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Derivation of Candidate Clinical Decision Rules to Identify Infants at Risk for Central Apnea
Paul Walsh1, Pádraig Cunningham2, Sabrina Merchant3
1Pediatric Emergency Medicine, Sutter Medical Center, Sacramento, California; Department of Emergency Medicine, University of California Davis, Sacramento, California; Department of Emergency Medicine, Kern Medical Center, Bakersfield, California; Walshp@sutterhealth.org.
Insights
This study developed clinical decision rules to identify infants at risk for central apnea in the emergency department. These rules showed 100% sensitivity and negative predictive value for subsequent central apnea.
Area of Science:
- Pediatrics
- Emergency Medicine
- Neonatology
Background:
- Central apnea is a significant complication of bronchiolitis in infants.
- Identifying infants at risk for central apnea in the emergency department (ED) is crucial.
Purpose of the Study:
- To prospectively derive candidate clinical decision rules (CDRs) for identifying infants at risk of central apnea.
- To evaluate the performance of these CDRs in a real-world emergency department setting.
Main Methods:
- Prospective observational study of 892 infants over 8 years.
- Development of three candidate CDRs using Poisson regression, classification and regression tree analysis (CART), and random forest (RF).
- Primary outcome was central apnea occurring subsequent to the initial ED visit.
Main Results:
- Central apnea occurred in 5% of infants post-ED visit.
- Factors including parental apnea report, prior apnea history, congenital heart disease, and younger age (≤6 weeks) identified high-risk infants.
- All derived CDRs demonstrated 100% sensitivity and 100% negative predictive value for subsequent central apnea.
Conclusions:
- Candidate clinical decision rules effectively identify infants at high risk for central apnea.
- The developed CDRs offer a valuable tool for risk stratification in the ED.
Background And Objectives:
Central apnea complicates, and may be the presenting complaint in, bronchiolitis. Our objective was to prospectively derive candidate clinical decision rules (CDRs) to identify infants in the emergency department (ED) who are at risk for central apnea.
Methods:
We conducted a prospective observational study over 8 years. The primary outcome was central apnea subsequent to the initial ED visit. Infants were enrolled if they presented with central apnea or bronchiolitis. We excluded infants with obstructive apnea, neonatal jaundice, trauma, or suspected sepsis. We developed 3 candidate CDRs by using 3 techniques: (1) Poisson regression clustered on the individual, (2) classification and regression tree analysis (CART), and (3) a random forest (RF).
Results:
We analyzed 990 ED visits for 892 infants. Central apnea subsequently occurred in the hospital in 41 (5%) patients. Parental report of apnea, previous history of apnea, congenital heart disease, birth weight ≤2.5 kg, lower weight, and age ≤6 weeks all identified a group at high risk for subsequent central apnea. All CDRs and RFs were 100% sensitive (95% confidence interval [CI] 91%-100%) and had a negative predictive value of 100% (95% CI 99%-100%) for the subsequent apnea. Specificity ranged from 61% to 65% (95% CI 58%-68%) for CDRs based on Poisson models; 65% to 77% (95% CI 62%-90%) for CART; and 81% to 91% (95% CI 78%-92%) for RF models.
Conclusions:
All candidate CDRs had a negative predictive value of 100% for subsequent central apnea.
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