageal reflux and apnea in infants. J Pediatr. 2000;137(3):321-326. [CrossRef] [PubMed]
 
Tonkin SL, Vogel SA, Bennet L, Gunn AJ. Apparently life threatening events in infant car safety seats. BMJ. 2006;333(7580):1205-1206. [CrossRef] [PubMed]
 
Côté A, Bairam A, Deschenes M, Hatzakis G. Sudden infant deaths in sitting devices. Arch Dis Child. 2008;93(5):384-389. [CrossRef] [PubMed]
 
Bass JL. The infant car seat challenge: determining and managing an “abnormal” result. Pediatrics. 2010;125(3):597-598. [CrossRef] [PubMed]
 
Franco P, Montemitro E, Scaillet S, et al. Fewer spontaneous arousals in infants with apparent life-threatening event. Sleep. 2011;34(6):733-743. [PubMed]
 
Fu LY, Moon RY. Apparent life-threatening events: an update. Pediatr Rev. 2012;33(8):361-368. [CrossRef] [PubMed]
 
Jung WJ, Yang HJ, Min TK, et al. The efficacy of the upright position on gastro-esophageal reflux and reflux-related respiratory symptoms in infants with chronic respiratory symptoms. Allergy Asthma Immunol Res. 2012;4(1):17-23. [CrossRef] [PubMed]
 
Tieder JS, Altman RL, Bonkowsky JL, et al. Management of apparent life-threatening events in infants: a systematic review. J Pediatr. 2013;163(1):94-99. [CrossRef] [PubMed]
 
Davis NL, Gregory ML, Rhein L. Test-retest reliability of the infant car-seat challenge. J Perinatol. 2014;34(1):54-58. [CrossRef] [PubMed]
 
Hasenstab KA, Jadcherla SR. Respiratory events in infants presenting with apparent life threatening events: is there an explanation from esophageal motility? J Pediatr. 2014;165(2):250. [CrossRef] [PubMed]
 
Tonkin SL, McIntosh C, Gunn AJ. Does tongue size contribute to risk of airway narrowing in preterm infants sitting in a car safety seat? Am J Perinatol. 2014;31(9):741-744. [CrossRef] [PubMed]
 
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