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Derivation of Candidate Clinical Decision Rules to Q:1; 2 Identify Infants at Risk for Central Apnea


Paul Walsh, Padraig Cunningham, Sabrina Merchant, Nicholas Walker, Jacquelyn Heffner, Lucas Shanholtzer, Stephen J. Rothenberg

Publication Type: 
Refereed Original Article
BACKGROUND AND OBJECTIVES: Central apnea complicates, and may be the presenting complaint, in abstract 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, 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 before presentation to the ED, previous history of apnea, congenital heart disease, birth weight #2.5 kg, lower weight at presentation, 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 classification and regression tree models; and 81% to 91% (95% CI 78%–92%) for RF models. CONCLUSIONS: All candidate CDRs had a negative predictive value of 100% to predict infants at Q:4 risk for subsequent central apnea.
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National University of Ireland, Dublin (UCD)
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