Undetected apnea and bradycardia in infants.

Despite routine monitoring, a number of prolonged apneic and bradycardic episodes were undetected in a group of infants in the neonatal intensive care unit (NICU). Sixty-one infants were evaluated by 12-hour pneumocardiograms at a post-conceptional age of 35 +/- 3 (SD) weeks. Nursing documentation failed to detect 11 infants with prolonged apnea and bradycardia. Three of these infants were not detected in spite of increased awareness following in-service education. Such a lack of documentation may lead to improper medical management of infants at risk for pathologic apnea and suggests the need for more accurate documentation at the time of discharge.