New at-home baby monitors that track everything from heart rate to oxygen saturation prove more alarming than helpful.
It’s been a busy night in the Pediatric ED, and you’re exhausted. But you look as fresh as a daisy compared to the bleary-eyed young parents in Room 3. They are here because their 8-week-old infant’s apnea alarm went off. The parents were recently persuaded by a friend to buy the monitor. It is a device that looks just like a baby bootie and keeps tabs on the infant’s heart rate, oxygen saturation, and skin temperature. The device communicates wirelessly with her parents’ cell phones. Tonight, it alerted them of low oxygen saturations. They immediately checked on the baby and she was easily aroused from sleep. Her color looked fine. But an hour later the alarm went off again so they brought her to the ED.
The infant has normal vital signs on arrival to the ED, including an oxygen saturation of 99%. She has bottle-fed well while waiting to be seen. Your exam reveals an alert and vigorous baby without any abnormalities. But the parents are worried that she might “stop breathing in her sleep and die.” That’s why they bought the monitor.
Home monitors were in vogue in the 1980s, when they were prescribed to infants thought to be at increased risk for Sudden Infant Death Syndrome (SIDS). This group included former preemies, siblings of infants who had died of SIDS, and babies who had experienced a Brief Resolved Unexplained Event (BRUE, formerly known as Apparent Life-Threatening Event [ALTE]).
Home Monitors Don’t Work
The main problem with the monitors is that they didn’t work as planned. Studies failed to demonstrate that home monitors reduced the risk of SIDS. A large study involving more than 9000 term and preterm infants was unable to demonstrate any findings on cardiorespiratory monitoring that predicted SIDS [1]. In another study analyzing over 700,000 hours of at-home monitoring, brief periods of apnea, bradycardia, and/or desaturation were observed in more than 40% of healthy infants without any apparent clinical consequence [2]. Other studies have reported no difference in mortality at 5-year follow-up between infants sent home with monitors and those who were not, though monitored infants had a significantly higher rate of rehospitalization [3,4]. Anecdotally, caregivers of infants prescribed home monitoring reported increased stress and fatigue as monitors frequently malfunctioned or gave false alarms. The cost of home monitoring was estimated conservatively at $24 million in 1999. Consequently, in 2003 the American Academy of Pediatrics (AAP) recommended against prescribing home apnea monitors for the purpose of preventing SIDS and reiterated this recommendation in a 2016 update [5,6]. Echoing the recommendation, Christopher Bonafide, a pediatrician at Children’s Hospital of Philadelphia, said, “There’s no role for any type of home monitoring of healthy infants, and there are further risks with using these sorts of non-FDA-approved devices in that we don’t know how accurate they are, and we think there could be risks of harm if parents do choose to use them.”
Smart Apps Not So Smart
But even as doctors have stopped prescribing monitors, the private market place has stepped in. New smartphone-connected infant home monitors have sprung up, similar to fitness tracking devices like the FitBit. One example of these is the Owlet smart sock. Most of these measure pulse rate and oxygen saturation via a sock or band-like device. A few also measure skin temperature and respiratory rate or motion. The four most popular devices retail between $150 and $300. All of them are marketed as consumer products rather than medical devices, and thus have not been tested by the Food and Drug Administration (FDA) for accuracy or efficacy. Recent editorials in the British Medical Journal and the Journal of the American Medical Association have raised concern that though the devices make no claim to prevent SIDS or any other condition, anxious parents are likely using them for just that reason [7,8]. This false reassurance may make parents less likely to follow other, evidence-based guidelines for preventing SIDS.
Back to Sleep
If continuous cardio-respiratory monitoring doesn’t prevent SIDS, what does? The Back to Sleep Campaign reduced SIDS deaths in the United States by about two-thirds to less than 1 per 1000 [9]. Infants should be placed to sleep on their backs, on a firm sleeping surface that is free from soft objects and loose bedding. The AAP Task Force on Sudden Infant Death Syndrome recommends that infant should have its own crib or bassinet in their parents’ room for the first year of life, as bed-sharing is a particularly high risk factor for SIDS and accidental asphyxiation [6]. Breastfeeding, use of a pacifier during sleep, and avoidance of exposure to second-hand smoke are all associated with decreased rates of SIDS. Infants who receive routine vaccinations as recommended and those born to mothers who received routine prenatal care also appear to have lower rates of SIDS. Additionally, the Task Force recommends that safe sleep practices be modeled by health care providers in the hospital and newborn nursery, at childcare centers, and by the media and advertising industry.
So, what to do with our little patient? You hook her up to a monitor in the ED and observe her for a couple of hours. Her exam and behavior remain normal. Twice the alarm goes off because the baby kicked (it was on her toe) and you use that as an opportunity to demonstrate that monitors aren’t perfect and false alarms can happen. You reassure the parents that their healthy, well-appearing child needs no further testing and educate them on the steps they can take to minimize their little one’s risk of SIDS.
Walking back down the hall with the resident you share the story of the last time you prescribed a monitor for a discharged premature infant in 1983. A week after sending the baby home you got a phone call from the local pawn shop asking if you were missing a monitor.
REFERENCES
- Southall DP et al. Identification of infants destined to die unexpectedly during infancy: evaluation of predictive importance of prolonged apnoea and disorders of cardiac rhythm. BMJ 1983;286: 1092-6.
- Ramanathan R et al. Cardiorespiratory events recorded on home monitors. Comparison of healthy infants with those at increased risk for SIDS. JAMA 2001;285:2199-207.
- Ward SL et al. Sudden infant death syndrome in infants evaluated by apnea programs in California. Pediatrics 1986;77:451-5.
- Malloy MH and Graubard B. Access or home apnea monitoring and its impact on rehospitalization among very low birth weight infants. Archives of Pediatric and Adolescent Medicine 1995;149:326-32.
- Committee on fetus and newborn. Apnea, sudden infant death, and home monitoring. Pediatrics 2003;111:914-7
- Moon RY et al. SIDS and other sleep-related infant deaths: updated 2016 recommendations for a safe sleeping environment. Pediatrics 2016;138:e20162938.
- King, D. Marketing wearable home baby monitors: real peace of mind? BMJ 2014;349:g6639.
- Bonafide, CP. The emerging market of smartphone-integrated infant physiologic monitors. JAMA 2017;317:353-4.