Home Apnea Monitoring Research Articles

Jerold Francis Lucey, MD (1926-2017)

We note with sadness the death of Jerry Lucey, a friend, mentor, and colleague. His name is familiar to all pediatricians though his life work and contributions as an outstanding clinician, neonatologist, investigator, advocate, educator, and editor. Dr Lucey was an internationally renowned neonatologist at the University of Vermont College of Medicine since 1956. He made numerous contributions to the care of premature infants, specifically advances in phototherapy and oxygen monitoring, and the promotion of randomized trials among neonatal units. He was the recipient of numerous awards in recognition of his outstanding qualities of scholarship and advocacy on behalf of children. In his role as the Editor of Pediatrics, Dr Lucey established policies and standards that have served to guide us all. His vision of having Pediatrics embrace the global medical community led to the establishment in that journal of a strong international science and clinical practice presence. Of specific note was his commitment to the highest ethical standards in research and publication. This is perhaps best exemplified by his response to an article published in Pediatrics in 1972, which had linked sudden infant death syndrome (SIDS) and breathing abnormalities.1Steinschneider A. Prolonged apnea and sudden infant death syndrome: clinical and laboratory observations.Pediatrics. 1972; 50: 646-654PubMed Google Scholar Several children from one family with apparent SIDS served as the basis for this study; they were later shown to be victims of medical child abuse. The published hypothesis of a genetic predisposition to SIDS, as well as a causal association between SIDS and infantile apnea, led to the use of home cardiorespiratory monitors to prevent SIDS. This widely cited report triggered not only parental anxiety but countess hours of fruitless investigation into the relationship between apnea and SIDS.2Consensus Statement National Institutes of Health Consensus Development Conference on infantile apnea and home monitoring, September 29, 1986–October l, 1986.Pediatrics. 1987; 79: 292-300PubMed Google Scholar, 3Firstman R. Talen J. The death of innocents. Bantam Books, New York (NY)1997Google Scholar, 4Duffy P. Bryan M.H. Home apnea monitoring in “near miss” sudden infant death syndrome (SIDS) and siblings of SIDS victims.Pediatrics. 1982; 70: 69-74PubMed Google Scholar Despite the fact that this article was accepted before Dr Lucey's tenue as editor, he addressed the issue head on, apologized for the mistake, and stated that the article was flawed and should never have been published.5Lucey J.F. A very important erratum? — 20 years later.Pediatrics. 1994; 93: 944Google Scholar Dr Lucey's dedication to the highest ethical standards is an enduring legacy. In 1990, he joined the editors of several general pediatric journals to express concern about ethical transgressions—such as the duplication of data in papers submitted to several journals (self-plagiarism) and the practice of dividing a study into several short reports (the “least publishable unit”)—in a constructive effort to maintain the quality of the pediatric literature.6Bier D.M. Fulginiti V.A. Garfunkel J.M. Lucey J.M. Spranger J. Valman B. et al.Duplicate publication and related problems.J Pediatr. 1990; 117: 903Abstract Full Text PDF Scopus (4) Google Scholar In 2009, Dr Lucey and the editors of the major US general pediatric journals met at the annual Pediatric Academic Societies meeting to initiate a workshop entitled “Ethics in Publishing”; this on-going workshop remains important and highly relevant today. Dr Lucey will be missed by all who have benefited from his contributions—his patients, his students, as well as pediatricians worldwide.

The butterfly pattern in a patient with chromosome 7 deletion.

The butterfly pattern in a patient with chromosome 7 deletion.

Hospital readmission in children with complex chronic conditions discharged from subacute care.

Children with complex chronic conditions (CCC) are responsible for a disproportionate number of hospital readmissions. This study sought to determine 30-day hospital readmission rates in children with CCC discharged from a rehabilitation and transitional care hospital and to identify factors associated with increased risk of readmission. We conducted a retrospective cohort study identifying children with CCC discharged over an 18-month period from a subacute care facility staffed by hospitalists from a freestanding children's hospital. The primary outcome measure was readmission to the referring acute care hospital within 30 days of the subacute discharge. Of the 272 discharged patients meeting inclusion criteria as children with at least 1 CCC, 19% had at least 1 readmission within 30 days of discharge. On univariate analysis, readmission was associated with the number of home medications (P = .001), underlying chronic respiratory illness (P < .001), home apnea or pulse oximetry monitor use (P = .02), tracheostomy and/or ventilator dependence (P = .003), length of stay (P = .04), and number of follow-up appointments (P = .02). On multivariate analysis, the number of discharge medications was associated with increased odds of readmission (odds ratio: 1.11 [95% confidence interval: 1.03-1.20]; P = .01). Receiver operating curve analysis identified a cutoff of 8 medications as most associated with readmission; in patients discharged with ≥8 medications, the hospital readmission rate was 29%. This is the first known study that investigated hospital readmission rates in children with CCC discharged from a subacute facility and specifically identified the number of discharge medications as a significant risk factor for readmission.

Pediatric Home Apnea Monitors: Coding, Billing, and Updated Prescribing Information for Practice Management

A series of new current procedural terminology codes have been created that allow health-care providers to code and bill for pediatric home apnea monitoring in the United States. Apnea monitors have been used at home on pediatric patients at risk for sudden death for > 30 years without the benefit of evidence-based efficacy studies. Nevertheless, new apnea monitor devices with expanded capability have been developed. Recommended indications for pediatric home apnea monitors are outdated and vague. It is important for the prescribing health-care provider to understand device function, as well as the pathophysiology of cardiorespiratory events in different disease states in order to make logical decisions about which monitor to prescribe, or whether to prescribe one at all. This article will review what apnea monitors are designed to do, common misperceptions about device indications vs device capability, and updated suggestions regarding the prescription, billing, and coding of pediatric apnea monitors for pediatric practice management.

Failure of apnea monitoring during bed-sharing

We report the case of an infant found dead in bed with an adult while attached to a respiratory monitor sensor. We experimentally re-created a bed-sharing situation with an infant mannequin to demonstrate that a Graseby home apnea monitor continues to sense adult breathing and movement in the absence of infant breathing when used in this sleep situation.

Contribution of Long-QT Syndrome Genes to Sudden Infant Death Syndrome

Sudden infant death syndrome (SIDS) is defined as unexplained and unexpected death within the first year of life, without any known preexisting inciting conditions or obvious cause of death on postmortem examination. It remains the most common cause of infant death (excluding neonatal period) in developed countries, occurring in ≈0.03% to 0.1% of live-born infants in the United States.1 Article p 361 The precise mechanisms for SIDS, or “crib death,” are not known, although multiple hypotheses have been proposed over the years, including abnormal brainstem respiratory control of arousal, dysautonomia, and malignant cardiac bradyarrhythmias or tachyarrhythmias.2–4 Genetic, developmental, and environmental risk factors for SIDS have been identified, such as premature birth, multiple gestations, being the sibling of a SIDS victim, maternal illicit drug use, prone sleeping position or bed sharing, and history of apnea/bradycardia or “near-miss SIDS” episodes.3–5 Investigators have suggested respiratory control regulatory abnormalities, neurological developmental defects, and cardiac rhythm disorders, including QT prolongation and ventricular arrhythmias, as underpinnings of SIDS. Supporting these various hypotheses are common autopsy findings such as petechial hemorrhages, pulmonary congestion, and developmental defects in the brainstem and neurotransmitters.4,5 Myriad diagnostic studies have been used for potential risk stratification of infants thought to be at higher risk for SIDS and have included electroencephalogram, pulse oximetry, 12-lead ECG, home apnea monitoring, and infant polysomnography sleep studies. The National Institutes of Health and the American Academy of Pediatrics have actively promoted the supine sleeping position for healthy term infants, and pediatricians have educated parents to put infants to sleep in the supine position. This simple recommendation has, at least in part, contributed to a significant reduction in the incidence of SIDS.6 Death from cardiac causes is uncommon in infancy and is most often the result of cardiac electrical diseases such as the …

A Special Issue: Coding for Children With Special Health Care Needs

A Special Issue: Coding for Children With Special Health Care Needs

CPT Code Changes for 2007

<i>CPT</i> Code Changes for 2007

31 Oral Feeding Disorders at Hospital Discharge: A Unique Marker of Disability?

The purpose of this study was to determine the prevalence of oral feeding problems at hospital discharge for preterm infants and to assess if these could be markers of later disability. This was a retrospective review of patients enrolled in a follow-up clinic database. Infants included were ≤ 32 wk GA, seen for the initial clinic visit between January 1, 2002 to December 31, 2004. 71/328 (22%) infants had oral feeding disorders (OFD) as defined by having one or more of the following at hospital dismissal: use of tubes and/or feeding pump, feeding more frequently than every 3 hours secondary to poor volume tolerance, and/or less than 100% of feeding orally. A comparison group of infants was determined by matching each study infant with the next infant in the database without a feeding problem but with the same GA (± 1 wk) and BW (± 100g). Medical complications and limited outcome data were obtained by database review. Group differences were determined by chi-square and univariate analysis of variance with significance indicated by P<.05. There were no group differences in BW (1023 ± 370 and 1026 ± 345 g, OFD and control, respectively), GA (27.6 ± 2.5 wk, both), or gender. OFD infants were, on average, discharged from the hospital 5 weeks later and 880 g heavier than comparisons (P=.000). There were no group differences in rates of severe IVH or ROP. OFD infants were more likely to have CLD (52% and 35%, P=.04) and be discharged on a home apnea monitor (47% and 25%, P=.009). 39% of OFD infants had neither CLD or IVH. A subset of infants had 24-month developmental screening using the Bayley Infant Neurodevelopmental Screener (BINS). Controlling for CLD and maternal race, OFD infants (n=14) tended to have a lower mean BINS scores than comparisons (n=30), 6.9 ± 3.6 and 4.3 ± 3.2, P=.08. Preterm infants appear to frequently have oral feeding problems at hospital discharge. Additional study of this population is needed to determine possible etiologies and long-term implications of delayed oral feeding, which could be a unique marker of disability.

Sudden infant death syndrome (SIDS) or cot death: a review.

Sudden death of an infant is not an uncommon event and when there is no adequate cause to explain the death it poses a diagnostic dilemma for the clinician, and makes discussion of the cause of death with parents quite difficult and unsatisfactory. Sudden infant death syndrome (SIDS) or cot death is a diagnostic entity which can be applied in such a case. It is one of the most common causes of infant deaths world-wide in the postneonatal period, from 1 month to 1 year of age. Features which may assist the clinician to arrive at such a diagnosis are discussed in this paper. Since the first sign of SIDS is death, leaving the clinician with no opportunity to intervene, attention has been focussed on whether or not the infants prone to suffer from this tragic demise can be identified and preventive measures instituted to save them. In this respect, intensive and extensive research efforts over the last two decades have led to what is now commonly referred to as the Apnea Hypothesis for SIDS, and the resultant current intervention method of home apnea monitoring. The apnea hypothesis and other aetiological factors that may help predict infants at risk are discussed. Finally, current management of infants at risk is discussed for completeness since the facilities for such management are not yet in common use in Nigeria and the West African sub-region, and the level of literacy may severely limit the size of the population that could benefit from such management even if the facilities were available.

The morbidity of the 34- to 35-week gestation: should we reexamine the paradigm?

Algorithms for the management of preterm labor avoid the use of tocolysis beyond 34 weeks' gestation, based in large part on low respiratory morbidity found at this gestational age. We sought to delineate the morbidities, not just respiratory, of this age group in a modern neonatal intensive care unit setting. We prospectively looked at hospital resource use and general morbidity in a consecutive 2-year cohort of 34-weekers at our hospital. The concurrent consecutive 35-week cohort was used as a control. Data were prospectively collected from obstetricians and bedside records. Compared with 35-weekers, the 34-week group had similar obstetric characteristics. Significant differences were seen in use of oxygen, nasal continuous positive airway pressure, methylxanthines, home apnea monitoring, antibiotics, and phototherapy. The 34-week group took longer to come off intravenous lines and were discharged later. Overall, they used approximately twice the resources of the 35-week group. To stop or not use tocolysis at 34 weeks' gestation based mainly on low respiratory morbidity ignores the significant other morbidities. These findings suggest a reconsideration of the paradigm regarding 34-week gestation as a cutoff point in decision making.

Treatment of apnea of prematurity.

In the last decade, knowledge regarding the neurodevelopment and functional aspects of the respiratory centers during postnatal maturation has increased substantially. However, an increase in such knowledge has not provided a basis for change in practice. The diagnosis of apnea of prematurity (AOP) is one of exclusion. All causes of secondary apnea must be ruled out before initiating treatment for AOP. Treatment will depend on the etiology as well as effectiveness and tolerability of the treatment by the patient. The primary goal of any treatment of AOP is to prevent the frequency of apnea lasting >20 seconds, and/or those that are shorter, but associated with cyanosis and bradycardia. The clinical management of AOP is not much different today than it was two decades ago, with pharmacologic and nonpharmacologic treatment options remaining the mainstay of therapy. Methylxanthines are still the most widely used pharmacologic agents. Due to the wider therapeutic index of caffeine and ease of once daily administration, it should be the preferred agent. Doxapram, or nonpharmacologic treatment measures such as nasal continuous positive airway pressure, may be considered in infants who are unresponsive to methylxanthine treatment alone. Treatment should be continued until there is complete resolution of apnea, and for some time thereafter. The choice of method for weaning treatment remains one of individual physician preference. Discharge from hospital after apnea requires close monitoring and some infants will require home apnea monitors. The decision to provide a home apnea monitor should be individualized for each patient, depending on the effectiveness of treatment and clinical response.

Home apnea monitor use in preterm infants discharged from newborn intensive care units

Purpose: To identify current factors associated with home apnea monitor use in preterm infants and to determine whether home monitor use was associated with a shorter length of hospital stay. Setting: We evaluated neonates who were ≤34 weeks’ estimated gestational age and admitted for neonatal intensive care. We excluded neonates with congenital anomalies, neonates transferred out before discharge, and neonates who died. Methods: Using a database created with a computer-assisted tool that generates hospital notes, we reviewed the epidemiology of monitor use. Differences between neonates sent home with an apnea monitor and those who were not were evaluated by using stepwise logistic regression analysis to identify which factors were independently associated with a neonate being discharged with a monitor. Results: We studied 14,532 neonates; 1588 (11%) were sent home with monitors and 12,944 (89%) were not. The most important variables associated with being discharged with a monitor were site of care and a diagnosis of apnea. Site variation remained significant when adjusted for gestational age, diagnosis of apnea, and a history of use of methylxanthines. When corrected for gestational age, monitor use was not associated with shorter hospital stays. Conclusion: The data suggest that monitor use is more dependent on physician preference than medical indication and is not associated with earlier hospital discharge. (J Pediatr 2001;139:245-8)

Family Social Work Intervention to Increase Parental Compliance with Infant Apnea Monitor Use in the Home

ABSTRACT Home apnea monitoring has been used for many years to continuously supervise infants at an increased risk for Sudden Infant Death Syndrome. While studies are available that discuss the psychological impact on the family of having a monitored infant, this article describes the first empirical investigation designed to promote apnea monitor use. Family social work intervention involving short term case management, behavioral prompting and reinforcement, and follow up support by a medical social worker increased home monitoring from zero hours per day to an average of over twelve hours per day. While more intervention research designed to promote compliance is necessary, in this case a low-cost social work intervention had immediate and dramatic positive results.

Parenting of at-risk infants in the face of uncertainty: Home apnea monitoring of subsibs

This article describes the experiences of a group of parents in New Zealand who lost infants to sudden infant death syndrome (SIDS) and who monitored their subsequent infants or subsibs (infants born after the death of an infant due to SIDS) at home for signs of apnea. Their caregiving experiences are explored within the framework of the substantive theory developed by Cohen (1993) that describes how another group of parents, those caring for children with chronic life-threatening illnesses, copes with living under conditions of sustained uncertainty. Attention is drawn to the similarities in both the grieving processes and coping strategies used by both groups of parents in these parallel situations.

The Effect of Education, Race and Socioeconomic Status and on Parental Compliance and Parental Perception of Documented Home Apnea Monitors

The Effect of Education, Race and Socioeconomic Status and on Parental Compliance and Parental Perception of Documented Home Apnea Monitors

Do apnea monitors decrease emotional distress in parents of infants at high risk for cardoopulmonary arrest?

Introduction: The immediate post partum period is stressful for most parents. The need to use a home aprea monitor may taxparental coping skills even further. Therefore, we conducted a study to assess thepsychosocial consequences of aphea monitoring on parental emotional distress and family functioning.Method: We studied 104 parents of infants at high risk for cardiopul-monary arrest. Fifty-two parents had infants who used home apnea monitors, and 52 parents were age matched and geneder-matched control subjects. Data were collected during the infant's hospitalization, and then at 2 weeks, 3 months, and 6 months after discharge. At 1 year, parents were interviewed about their attitudes toward using the apnea monitor.Results: Both groups experienced elevated levels of emotinnal distress, but the group with infants who used the monitors had significant increases in depression and hostility immediately following discharge from the hospital compared with baseline, whereas the non-monitored group had a significant increase in hostility at 6 months. At 1-year follow-up, the majority of the parents reported that they used the monitor every night, felt more secure in using it, and judged it helpful.Discussion: The immediate period following hospital discharge of infants who need to use a home apnea monitor is characterized by significant emotional distress for the parents, which resolves over time. Anticipatory education and counseling of parents is recommended.

Does Weekly Telephone Contact Enhance the Compliance of Home Apnea Monitoring? † 1299

Objective:To evaluate the efficacy of weekly telephonic contact with families in enhancing the use of home apnea monitoring.Methods: This was a prospective randomized single blinded study of 38 infants who were prescribed home apnea monitoring for the following indications 1.Apnea of prematurity (92%)2.Other pulmonary, cardiac or neurologic problems(8%). Exclusion criteria included 1.No home telephone 2.Participation in any other study involving home monitoring. Infants were assigned to a 'standard care' or 'Weekly telephone call' group by a stratified balanced block technique. All families were given the following instructions for monitor use: 1.During the first 4 week period the monitor was to be used at night and unattended times (appox 95%); 2.During the second 4 week period the monitor was to be used at night and unattended times (appox 60%). The families in the telephone group were contacted weekly for 8 weeks. The telephone contact reviewed the events of the previous week but did not include specific encouragement to use the monitor to avoid the Hawthorne effect. Both groups received routine Pediatric care and follow up at high risk premature clinic. Our primary outcome measure was compliance which was defined as the percentage of time the infant spent on the monitor as recorded by the event monitoring. Results:The Telephone (n=18) and Standard care (n=20) groups were similar (p>.40) with respect to birth weight (1647 +/- 856 vs 1509 +/- 678gms), gestational age (31.4 +/- 4.3 vs 29.8 +/- 4.0wks); maternal age (24.1 +/- 5.4 vs 25.3 +/- 5.7yr) and commercial insurance (44% vs 40%), a marker of higher socioeconomic status. Compliance of the telephone verses the standard care group was similar (70.0 +/- 21.3 vs 70.2 +/- 24.6%; p=.715, MannWhitney U):1st 4 week period (76.9 +/- 21 vs 81.4 +/- 25.5, p=.143); 2nd 4 week period (54.9 +/- 32 vs 61.1 +/- 29, p=.564). The only factor which improved compliance was rehospitalisation (88.0 +/- 15.6% vs 75.8 +/- 24.8%; p=.037) Conclusions:Weekly telephone contact, without specific encouragement to use the monitor, did not improve compliance. Compliance was greater in subjects who were rehospitalised regardless of their telephone/standard care group status. We speculate that in this already compliant population, more targeted advice is necessary to further improve compliance.

Effects of pediatrician characteristics on management decisions in simulated cases involving apparent life-threatening events.

To study variations in the way pediatricians would evaluate and manage an infant with an apparent life-threatening event. A survey was mailed to the chief residents of all pediatric residency training programs in the United States in which respondents were presented with a simulated case and asked how they would manage an infant who had experienced an apparent life-threatening event that did not require resuscitation. The survey also explored each physician's tolerance of uncertainty, knowledge of apparent life-threatening events, experience, fear of litigation, responsiveness to parental demands, and propensity to order tests. Presumed decisions to prescribe antibiotics and/or order home apnea monitoring in a simulated case of an infant who had experienced an apparent life-threatening event not requiring resuscitation. Logistic regression analysis revealed 2 characteristics that made significant and independent contributions to respondents' presumed decision to prescribe antibiotics: (1) experience with an adverse outcome, and (2) propensity to order diagnostic tests. Presumed decisions to order a home apnea monitor were notably affected by fear of litigation. These findings suggest that differences in pediatricians' characteristics contribute to variations in care. Efforts to make management more uniform must consider that decisions are influenced by a host of different characteristics and experiences.

Home Apnea Monitoring and Sudden Infant Death Syndrome

Objective.To estimate the U.S. national prevalence of apnea monitor use by birth weight classification and to examine the relationship between the use of apnea monitors and the occurrence of Sudden Infant Death Syndrome (SIDS).Design and setting.Data obtained from the 1988 National Maternal and Infant Health Survey (NMIHS) were used. Prevalence estimates of apnea monitor use were obtained by weighting survey data, and the relationship between monitor use and SIDS was accomplished by a case–control analysis using SIDS deaths and live controls obtained from the NMIHS.Outcome measure.Weighted estimates of the prevalence of apnea monitor use and odds ratios for the odds of use of an apnea monitor among SIDS victims compared with the odds of use of an apnea monitor among living controls.Results.The national prevalence estimates for home apnea monitor use among birth weight strata of 500 to 1,499 g, 1,500 to 2,499 g, and 2,500 g or more for blacks were 19.9, 2.6, and 1.1% compared with 44.0, 8.8, and 1.2% for non-blacks. The only significant association between the use of apnea monitors and SIDS was for black 500- to 1,499-g infants. The adjusted odds ratio for SIDS among monitored black 500- to 1,499-g infants vs unmonitored infants was 3.93 (1.09, 14.17).Conclusions.This analysis suggests a marked difference in reported monitor use between U.S. black and non-black infants. In addition, black very low birth weight infants at highest risk for SIDS appear to be preferentially selected for monitoring.The protective effect of home apnea monitoring in this survey population is unclear.