Transcript Black and White - Stanford University

Apparent Life-Threatening
Events (ALTE) in Infants
Ashna Khurana, MD
Santa Clara Valley Medical Center
Goals and Objectives

Review the Differential Diagnosis for ALTE

Discuss the most common Etiologies of ALTE

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Discuss the yield of Diagnostic Testing in
infants who have had an ALTE
Identify infants with ALTE that need to be
Hospitalized.
Case Study
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
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 ALTE
NIH 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)
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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

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True frequency and prevalence are unknown.
Estimated to be 0.05 to 1% in populationbased studies.
Other studies have shown an estimate of up to
6% of all infants or 0.6 to 9.4 in 1000 of liveborn infants.
Account for 0.6% to 0.8% of all emergency
department visits for children under 1 year of
age.
ALTE vs. SIDS
No clear association or link
ALTE

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< 2 months of age
No maternal age
difference
Usually occurs between
8am and 8pm
No change in incidence
with Back to Sleep
campaign
SIDS
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

Esani et al. Journal of Pediatrics March 2008
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
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

RSV/bronchiolitis, Pertussis, UTI, Sepsis,
Meningitis, Encephalitis, Pneumonia
ID
Differential Diagnosis (cont’d)

Respiratory


Cardiac Disease


Upper airway obstruction, foreign body aspiration,
Immaturity or prematurity, Central hypoventilation
syndrome, Vocal cord dysfunction,
Laryngotracheomalacia, vascular ring
Arrhythmia (long QT syndrome, WPW), congenital
heart disease, cardiomyopathy, myocarditis
Metabolic disorders

IEM, Hypoglycemia, Hypocalcemia,
Hypomagnesemia
Differential Diagnosis (cont’d)

Child Abuse

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Other
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Developmental delay, Feeding difficulties,
Medications, Hypothermia, Anemia, Food Allergy,
Anaphylaxis
Normal Behaviors of Infants


Accidental or intentional poisoning, Non-accidental
suffocation, Physical injury, Head injury, Factious
illness (MBP)
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
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HISTORY is the most important diagnostic tool
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Detailed description of the event including:
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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
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Pregnancy and Birth History
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Developmental History
History (cont'd)
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Family history:

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Social history:

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siblings with early deaths, rare conditions, or
SIDS
smokers, substance abuse, medications in
the home
Administration of medications prior to event,
including OTC meds and homeopathic medications
Evaluation (cont'd)
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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
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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).
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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
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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 LifeThreatening Event. Pediatrics 2008; 122: 125-131.
ALTE and Infectious Diseases
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Third most common cause of ALTE
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Pertussis
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RSV/Bronchiolitis 
cause for apnea in High Risk Infants:
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
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
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Few studies done to determine incidence of infants
with ALTE that were found to be victims of abuse
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Some studies have detected up to 2-3%
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Historical clues
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Occurs only in presence of single caretaker
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Presents with apnea or cyanosis
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Infant required CPR
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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
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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 LifeThreatening 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
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CSF analysis and culture
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Metabolic screening
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Screening for respiratory
pathogens
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Screening for GER
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CXR

Brain neuroimaging
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Skeletal survey
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EEG
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Echo
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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 noncontributory history and physical
Diagnostic Studies (cont'd)
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Highest diagnostic yield:
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Rapid glucose determination
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CBC
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Urinanalysis and culture
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RSV and Pertussis test
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EKG

CXR
Consider – dilated fundoscopic exam, brain
neuroimaging, urine toxicology screen, lactate,
EEG, testing for pathologic reflux
Who should be admitted?
Admission Criteria
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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.