Baby Stopped Breathing

     Attack One responds to a call for an infant who stopped breathing. Preliminary information indicates this child is less than a month old. There's little conversation on the way to the address—times like this are good opportunities to think through the process of running a pediatric code. One crew member even pulls out a copy of the medical orders and checks through a few doses of resuscitation medications. The parents certainly seem concerned as they meet the crew at the front door, the child in her father's arms. Fortunately, the child is breathing, and on first appearance looks pink and healthy. But the parents are frightened by what they've seen, and feel sure their child was dead until the father blew air into her face.

     The crew could just have the parents carry the infant directly to the ambulance and do the history and evaluation there, but the crew leader suggests the setting might be better inside the apartment where the parents and child live. Inside, the crew leader suggests the parents go to the spot where the event occurred and describe exactly what happened. She makes sure all crew members hear the history and observe the area where the child was when the event occurred. They ask the mother to sit with the child, and the crew starts their evaluation with the paramedic taking the lead, explaining to the parents what they will be doing.

     The mother says she was watching the child in the crib when the child stopped breathing. The mother yelled for her husband, who came, grabbed the infant and blew in her face. The mother states the child had "turned a blue color" and didn't breathe until the husband blew in her face. She remained limp, moving little, and never cried. The crew assesses the environment, looking specifically at the bed for loose bedding, a soft mattress and toys in the crib. Other observations include a lack of smells of cigarettes or chemicals, a normal room temperature, and the lack of other children or adults in the house.

     The paramedic touches the child to begin assessment, and the child is awake and making noises. The paramedic listens to heart and lung sounds, which are normal for the child's age. A pulse oximeter on her finger, a normal skin temperature. Normal, quick capillary refill. Her oxygen saturation is in the high 90s, and her pulse rate is regular at 124, normal for her age. Blood sugar is 66.

     After the assessment the crew arranges for transport of the infant in her own child restraint seat, along with her parents in the medic. The child is carefully loaded into the seat and placed on the cot. The father joins her, belted into the captain's seat.

     The child is quiet en route to the hospital and asleep as they enter the emergency department.

     A 20-day-old female in no distress, but mother reported child stopped breathing and "turned blue."

     Airway: Intact and uncompromised.

     Breathing: In no distress, no flared nostrils or use of accessory muscles.

     Circulation: Normal capillary refill, pink skin.

     Disability: Moving around and active.

     Exposure of Other Major Problems: No signs of trauma, congestion.

     Allergies: None.

     Medications: None (immunizations not started yet).

     Past Medical History: Child born by normal vaginal delivery, and had no problems before being released home with mother. Child is breast-fed.

     Last Intake: Child is bottle-fed, last ate about an hour ago.

     Event: Child "quit breathing," according to mother, but now appears normal.

     The child is taken to the Children's Hospital ED. The ED staff takes the report and confirms normal vital signs, and that the child is breathing normally. The emergency physician begins his evaluation and asks for a complete report from Attack One on the condition of the child on arrival, as well as the conditions around her. He asks to see the patient care report once it's completed, so the ED care record will be consistent with the EMS record. The Attack One crew offers a procedure they've often utilized with difficult patient encounters, which is to have the physician proofread the care report before it's completed, to make sure it's thorough, accurate and includes all appropriate findings the prehospital providers can furnish.

     The emergency physician is concerned about the child's history, and by the time the Attack One crew is leaving (making sure to wish the parents well), has initiated a series of tests.

     About six hours later, the crew returns to the hospital with another patient, and the ED staff relays that the girl was admitted to the ICU. She'd had another episode where she stopped breathing, with her oxygen saturation dropping and heart rate slowing significantly. Blood tests revealed significant abnormalities, and pediatric staff were concerned about a systemic infection. The child was started on antibiotics and admitted for careful observation. Ultimately, she does well and is released home with no subsequent problems.

     This case typifies a frequent occurrence EMS responders must manage. The chief complaint is often for a child who has stopped breathing. In the newborn age group, parents will often observe the child in some form of distress, or appearing to choke or seize. The infant is of course unable to relate what has happened or offer any complaint. It is also common to hear that a parent performed chest compressions or did some form of breathing for their child.

     In recent years, this disturbing presentation has come to be referred to as an "apparent life-threatening event," or ALTE. The term describes a sudden and unexpected change in an infant's breathing behavior that frightens the parents or caregivers, and includes some of the following features:

• Apnea, choking or gagging, reflecting either no respiratory effort or difficulty breathing;
• Color change—pale, cyanotic/blue, or occasionally bright or splotchy red;
• A change in muscle tone—usually limp, but occasionally stiff or seizure-like.

     Another typical feature of these episodes is that the infant appears normal and is in no distress at the time of presentation to medical care.

     An ALTE does not represent a specific disease, but rather is a complaint that brings a child to emergency medical attention. It is important to note that ALTE infants represent a mixed group that could have neurologic, heart, lung or endocrine problems. There was speculation at one time that ALTE events occurred in infants who later died of SIDS, but studies over the past two decades have not found a causal relationship between ALTE and SIDS.

     EMS personnel contribute much to the care of the infant suffering one of these events. First, if the infant is in respiratory distress or having other major problems at the time of presentation, EMS will initiate resuscitation and provide medical care on the way to the emergency department. If no immediate resuscitation is needed, the EMS crew must get a very important history of the event and make important observations about the infant and their environment. In this case, the paramedic facilitated these observations by asking the parents to come into their home and show the crew what happened. This allowed the EMS personnel to all make observations, and to produce an accurate report about what was surrounding the child when the event happened. The ED staff will be able to obtain their own history, but the only providers who can make observations about the home are the EMS personnel on scene.

     Infants can have a broad range of emergency problems, and they present with a narrow range of chief complaints from parents or caregivers. The chief complaint of "stopped breathing" is a high-risk presentation and, as with this case, represents a very serious condition. Certain factors would make the presentation even more worrisome, including family history of SIDS; a child born prematurely; previous ALTEs or multiple ALTEs within 24 hours; age less than 90 days; presence of upper respiratory infection symptoms; color and tone changes during the ALTE; longer duration of the ALTE; interventions required to restore breathing; prior suspicion of child abuse; and exposure to cigarette smoke. It is critical that EMS providers evaluate the infant and their environment with appreciation for these factors. A list can be prepared to assist the provider in caring for (and documenting the care of) an infant who stopped breathing.

     James J. Augustine, MD, FACEP, is deputy chief-assistant medical director for Washington, DC, Fire and EMS and a clinical associate professor in the Department of Emergency Medicine at Wright State University in Dayton, OH, as well as a member of EMS Magazine's editorial advisory board. Contact him at jaugustine@emp.com.

     Parents, grandparents and other adult caregivers can be extremely stressed by incidents with children. They deserve concern and attention. It is not possible in the field to give the adults a diagnosis or explain exactly what happened, but it's well within the capability of EMS to advise the adults that the child had an event, but now has normal vital signs and will need a thorough evaluation in the emergency department. In some cases the child will be admitted, particularly if there are factors that place them at high risk for a repeat event or sudden death.

     Historical information to obtain in ALTE episodes, as described by the infant's parents or caregiver:

     Condition at time of event: Awake or asleep; physical position (prone, supine, on side); location (crib, parents' bed, baby seat, other); status of bedclothes, blankets, mattress, pillows, crib toys, etc.

     Activity at time of event: Feeding, coughing, gagging, choking, vomiting, etc.

     Breathing: None, shallow, gasping, choking, etc.

     Color: Pale, blue, red, purple, etc.

     Duration of event: Time required to restore regular breathing and normal behavior/tone.

     Movement/tone: Limp, floppy, rigid, tonic-clonic, etc.

     Observations: Cough, blood, vomiting, etc.

     Environment: Chemical or smoke odor, etc.

     Parental interventions: Blowing, mouth-to-mouth, chest compressions, shaking, clearing the airway, etc.

     Learning Point: An infant "quit breathing" call highlights the need to obtain and document a great history, and to note the child's behavior, surroundings and any history of color change. An "apparent life-threatening event," or ALTE, can represent a serious medical problem in an infant.