What is the appropriate management for a 2-month-old infant experiencing brief apnea episodes while crying?

Brief Apnea Episode in 2-Month-Old While Crying

Immediate Assessment and Classification

This event should be evaluated as a potential Brief Resolved Unexplained Event (BRUE), but only after excluding all identifiable causes through careful history and physical examination. 1

The American Academy of Pediatrics defines BRUE as an event in an infant <1 year old that is sudden, brief (<1 minute, typically 20-30 seconds), completely resolved, and includes at least one of: cyanosis/pallor, absent/decreased/irregular breathing, marked tone change, or altered responsiveness. 1 Critically, BRUE can only be diagnosed when no explanation exists after appropriate evaluation. 1

Critical Differential Diagnoses to Exclude First

Choking/Foreign Body Aspiration

• If the infant was witnessed choking with any objects in the mouth, this is pathognomonic for foreign body aspiration until proven otherwise, even if currently asymptomatic. 2
• Never perform blind finger sweeps as they may push foreign bodies deeper into the airway. 1, 2
• Normal chest X-ray does NOT exclude foreign body aspiration—clinical history takes precedence. 2

Gastroesophageal Reflux (GER)

• Events characterized as choking after vomiting or feeding strongly indicate GER and are NOT classified as BRUE. 2
• GER can present with respiratory symptoms including apparent choking episodes. 2
• The temporal association between GER and respiratory symptoms occurs in approximately 30% of infants with BRUE-like events. 1

Seizure Activity

• Assess for tonic eye deviation, nystagmus, tonic-clonic movements, or infantile spasms during the event. 2
• Post-ictal phase may be mistaken for resolution of the episode. 2

Cardiac Arrhythmia

• Obtain family history of sudden unexplained death in first- or second-degree relatives before age 35, particularly in infancy. 2
• Ask specifically about family history of long QT syndrome or arrhythmias. 2

Risk Stratification for BRUE (If Diagnosis Confirmed)

Your 2-month-old patient meets criteria for lower-risk BRUE if ALL of the following are present: 1

• Age >60 days (your patient qualifies at 2 months)
• Gestational age ≥32 weeks and postconceptional age ≥45 weeks
• First event (no prior BRUE)
• Event duration <1 minute
• No CPR required by trained medical provider
• No concerning history or physical examination findings

Management Algorithm

For Lower-Risk BRUE:

The American Academy of Pediatrics recommends AGAINST routine extensive testing in lower-risk infants. 1

Specifically:

• Do NOT routinely obtain serum lactic acid or bicarbonate to detect inborn errors of metabolism 1
• Do NOT routinely prescribe acid suppression therapy (proton pump inhibitors) 1
• The benefits of reducing medication adverse effects and avoiding unnecessary treatment outweigh the risk of delaying treatment of gastrointestinal disease 1

Non-Pharmacologic Management for GER (if suspected):

• Avoid overfeeding and ensure frequent burping during feeding 1
• Maintain upright positioning in caregiver's arms for 10-20 minutes after feeding before placing in "back to sleep" position 1
• Avoid car seats or semisupine positions immediately after feeding as these exacerbate reflux 1
• Encourage exclusive breastfeeding when possible 1
• Avoid secondhand smoke exposure 1

For Higher-Risk Features:

If your patient does NOT meet all lower-risk criteria, further investigation, monitoring, and/or treatment is warranted, though specific recommendations vary based on the concerning feature identified. 1

Common Pitfalls to Avoid

• Do not be falsely reassured by normal radiographs when clinical history suggests foreign body aspiration. 2
• Do not classify an event as BRUE if there was vomiting or feeding-related choking—this suggests GER. 2
• Do not misinterpret transient bradycardia during feeding, sleep, or defecation as pathological, as these represent normal vagal tone increases. 3
• Altered mental status, poor peripheral perfusion, or weak pulses warrant immediate evaluation regardless of specific vital sign values. 3

When Immediate Intervention is Required

Provide rescue breathing at 1 breath every 2-3 seconds (20-30 breaths per minute) if pulse is present but breathing is absent or inadequate. 3

If heart rate <60 bpm with signs of poor perfusion, immediate CPR and chest compressions are required as cardiac arrest is imminent. 3

Key Distinction from Apnea of Prematurity

Note that apnea of prematurity is a distinct entity affecting premature infants and typically resolves with maturation. 4, 5 Your 2-month-old term infant's brief event during crying represents a different clinical scenario requiring the BRUE evaluation framework. 1, 6