Dominic Lucia M.D
Assistant Professor of Emergency Medicine
Texas A&M Health Science Center
Medical Director Emergency Medicine
McClane Children’s Hospital
Scott and White
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Define ALTE
ALTE Relationship to SIDS
What could this be?
Work-up
Disposition
Take home points
Discussion
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Nurse “skeptically” hands you a chart.
CC: 3 month old coughing spell
VS: p115 rr30 O2sat 98% ra t 37.1
Mother states that 30 minutes ago she had
put child down after his evening feeding; she
heard a noise (coughing?) and looked at baby
and he “didn’t look right”….
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An event that is frightening to the observer
accompanied by a combination of color
change(cyanosis, pallor, or plethora), apnea,
a change in muscle tone (limp or stiff),
choking or gagging
…(In some cases the observer fears the infant
has died or would have died without
significant intervention…)
Many times child is well appearing at time of
presentation
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Symptom…not a diagnosis.
Think of it as a warning of sorts…
Adult equivalent: TIA
Ambiguity…
Concern for future event
What will they do in the hospital
with this?
But with infants….we are more careful!
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Generally talking about under 1 year of age
Peak incidence occurs between 1w-2m
More common in preemies
Male 2:1 Females
Am Fam Physician. 2005 Jun 15;71(12):2301-8.
Evaluation and management of apparent lifethreatening events in children. Hall KL, Zalman B.
Rocker JA, Israel J: emedicine, Pediatrics,
apnea
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The parent is the historian.
Variety of crazy stories out there.
It’s time to get SPECIFIC
History (and Physical) is VERY IMPORTANT
Be firm in explaining how important the
details of the situation are to your diagnostic
and treatment decisions.
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~5% of children who die of SIDs have had an
ALTE
Causal relationship has not been established
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ALTE- heterogenous group of problems
SIDs and ALTE event times vary
Interventions have not decreased incidence of ALTE
Risk factors vary
The sudden and unexpected death of an
apparently well, or almost well infant (child< 1
year of age) in which death remains unexplained
after the performance of an adequate
postmortem investigation including:
1) an autopsy, 2) investigation of the scene and
circumstances of the death, and 3) exploration of
the medical history of the infant and the family.
Pediatric Pathology 1991
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Season: winter
Socioeconomic status: low
Ethnicity: cultural differences
Race: higher in African Americans and Native
Americans
Male predominance
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Infant factors and increased risk
◦ low birth weight
◦ short gestational age
◦ IUGR
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Maternal factors and increased risk
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tobacco use pre and post delivery
opiate and cocaine use
young age
high parity
multiple gestation
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Other factors that increase risk
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thermal stress
co-sleeping combined with other factors
soft surfaces
prone position
history of SIDS in prior sibling
Triple Risk Model for SIDS
Vulnerable infant
Despair.com
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Duration
Color changes
Respiratory effort
Muscle tone
Intervention required
Activity of infant prior to event
Relationship to feeding
Presence of choking, gasping, emesis
Rhythmic movements, eye movements
Nasal congestion
Fever
Post event appearance and time to norm
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Gastroenterologic (33%)
Idiopathic Apnea of Infancy (23%)
Neurologic (15%)
Respiratory (11%)
Otololaryngologic (4%)
Cardiovascular (1%)
Metabolic/Endocrine
Infectious
Other
DeWolfe CC:Apparent Life Threatening Event:
a review Pediatr Clin North Am.
2005 Aug;52(4):1127-46, ix.
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Gastroesophageal reflux disease
Gastroenteritis
Esophageal dysfunction
Surgical abdomen
Dysphagias
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Large children's hospital of infants aged 1
year old and younger hospitalized from
January 1, 2004, to March 1, 2007…Three
hundred thirteen infants met inclusion. Mean
age was 2.1 months; mean length of stay was
2.5 days. A discharge diagnosis of GERD was
most common (n = 154, 49%)…
It is important to recognize that
gastroesophageal impairments such as GERD
or CGV could be responsible for many
incidences of ALTE in infancy. ..including
gastroesophageal evaluations in all infants
with ALTE…
Apparent life-threatening event admissions and
gastroesophageal reflux disease: the value of
hospitalization.
Pediatr Emerg Care. 2012 Jan;28(1):17-21.
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Seizure
Central apnea/hypoventilation
Meningitis/encephalitis
Hydrocephalus
Congenital brain malformation
Increased ICP: hydrocephalus, tumor
Neuromuscular disorders
Vasovagal reaction
Head trauma
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Abstract
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BACKGROUND:
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Apparent life-threatening events (ALTE) and/or prolonged apnoea have been welldocumented during respiratory syncytial virus (RSV) infection in infants less than 2 months of
age but fundamental mechanisms remain unclear. The possibility of a central origin for the
development of severe cardiac and respiratory events encouraged us, to explore the
autonomic nervous system (ANS) profile of infected infants, since ANS activity may contribute
to the constellation of symptoms observed during severe forms of RSV bronchiolitis.
METHODS:
Eight infants (2 preterm and 6 full-term) less than 2 months of age and presenting with
severe and apnoeic forms of RSV infection were evaluated using non-invasive
electrophysiological monitoring obtained simultaneously for approximately 2 consecutive
hours, including a quiet sleep period. Eight control subjects, paired for gestational and
postnatal age, were also evaluated. ANS status was monitored using electrocardiogram
recordings and quantified through a frequency-domain analysis of heart rate variability
(HRV). This included sympathetic (VLF and LF) and parasympathetic (HF) indices as well as a
measure of baroreflex sensitivity (BRS) obtained using non-invasive continuous arterial
pressure.
RESULTS:
Regardless of gestational and postnatal age, heart rate variability components (Ptot, VLF, LF,
and HF) and baroreflex components (alpha LF, alpha HF and sBR) were found to be
significantly lower in the RSV-infected group than in the control group (p<0.05).
CONCLUSION:
RSV infection in neonates is associated with profound central autonomic dysfunction. The
potentially fatal consequence stresses the importance of maintaining prolonged
cardiopulmonary monitoring.
Autonomic dysfunction with early respiratory syncytial virus-related
infection.
Stock C, Teyssier G, Pichot V, Goffaux P, Barthelemy JC, Patural H.
Autonomic Neuroscience 2010 Aug
25;156(1-2):90-5. Epub 2010 Apr 18.
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Respiratory syncytial virus
Pertussis
Congenital malformation
Laryngospasm (choking/GERD)
Aspiration
Respiratory tract infection (obligate nasal
breathers)
Reactive airway disease
Foreign body
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Laryngomalacia
Choanal atresia
Laryngeal cleft
Tracheoesophageal fistula
Subglottic and/or laryngeal stenosis
Obstructive sleep apnea
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Anemia
Congenital heart disease
Cardiomyopathy
Vascular rings and slings
Cardiac arrhythmias/prolonged QT syndrome;
WPW
Myocarditis
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Hypoglycemia
Electrolyte disturbance
Inborn error of metabolism
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Sepsis
Urinary tract infection
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Emerg Infect Dis. 2009 Sep;15(9):1506-8.
Role of rhinovirus C in apparently life-threatening events
in infants, Spain.
Calvo C, Garcia ML, Pozo F, Reyes N, Pérez-Breña P, Casas
I.
Source
Hospital Severo Ochoa, Leganes, Madrid, Spain.
ccalvorey@ono.com
Abstract
To assess whether infants hospitalized after an apparently
life-threatening event had an associated respiratory virus
infection, we analyzed nasopharyngeal aspirates from 16
patients. Nine of 11 infants with positive virus results were
infected by rhinoviruses. We detected the new genogroup
of rhinovirus C in 6 aspirates.
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Child maltreatment syndrome
Shaken baby syndrome
Breath-holding spell
Choking
Drug or toxin reaction
Dehydration
Unintentional smothering
Periodic breathing
Munchhausen-by-proxy syndrome
Pediatrics September 2002
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Children < 24mo with an ALTE btwn 3/97-2/99
opthalmologic exam as well as, lab tests
Results:
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128 with ALTE
mean age 2.1 mo, 44.5% boys; 67.2% caucasian
26/128: 20.3% hx of ALTE
4/117: 3.4% fam hx of ALTE
15/117: 12.8% fam hx of SIDs
 dilated fundoscopic exam done in 73/128: 1 (1.4%) ret
hemorrhage
 4 children including above underwent CPS investigation
 3/128 (2.3%) were found to have been abused
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Periodic Breathing
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Breath holding spells (older)
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Standard reflux
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*Be sure your history physical and
subsequent documentation firmly support
your diagnosis
Never trust a neonate…
 “Well appearing”
 Social Smile…?
 Feeding issues…
 Significant episode
Under 6 weeks, consider
Full sepsis workup
(even if afebrile…)
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Monitoring while in the department
Being very specific to caretaker that if the
event or similar symptoms occur while in the
ED to immediately notify the staff.
The child should be visually re-checked in the
department by a physician at least every 30
minutes (document)
BVM and other resuscitative equipment
should be readily available.
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Younger…more aggressive
Punky…listless…full court press
Let the history and physical exam guide your
work-up.
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Blood glucose*
CBC with diff
CMP
Mg, Phos, Ca
Blood Culture
UA
Urine Culture
UDS
VBG
RSV
Respiratory Virus Panel
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Chest X-Ray
EKG
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Abuse? CT, skeletal survey, UDS
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All children who have suffered an ALTE
should be transported for evaluation by a
physician (EMS)
Admission for observation at the least
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Anyone with cyanosis
Apnea
Loss of tone
Required CPR
Home only if clearly NOT an ALTE
Despair.com
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Benefit
Pushback
What can an inpatient stay offer?
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Prolonged monitoring
Culture monitoring
Sleep studies
pH probe testing
EEG
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Parental calming…
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More scholarly reading….
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OBJECTIVE:
To compare the risk factors of 153 cases of apparent life-threatening
event (ALTE) enrolled in the multicenter Collaborative Home Infant
Monitoring Evaluation (CHIME) from 1994 to 1998 with the published risk
factors for sudden infant death syndrome (SIDS).
STUDY DESIGN:
Trained CHIME interviewers gathered histories of infants with ALTE who
met the criteria. The following risk factors were analyzed: male
predominance, gestational age, low birth weight, very low birth weight,
incidence of small for gestational age (SGA), age at the event, multiparity,
maternal age, and smoking. Population-based SIDS studies with >100
deaths, focusing on 1 or more pertinent risk factors and carried out
during the decade in which CHIME data were collected, were chosen for
comparison.
RESULTS:
One of the 153 infants with ALTE in this study died during follow-up
(0.6%). CHIME ALTE differed significantly from SIDS in 4 respects: fewer
infants with low birth weight and SGA at birth, fewer teenage pregnancies,
and a younger infant age at ALTE.
CONCLUSIONS:
Although a number of risk factors for ALTE are similar to those for SIDS,
the differences warrant a separate focus on ALTE beyond that on SIDS
Apparent Life-threatening events and SIDS:
comparison of risk factors
Journal of Pediatrics
. 2008 Mar;152(3):365-70. Epub 2007 Nov 5.
Apparent life-threatening events and sudden infant death
syndrome: comparison of risk factors.
Esani N, Hodgman JE, Ehsani N, Hoppenbrouwers T.
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PURPOSE OF REVIEW:
Apparent life-threatening events are an ongoing diagnostic dilemma for
clinicians. Since most apparent life-threatening event episodes occur in infants
under 6 months of age, they can generate considerable anxiety in parents and
providers. This review will discuss issues to consider in the evaluation of infants
after an apparent life-threatening event. To ensure proper management, a
systematic approach should be taken to attempt to determine the cause of the
event.
RECENT FINDINGS:
More recent literature suggests that infants with apparent life-threatening events
frequently present without signs or symptoms of illness. Obtaining a careful
history and physical examination is essential in determining the cause of the
event. In this article, we will review the most current literature and discuss the
American Academy of Pediatrics new recommendations on sudden infant death
syndrome prevention.
SUMMARY:
After a careful review of the literature, prone sleeping is one of the biggest risk
factors for sudden infant death syndrome. The association between apparent
life-threatening events and sudden infant death syndrome remains to be
explored further, but current evidence suggests minimal risk after an apparent
life-threatening event episode. This article will help clinicians prepare for this
difficult challenge by providing up-to-date information and identifying problems
to be addressed in future research.
An update on the approach to apparent life-threatening
events.
Curr Opin Pediatr. 2007 Jun;19(3):288-94.
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AIMS:
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To determine the most likely diagnoses when infants first present with an apparent life
threatening event (ALTE).
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METHODS:
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Medline (1966-2002), Embase (1980-2002), and Cinahl (1982-2002) were searched. Primary
authors and content experts were contacted to identify further studies. Bibliographies from
studies, reviews, and textbooks were searched. Foreign language studies were translated.
Articles were included if the ALTE was clearly defined and if the evaluation recorded was from
the initial contact. Case reports and studies focusing on single conditions or non-clinical data
were excluded.
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RESULTS:
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From an initial 2912 papers, eight studies involving 643 infants (aged 0-13 months) were
included. All studies were non-randomised and methodological quality varied. All diagnoses
were made after evaluation in hospital but investigation protocols varied widely. There were
728 diagnoses assigned overall. Some infants had multiple diagnoses. The most common
diagnoses were gastro-oesophageal reflux (n = 227), seizure (n = 83), lower respiratory tract
infection (n = 58), and "unknown" (n = 169). Five deaths were noted in total.
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CONCLUSIONS:
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There is a wide range of diagnoses reported after evaluation of an ALTE. Differing
management protocols contributed to variations in the frequency of the diagnoses. The
development and validation of an evidence based management plan may contribute to the
care of this common condition.
Causes of apparent life threatening events in infants: a
systematic review
Arch Dis Child. 2004 Nov;89(11):1043-8.
Causes of apparent life threatening events
in infants: a systematic review.
McGovern MC, Smith MB
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Know definition of ALTE
H&P very important
Be careful on the non-ALTES documentation
Family history of SIDS?
Work-up should be guided by H&P
When in doubt…admission.
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Natalie Lane MD
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Marisa, Derian, Malaya, and Lillian