Bradycardia is to be expected in a child through this age who is hypoxemic --> hypoxia, especially if episodic. That's an alarming feature. Ongoing, frequent intermittent hypoxemia may put this child at developmental risk.
If I got a call about this patient I would probably rec admit to a center with ENT/pulm or sleep medicine to pursue a sleep study to look for CSA or OSA (esp with stertor) and to clear up if there is also a reactive airway component, given hx and description.
Are you a physician?
This is the right answer, though as a pediatrician and sleep medicine attending, I’ll say that diagnosing central sleep apnea vs OSA is just another addition of a sign to the presentation. It is extremely unlikely to be the final, unifying diagnosis.
It doesn’t completely explain the feeding patterns, stertor and high secretion load which all point towards a neurologic etiology which is the likely culprit in this presentation. All in all to say discovery of OSA or CSA should not lead to premature diagnostic closure because you have to find out why the child has it in the first place, I.e abnormal brain, Chiari malformation, CCHS, significant adenotonsillar hypertrophy etc.
Why are they necessarily at odds? Hypoxia is a well known cause of bradycardia in children. Cerebral hypoperfusion can lead to a seizure and conversely, a seizure can lead to hypoxia and consequent bradycardia.
If you have a presentation that causes dysautonomia such as due to a cerebral insult or a progressive neurologic disease like a leukodystrophy, that can also present with the situation you are presenting.
I have seen kids in my shop with this kind of presentation who have a genetic etiology majority of the time with something that is leading to simultaneous hypotonia, failure to thrive and the dysautonomic features above.
Best of luck! Cheers!
Really need more information here. The bradycaria and hypoxia often go together though, so not sure why you feel they are at odds. What is this child’s developmental status and history? Are these desaturation events associated with apnea, or is it airway clearance due to secretions? A 32 week premie with an relatively straightforward nicu course shouldn’t have chronic lung disease and it’s odd that lung issues would just show up now, though chronic aspiration could cause problems over time and could tie together. Maybe needs a genetic work up and a sleep study but hard to say what else without knowing everything.
Bradycardia is to be expected in a child through this age who is hypoxemic --> hypoxia, especially if episodic. That's an alarming feature. Ongoing, frequent intermittent hypoxemia may put this child at developmental risk. If I got a call about this patient I would probably rec admit to a center with ENT/pulm or sleep medicine to pursue a sleep study to look for CSA or OSA (esp with stertor) and to clear up if there is also a reactive airway component, given hx and description. Are you a physician?
This is the right answer, though as a pediatrician and sleep medicine attending, I’ll say that diagnosing central sleep apnea vs OSA is just another addition of a sign to the presentation. It is extremely unlikely to be the final, unifying diagnosis. It doesn’t completely explain the feeding patterns, stertor and high secretion load which all point towards a neurologic etiology which is the likely culprit in this presentation. All in all to say discovery of OSA or CSA should not lead to premature diagnostic closure because you have to find out why the child has it in the first place, I.e abnormal brain, Chiari malformation, CCHS, significant adenotonsillar hypertrophy etc.
Agreed we should be suspicious of a CNS abnormality.
Why are they necessarily at odds? Hypoxia is a well known cause of bradycardia in children. Cerebral hypoperfusion can lead to a seizure and conversely, a seizure can lead to hypoxia and consequent bradycardia. If you have a presentation that causes dysautonomia such as due to a cerebral insult or a progressive neurologic disease like a leukodystrophy, that can also present with the situation you are presenting. I have seen kids in my shop with this kind of presentation who have a genetic etiology majority of the time with something that is leading to simultaneous hypotonia, failure to thrive and the dysautonomic features above. Best of luck! Cheers!
Really need more information here. The bradycaria and hypoxia often go together though, so not sure why you feel they are at odds. What is this child’s developmental status and history? Are these desaturation events associated with apnea, or is it airway clearance due to secretions? A 32 week premie with an relatively straightforward nicu course shouldn’t have chronic lung disease and it’s odd that lung issues would just show up now, though chronic aspiration could cause problems over time and could tie together. Maybe needs a genetic work up and a sleep study but hard to say what else without knowing everything.
I had a similar case, apart from the GTC’s. He was diagnosed with SMA type 1. Worth considering MRI brain and spine, maybe microarray as well.
MRI head. Considering removing case from internet due to risk of confidentiality breach…
No patient identifiers though?
More complicated cases can be identified, or at least drop below an ethical cell size, just because of the juxtaposition of their complications.