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Case 25
2-MONTH-OLD WITH APNEA - JEREMY
Author: Kathleen Previll, M.D., East Carolina University

Learning Objectives
1. Formulate a differential diagnosis for an infant with apnea or apparent
life-threatening event (ALTE).
2. Obtain an appropriate history, including social history, for an infant with
suspected shaken baby syndrome.
3. Describe physical signs and symptoms of shaken baby syndrome.
4. Order appropriate laboratory and radiological studies for an infant with
suspected physical abuse and shaken baby syndrome.
5. Discuss the ethical and legal responsibility of health care workers to report
suspected child abuse to the Department of Human Services.

Summary of clinical scenario: Two-month-old Jeremy is brought to the

emergency department by his mother. When she checked him while he was taking
a nap, he did not seem to be breathing, he had no color, and was not moving.
Jeremy is now pink and breathing without distress. While in the emergency
department, Jeremy has a minute-long tonic-clonic seizure. After his seizure,
physical exam findings demonstrate that he is hypothermic, tachycardic,
bradypneic, hypertensive, and has an abnormal neurological exam (poor suck,
tense full fontanelle, intermittent crying, decreased tone, and inability to fix and
follow visually). A difficult home situation and Jeremys abnormal neurological
status raise the suspicion of a closed-head injury. Computed tomography (CT) and
magnetic resonance imaging (MRI) show a subdural hematoma. Ophthalmologic
exam reveals bilateral retinal hemorrhages. Jeremys mothers fianc confesses to
shaking him. Jeremy is diagnosed with shaken baby syndrome.

Apnea
Key Findings from History
Normal vital signs

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Neurological depression
Difficult home situation

Hypothermic
Tachycardic
Bradypneic
Key Findings from Physical
Hypertensive
Exam
Abnormal neurological exam (poor suck, tense
full fontanelle, intermittent crying, decreased
tone, inability to fix and follow visually)

Differential Diagnosis
Meningitis, encephalitis
Gastroesophageal reflux
Closed-head injury
Cardiac arrhythmia
Respiratory infection

Key Findings from Testing Subdural hematoma on CT and MRI

Closed head injury secondary to shaken baby

Final Diagnosis
syndrome

Case highlights: This case explores the evaluation and management of an infant
who presents with apnea. Students work through problems about initial
assessment and stabilization, a focused history, and complete physical
examination. Students explore in depth the various causes of apnea, with a focus
on shaken baby syndrome. Students also become familiar with the responsibilities
of health care workers to report child abuse and specific resources about domestic
violence. The case models an approach to discussing child abuse, provides
resources for advocacy, and teaches the epidemiology and morbidity associated
with child abuse. Multimedia features include: CT scan and MRI showing a
subdural hematoma; photo of retinal hemorrhages.

Key Teaching Points

Knowledge
Shaken baby syndrome:

Epidemiology

1012% of all deaths among children who are victims of child abuse are due

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to shaken baby syndrome.

Mortality rate is 25%, and 2040% have poor outcomes due to neurological
injury.

Pathophysiology

Injuries, including closed head injury (CHI) and retinal hemorrhages, are
due to violent shaking or throwing (with resulting blunt trauma to the
head). Bridging vessels tear when infant is shakenor shaken and thrown
achieving an extreme rotational acceleration force to the brain and diffuse
axonal injury to neurons.
Victims of shaken baby syndrome often have no other signs of physical
abuse.

Presentation: Signs and symptoms of shaken baby syndrome may include:

Constant crying
Stiffness
Excessive sleeping
Difficulty to arouse
Seizures
Dilated pupils
Decreased appetite
Retinal hemorrhages (retinal hemorrhages outside the newborn period are
pathognomonic for shaken baby syndrome and are found in 6590% of
victims)

Outcomes

Increased risk for intellectual disability, developmental delays, motor delay

or extreme motor deficit, difficulty with vision (including blindness), and
seizures.

Apnea: Cessation of inspiratory gas flow for 20 seconds, or for a shorter period of
time if accompanied by bradycardia (heart rate < 100 bpm), cyanosis, or pallor.

Apparent life-threatening event (ALTE): Not a diagnosis, but a description of

an event. Caregiver usually describes apnea, color change, change in tone, and
possibly choking or gagging. The observer may think the infant has died.
Recovery occurs only after stimulation or resuscitation. Incidence is 0.05% to 1%
in population-based studies.

Potential causes

Central nervous system:

Seizures (due to bleeding, infection, structural abnormalities,
metabolic disorders, electrolyte imbalances, genetic syndromes,
epilepsy)
Breath-holding spells (pallid or cyanotic)
Increased intracranial pressure (due to bleed, trauma, tumor,

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infection)
Cardiac:
Arrhythmia (bradycardia, long QT syndrome)
Congenital heart disease (ductal dependent lesions, unrepaired
Tetralogy of Fallot)
Pulmonary:
Respiratory infections (including respiratory syncytial virus, pertussis)
Gastrointestinal:
Gastroesophageal reflux (may cause choking and laryngospasm)
Swallowing abnormalities/tracheoesophageal fistula (coughing,
difficulty with feeds)
Systemic:
Infection (sepsis due to Group B streptococcal, Escherichia coli, or
Listeria infection, among others)
Metabolic disorders (inborn errors of metabolism)
Intoxication (ingestions of medications or toxins)
Infant botulism (exposure to botulinum toxin in soil or honey)
Environmental exposure (carbon monoxide)

Skills
Mandated reporting:

Each state has a statute that mandates health care workers (including
medical students!) to report suspected child abuse.
It is not the health care teams job to assign blame or determine who may
have inflicted an injury, but rather to determine the likelihood that an injury
was accidental or non-accidental.
Once a report is filed, the Department of Human Services works in
conjunction with law enforcement agencies to investigate.

History:

Obtain family history of cardiac arrhythmias, epilepsy, or early childhood

deaths.
Review of systems to obtain information about recent illnesses, growth
history, spitting up, irritability
Social history may reveal family stressors, difficult home environment

Physical exam:

Vital signs

Tachycardia: Indicates a deterioration in cardiovascular status and may be

related to sepsis or increased intracranial pressure (ICP).
Respiratory rate: A low respiratory rate suggests central nervous system
depression of respiratory center rather than sepsis or a respiratory infection,
which generally present with increased respiratory rate.

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Blood pressure: Elevated blood pressure indicates a response from the

cardiovascular system either to pain, compensated shock, or increased ICP.

Normal neurologic exam in a two-month-old infant

At two months of age a typically developing infant:

Can fix and follow easily with his eyes, smiles to voices; has a strong
suck and is beginning to coo.
Lies flexed at hips with good tone and moves all four extremities well
Lacks good head control when held upright and cannot roll over
When prone, can raise head and move it from side to side

Differential Diagnosis
1. Closed-head injury (CHI):
Apnea, seizure, and altered neurological status are common in
closed-head injuries.
Subdural hematomas result from trauma, either accidental or
non-accidental. They can be seen in newborns, particularly after
vacuum extraction deliveries. Not seen as a result of cardiopulmonary
resuscitation or seizuresanddo not occur from short falls (e.g., from a
height of < 4 feet). Subdural hematomas are often found in infants
who have experienced violent shaking.
2. Meningitis:
Meningitis in young infants causes increased ICP and may present
with apnea.
Infants are irritable, do not eat well, vomit, and usually have fever >
38.2 C.
Infants are inconsolable and lethargic.
3. Gastroesophageal (GE) reflux:
May cause emesis, gagging, and aspiration pneumonia.
Seldom presents as apnea without associated symptoms.
Infants with GE reflux would have normal vital signs; may be irritable
at times, but would not present with abnormal neurological findings.
4. Cardiac arrhythmia:
Arrhythmia may cause apnea, but would not lead to persistent
alteration of mental status.
A long QT syndrome or other arrhythmia may be identified on
electrocardiogram.
5. Respiratory infection:
Respiratory infection may present as apnea; other symptoms include
tachypnea, fever, decreased feeding, and change in activity.
Respiratory rate may be increased.
Infants may not cough or wheeze initially.

Studies

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Coagulation studies: Necessary to rule out a bleeding disorder

Skeletal survey: X-rays of the entire body to evaluate for old or new fractures.
Involvement of a pediatric radiologist skilled in interpreting these films can be
critical. Skeletal survey findings that raise suspicion for abuse include:

Fractures or injuries that are inconsistent with reported mechanism of injury

and/or the developmental stage or abilities of the child.
Multiple fractures or injuries at different stages of healing
Fracture of the femur or tibia in a non-walking child
Posterior rib fracturesfrequently associated with shaken baby syndrome
due to squeezing of the thorax by the perpetrators hands during shaking.
Skull fracture in an infantis also very suspicious for abuse.

Computed tomography (CT) of the head: CT is often the first and definitive
study to confirm subdural hematomas. Repeat CT should be considered if there is
a concern about clinical deterioration.

Magnetic resonance imaging (MRI): MRI requires sedation and is not done
until the child is stable. MRI is superior to CT for defining ischemia, visualizing
shearing injuries to neurons. MRI can act as confirmation for findings identified on
a head CT.

Management
Initial emergency management of head trauma:

1. Assess circulation, airway, and breathing, (CABs) before beginning

resuscitation efforts. The airway should be clear and stable.
2. Assess heart rate, respiratory rate, pulse oximetry, and strength of pulses.
3. If CABs or vital signs are abnormal, immediate intervention is required.
4. Obtain intravenous access.
5. Obtain head CT.
6. Admit to critical care unit.
7. Consult neurosurgery/neurology.

Management of shaken baby syndrome:

Consult with child advocacy specialist: Investigate for other signs of child
abuse: A skeletal survey should be performed if there is suspicion of child abuse.

Refer to ophthalmology: A ophthalmology consultation is required to look for

retinal hemorrhages (highly suggestive of shaken baby syndrome).

Social worker: Hospital social workers are helpful as team coordinators. They
provide emotional support for the family and can evaluate the home situation. The
Department of Child Services (or Child Protective Services) will coordinate with
the social workers to investigate cases of possible abuse.

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