Home A-B monitor criteria?

Jolie, BSN · Aug 1, 2005

Hi all,
I have a friend who had a 33-weeker (born IUGR at 3#3oz) who was in NIC for 4 weeks and had a Grade I and Grade II (or III) IVH. While in NIC he had a few apnea episodes. A week after discharge he had a nearly fatal episode at home. If not for an AngelCare monitor her parents had provided and her husband's CPR capabilities, he would not be here.
He was re-admitted and is awaiting tests.
Should he have been provided a home monitor with his history of IVH despite a lack of a-b episodes?
Also~ my 34-weeker had many ALTE episodes while in NIC but was sent home sans monitor. Of course she had to pass her 7-day watch to be discharged. But is the 7-day watch that reliable that it assures no need for home monitoring? In our case that proved to be true, thank goodness...but what if it hadn't? Shouldn't all preemies with any remote potential for life-threatening episodes post-discharge be on a home monitor?
Wen
*preemie mom*

I'm not exactly sure what you mean by "ALTE" episodes, but I assume you are referring to apnea.

Your question points up the inexact science that neonatology (and medicine in general) is. While it is natural to want to protect your baby from every imaginable bad outcome, it is simply not possible. Your child passed her 7 day watch, meaning that her risk of experiencing a life-threatening apneic episode at home was very remote, but not zero. Even a healthy term baby with no known risk factors has some risk of SIDS. It is simply not possible to reduce that risk to zero for any baby.

Your friend's baby apparently did not display apneic episodes during his hospital stay, leading the staff to believe that home monitoring was not necessary. It will be interesting to see whether his test results reveal the cause of his apneic episode at home. If he is having central apnea, then he will need home monitoring. If his episode was related to an isolated choking or gagging incident, then home monitoring might not be indicated. If no cause can be determined, he will probably be sent home on a monitor "to be on the safe side", but that comes with it's own set of risks. Statistics show that babies sent home on monitors have a higher rate of abuse. Parents are at risk for anxiety,fatigue and isolation when caring for a monitored infant. And home monitors do not prevent all sudden infant death. It is a risk/benefit situation that must be assessed by the parents and pediatrician, a mixture of art, science, experience and gut instinct.

Gompers, BSN, RN · Aug 1, 2005

Should he have been provided a home monitor with his history of IVH despite a lack of a-b episodes?

Not that I know of.

We only send home kids on monitors if they still are having A's and B's despite caffiene and reflux meds...or if they go home with an NG tube or oxygen...but otherwise, no. If they are not on caffiene anymore and are not having A's and B's for 7 days, they are discharged home without a monitor. As far as I know, this is pretty standard practice. I have personally not seen babies with IVH have A's and B's more than other babies unless they are severe grade III and IV bleeds.

Even a healthy full term baby who went home with mom the day after delivery might have either a choking or apniec episode at home, and those kids are never even considered for home monitoring.

The other factor is that preemies have a higher incidence of SIDS. Some preemie moms insist on monitors or buy their own because of this. Usually insurance will not cover a "healthy" preemie for monitors.

fergus51 · Aug 1, 2005

Our protocols are the same. I know all parents probably want monitors "just to be safe" but it isn't really necessary and can cause problems.

mermom · Aug 1, 2005

Thank you for the info~ after 4 years I'm still learning.

I realize there are no guarantees even with healthy FT babies, but with the increased risk of prematurity and according to history, I think a few months of home monitoring would have been prudent in both of our cases. I know of several 35 and 36-weekers who were sent home on monitors without apneic histories or evident risk, and were referred for Synagis with less risk factors than my 34-weeker (discharge in late October, K-age sibling, history of RDS). It's just frustrating when protocol varies so widely and makes little sense (to me).

Wen

mermom · Aug 1, 2005

I'm not exactly sure what you mean by "ALTE" episodes, but I assume you are referring to apnea.

ALTE = Apparent Life-Threatening Event

Sometimes (in our case) used to describe un-self-resolving A-B episodes

Wen

fergus51 · Aug 1, 2005

It's just frustrating when protocol varies so widely and makes little sense (to me).
Wen

This is one reason I always caution parents about on-line support groups and the like. What is standard in one hospital may be completely unheard of in another. It doesn't mean that one way is right and the other is wrong. It is just part of NICU care because the research and evidence is often contradictory and can be interpreted in different ways (if it even exists!).

My current hospital sends a lot of babies home on monitors just to appease parents and I don't think it's a good thing. Those are the same parents who call us a few weeks later in tears because the monitor has them so stressed.

mermom · Aug 2, 2005

This is one reason I always caution parents about on-line support groups and the like. What is standard in one hospital may be completely unheard of in another. It doesn't mean that one way is right and the other is wrong. It is just part of NICU care because the research and evidence is often contradictory and can be interpreted in different ways (if it even exists!).

In defense of online support groups, they saved my sanity.

I'm sure I would've dealt with the experience on my own terms somehow without them, possibly found a few preemie parents in my small community to relate to who understood what I was going through, but it was an invaluable source of comfort and companionship right at my fingertips 24/7 throughout a very unique, isolating, traumatic, misunderstood, and underestimated ordeal and emotional recovery.

My current hospital sends a lot of babies home on monitors just to appease parents and I don't think it's a good thing. Those are the same parents who call us a few weeks later in tears because the monitor has them so stressed.

I've heard how stressful the home monitors can be from my online communities, but on the other hand, I had severe sleep deprivation and stress worrying that my preemie would have an ALTE while we slept. So that can go both ways. Of course *all parents* worry about SIDS, but when your baby is a preemie and you've been through the trauma of seeing them stop breathing and turn gray many times, I think the stress of home monitoring would've been much easier to tolerate, again *for me*. And well, I think my friend who's baby would've died without one, would agree.

Wen

fergus51 · Aug 2, 2005

Wen, I don't mean I tell them that online support groups are bad or that they shouldn't participate. I just caution them that there is no one set protocol for many things in neonatology so hospitals have different policies. As long as those policies can be supported with the evidence that is out there, they are valid. You wouldn't believe the number of parents I have had freaking out because of something they read on-line and I try to minimize that from the beginning if I can.

I used to work in a large hospital in Toronto and we would routinely send babies to smaller facilities when they were ready, and I had to do the same thing. We would always tell the parents that just because the other hospital does things differently doesn't mean that they are doing it wrongly. Of course it's difficult for a parent to see things being done differently and not assume they are wrong (it's hard for nurses too:)). I know some of the smaller hospitals used to say our parents got Toronto-itis because they would often start sentences with "Well, in Toronto they did it like this....". Just go through this forum and you will see thread after thread about the different practices in different hospitals. Some things definitely need to be done one way, but many more are grey areas.

I understand you would have liked a monitor. I just want you to know that the hospital wasn't being mean or anything by not giving you one. They were following what most hospitals do, weighing the pros and cons (the VERY remote possibility of an AB vs the stress, the increased risk for abuse, etc). Having worked at more than a few hospitals, I can't think of one that would have sent your baby home on a monitor (unless you threw a fit and the doctors just wanted to please you).

I personally have never heard of a baby from our hospital who passed their 7 day watch die from an AB at home. I've seen many readmits and deaths unfortunately, but none of them were due to ABs.

RNin2007 · Aug 14, 2005

Hi all,
I have a friend who had a 33-weeker (born IUGR at 3#3oz) who was in NIC for 4 weeks and had a Grade I and Grade II (or III) IVH. While in NIC he had a few apnea episodes. A week after discharge he had a nearly fatal episode at home. If not for an AngelCare monitor her parents had provided and her husband's CPR capabilities, he would not be here.
He was re-admitted and is awaiting tests.
Should he have been provided a home monitor with his history of IVH despite a lack of a-b episodes?
Also~ my 34-weeker had many ALTE episodes while in NIC but was sent home sans monitor. Of course she had to pass her 7-day watch to be discharged. But is the 7-day watch that reliable that it assures no need for home monitoring? In our case that proved to be true, thank goodness...but what if it hadn't? Shouldn't all preemies with any remote potential for life-threatening episodes post-discharge be on a home monitor?
Wen
*preemie mom*

My daughter also passed her watch, and her pediatrician told me I could take it or leave it (the monitor). Since she was my first child, and I was only 20...I decided to take it home. Not even a few days after we got home she alarmed and turned VERY blue, and we rushed her to the hospital. I still think having that monitor saved her life. She didn't wear it during the daytime when we could constantly monitor her but she wore it every night for several months. I agree that any preemie with episodes that recurrent should go home on a monitor...but I imagine more plays into it than just the parents needs/desires. Insurance, an agreeable pediatrician, etc.

~J

forgot to mention, my girl was a 26 weeker (680 gr.)