Apparent Life- Threatening Events (ALTE) in Infants Ashna Khurana, MD Santa Clara Valley Medical Center
Apparent Life-Threatening Events (ALTE) in Infants
Ashna Khurana, MDSanta Clara Valley Medical Center
Goals and Objectives
Review the Differential Diagnosis for ALTE Discuss the most common Etiologies of ALTE Discuss the yield of Diagnostic Testing in
infants who have had an ALTE Identify infants with ALTE that need to be
Hospitalized.
Case Study
3 week old FT female infant presents to the SCVMC ED after experiencing an episode at home where mother found the infant:
Gagging, one hour after feeding Turned limp Unresponsive for about 45 seconds Cried spontaneously
Mother thinks the infant stopped breathing at the time and thought her baby was going to die.
Case Study (cont'd)
In the ED:
Stable vitals Well appearing Normal physical exam
ED physician pages the pediatric resident for consult and wants to know what to do with the infant.
Definition of ALTENIH Consensus Development Conference on Infantile Apnea and Home
Monitoring 1986
An episode that is frightening to the observer and is characterized by some combination:
Apnea Color change Marked changes in muscle tone Choking Gagging
Definition of ALTE (cont'd)
In some instances, the caregiver has feared that the infant was going to die.
Previous misleading terms such as “near-miss SIDS” or “aborted crib deaths”
Not a diagnosis
Incidence of ALTE
True frequency and prevalence are unknown. Estimated to be 0.05 to 1% in population-
based studies. Other studies have shown an estimate of up to
6% of all infants or 0.6 to 9.4 in 1000 of live-born infants.
Account for 0.6% to 0.8% of all emergency department visits for children under 1 year of age.
ALTE vs. SIDSNo clear association or link
ALTE < 2 months of age No maternal age
difference Usually occurs between
8am and 8pm No change in incidence
with Back to Sleep campaign
SIDS Peak age 2-4 months Mothers more likely to
be under age 20 years Usually occurs between
midnight and 6am Decreased incidence
with Back to Sleep campaign
Low-birth weight and SGA
ALTE
< 2 months of age
No maternal age difference
Usually occurs between 8am and 8pm
No change in incidence with Back to Sleep campaign
Esani et al. Journal of Pediatrics March 2008
Why is an infant with an ALTE episode so
worrisome to the medical provider?
Differential Diagnosis GI
Gastroesophageal reflux Intussusception, Volvulus, Swallowing
incoordination, Incarcerated hernia Neurologic
Seizures, breath holding spells, Vasovagal syncope, CNS hemorrhage, hydrocephalus, Neuromuscular disorders
ID
RSV/bronchiolitis, Pertussis, UTI, Sepsis, Meningitis, Encephalitis, Pneumonia
Differential Diagnosis (cont’d)
Respiratory Upper airway obstruction, foreign body aspiration,
Immaturity or prematurity, Central hypoventilation syndrome, Vocal cord dysfunction, Laryngotracheomalacia, vascular ring
Cardiac Disease Arrhythmia (long QT syndrome, WPW), congenital
heart disease, cardiomyopathy, myocarditis
Metabolic disorders IEM, Hypoglycemia, Hypocalcemia, Hypomagnesemia
Differential Diagnosis (cont’d) Child Abuse
Accidental or intentional poisoning, Non-accidental suffocation, Physical injury, Head injury, Factious illness (MBP)
Other Developmental delay, Feeding difficulties, Medications,
Hypothermia, Anemia, Food Allergy, Anaphylaxis
Normal Behaviors of Infants Irregular breathing of REM sleep, periodic breathing,
respiratory pauses, transient choke, gag, cough during feeding
Idiopathic/Unknown etiology
Most common discharge diagnosis for ALTE: Idiopathic/Unknown (50% of all ALTE cases) Gastroesophageal Reflux Seizure Lower respiratory tract infection
Evaluation
HISTORY is the most important diagnostic tool Detailed description of the event including:
position of infant at the time events leading up to the episode interventions taken prior to presentation was infant awake or asleep
Infant's usual behavior with regards to sleep and feeding habits
Pregnancy and Birth History Developmental History
History (cont'd)
Family history:
siblings with early deaths, rare conditions, or SIDS
Social history:
smokers, substance abuse, medications in the home
Administration of medications prior to event, including OTC meds and homeopathic medications
Evaluation (cont'd)
Physical Examination is the second most important diagnostic tool
Obtain Vital Signs, including Pulse Oximetry Plot out height, weight, and head
circumference Complete head to toe exam with particular
attention to the respiratory, cardiac and neurologic exam
Consider fundoscopic exam
ALTE and GER Most common diagnosis for an ALTE episode Direct cause of the respiratory event is likely
laryngospasm (resulting response is apnea, bradycardia, swallowing and/or hypertension).
More likely due to reflux when: Gross emesis occurs at time of ALTE Episodes occur when infant is awake and supine The ALTE is characterized by obstructive apnea
Reflux is pathologic when the infant has esophagitis, bleeding, FTT, or pulmonary aspiration.
Mousa et al. Testing the association between GER and apnea in infants. Journal of Pediatric Gastroenterology and Nutrition 2005; 41: 169-177
ALTE and SEIZURES Second most common cause of ALTE
Studies have determined seizures to be etiology of ALTE in up to 15-25% of all diagnosable cases.
Of those that developed chronic epilepsy, 71% returned within 1 month with second ALTE.
Significant predictors of adverse neurologic outcomes are family history of seizures and male gender
Neurological evaluation with first time ALTE is low yield.
Bonkowsky et al. Death, Child Abuse, and Adverse Neurological Outcome of Infants After an Apparent Life-Threatening Event. Pediatrics 2008; 122: 125-131.
ALTE and Infectious Diseases Third most common cause of ALTE Pertussis RSV/Bronchiolitis -
cause for apnea in High Risk Infants: full term but less than 1 month of age preterm but less than 48 weeks PCA infants with h/o apnea prior to evaluation.
any infant with bronchiolitiis may develop apnea as result of respiratory distress, respiratory muscle fatigue or hypoxia.
Shah S. Sharieff G, An update on the approach to apparent life-threatening events. Current Opinion in Pediatrics 2007; 19: 288-294.
ALTE and Child Abuse Few studies done to determine incidence of infants
with ALTE that were found to be victims of abuse Some studies have detected up to 2-3% Historical clues
Occurs only in presence of single caretaker Presents with apnea or cyanosis Infant required CPR Even though recurrent, a myriad of diagnostic
testing is all negative Siblings may have history of SIDS
The physical exam is normal in up to 85% of infants after an ALTE.
NOW WHAT?
Brand et al. Pediatrics 2005
Looked at yield of diagnostic testing in infants who have had an ALTE
243 infants who were admitted to large Children's Hospital outside of New York over 32 month period
Of 3776 tests ordered, 669 (18%) were positive but only 224 (6%) contributed to the diagnosis
Brand et al. Yield of Diagnostic Testing in Infants Who Have Had an Apparent Life-Threatening Event. Pediatrics 2005; 115: 885-893.
Brand et al. Pediatrics 2005 (cont'd)
Useful tests in patients who had a CONTRIBUTORY History and Physical:
CBC, Chemistry Panel, UA and cultures
CSF analysis and culture Metabolic screening Screening for respiratory
pathogens Screening for GER CXR
Brain neuroimaging Skeletal survey EEG Echo pneumogram
Brand et al. Pediatrics 2005 (cont'd)
Useful tests in patients who had a NON-CONTRIBUTORY History and Physical:
screening for GER CXR UA and culture Pneumogram brain neuroimaging WBC
Concluded that broad evaluations for systemic infections,metabolic diseases, and blood chemistry abnormalities are not productive in the group of infants who have a non-contributory history and physical
Diagnostic Studies (cont'd)
Highest diagnostic yield: Rapid glucose determination CBC Urinanalysis and culture RSV and Pertussis test EKG CXR
Consider – dilated fundoscopic exam, brain neuroimaging, urine toxicology screen, lactate, EEG, testing for pathologic reflux
Who should be admitted?
Admission Criteria
Most studies recommend ALL infants with ALTE should be admitted for observation and further evaluation over 24-72 hour period, regardless of the cause of the ALTE and the appearance of the infant at presentation.
Few studies have specifically evaluated admission vs. discharge home criteria
Admission Criteria (cont’d)
• No consensus guidelines for admission
• Most hospitalizations are done on an individual patient need basis
• Further benefits to hospitalization:
• Alleviating parental fears and anxiety
• CPR training
• Possibility of health care provider to witness an episode
Return back to Case Study
• 3 week FT female infant presents to the SCVMC ED after experiencing an episode at home where mother found the infant:
– Gagging one hour after feeding
– Turned limp
– Unresponsive for about 45 seconds
– Cried spontaneously
• In the ED:
– Stable vitals
– Well appearing
– Normal physical exam
Case Study (cont'd)
What do you tell the ED physician?
Case Study (cont'd)
• Given that the infant has a history significant for ALTE episode consider:
– CBC, CRP, Chem 10, UA/U.cx, EKG, CXR
• But remember – “Monitoring only” may be appropriate if event was promptly reversible; short-lived, self-limited; baby is stable on initial monitor, and all observed feeds are reassuring
• Given infant's age, as well as mother's fear that her baby was going to die, would admit for a minimum of 24 hour period of observation on CR monitor.
Take Home Points
• Most common etiologies include GER, Seizures, and Lower Respiratory Tract Infection
• Always consider Child Abuse
• History is the most important diagnostic tool
• Most infants should be admitted for period of observation at minimum, but there may be a small subset that can be discharged.