APPARENT LIFE THREATENING EVENTS GUIDELINE
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Background
Etiology
Assessment and Workup
Risk Stratification
Low Risk Infants
High Risk Infants
References
BACKGROUND
An apparent life threatening event (ALTE) is not a specific diagnosis but a description of a sudden
change in infant behaviour and/or condition that is perceived by the caregiver to be life threatening.
The most prominent features are combinations of apnoea, colour change, change in muscle tone and
choking or gagging.1
The term ALTE has replaced misleading terms such as near-miss SIDS.
In some cases the child is perceived to have died and CPR is attempted by the caregiver, during
which time the infant recovers. However spontaneous recovery from the event is more common.
ALTE infants represent a heterogenous group of patients with diverse pathophysiology. As such
evaluation and management should be individualized. A substantial portion of ALTEs are medically
insignificant. The incidence is 0.05-1% of the population.
ALTE and SIDS
SIDS is more correctly termed sudden unexplained death in infancy (SUDI). There is no relationship
between ALTEs and SIDS, particularly the effective interventions to reduce SIDS (e.g. supine
sleeping) have not affected the incidence of ALTE.
ETIOLOGY
The majority of events are explained by:
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Gastroesoophageal reflux is evoked commonly as the cause (up to 30%). However there is
little evidence to support the notion that the reflux with or without associated laryngospasm is
pathologic in most cases or that treating the reflux prevents further events. 2 3 4 5 Rarely GERD
is pathologic in that it causes true apnoea, and the only truly effective therapy is anti-GERD
surgery.6
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Laryngospasm that may occur during normal feeding and may reflect some degree of
maturational oropharyngeal incoordination. Again, there is no firm scientific evidence that
ALTE events are actually due to this phenomenon.
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CNS disorder, most commonly seizures (15-20%).
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Infection, most commonly RSV or similar diseases, but occasionally serious infections such as
viral or bacterial meningitis.
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Apnea of prematurity.
Custodian (developed by): Simon Parsons, Pediatric Intensivist
Authorized by (departmental areas): Section of Critical Care, ACH
Effective Date: June 2013
Review Date: June 2015
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APPARENT LIFE THREATENING EVENTS GUIDELINE
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Idiopathic.
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Accidental or intentional poisoning (8%).
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Non-accidental injury (NAI) such as intentional suffocation (Munchausen syndrome by proxy)
or abusive head injury (2.5%). NAI is particularly associated with recurrent severe ALTE
events requiring CPR and repeated ER presentation.
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Cardiac disease, upper airway obstruction, or metabolic diseases.
ASSESSMENT & WORKUP
A detailed and careful history of the event is very important.
Examination of infant with a focus on evidence of infection, airway obstruction and facial
dysmorphism, signs of non-accidental injury, respiratory status and neurological status.
Investigations should be tailored to the individual clinical scenario and thus suggested working
diagnosis.
Simple investigations such as CBC, electrolytes, glucose, capillary blood gas, urinalysis, ECG with
calculated QTc, NPA are appropriate for many cases.
CXR, LP for CSF, blood cultures, urine culture, urine drug screening, metabolic screening,
neuroimaging, EEG, Upper GI series, pH probe, skeletal survey, cardiac ECHO, pH/impedence with
simultaneous polysomnography may be indicated in particular cases.
A lumbar puncture is not required in a well and afebrile infant after a single ALTE.
RISK STRATIFICATION
Only 7.4% of infants in a series of 625 infants with an ALTE history have additional events that are
considered to be clinically significant during hospital admission7, although parents report further
events more frequently. In this study risk factors for recurrence were PCA < 43 weeks, viral
respiratory tract infection (e.g. bronchiolitis) and history of prematurity.
In a recent study of 313 ALTE infants of whom 154 had a discharge diagnosis of GERD, recurrent
events were reported in 9% of the GERD diagnoses, although at least 1/3 of these recurrent events
lead to a new diagnosis.8 The average length of admission in this study was 2.5 days.
In a longitudinal study of 1079 infants monitored at home after idiopathic ALTE only preterm infants
were at risk of extreme alarm events and these all disappeared after 43 weeks PCA.9
The overall risk of subsequent death is < 1%. The risk of death post an ALTE has been reported
ranging between 10-30% if CPR is truly required at the time of the initial event, but in these cases the
ALTE is not idiopathic.
Custodian (developed by): Simon Parsons, Pediatric Intensivist
Authorized by (departmental areas): Section of Critical Care, ACH
Effective Date: June 2013
Review Date: June 2015
Page 2 of 5
APPARENT LIFE THREATENING EVENTS GUIDELINE
LOW RISK INFANTS
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Single episode of colour change, choking, gasping, gagging, or change in body tone without
need to perform CPR, or indication for CPR or ‘rescue breaths’ is poor (i.e. the child received
CPR but did not truly need it).
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Well on arrival to ER.
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No clinical findings.
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No serious underlying disease process.
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Normal basic investigations.
THESE INFANTS DO NOT REQUIRE PICU CONSULTATION OR ADMISSION
Routine monitoring of these infants on inpatient units should include:
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In addition to regular vital signs, centrally displayed continuous cardio-respiratory
monitoring (CRM - monitoring of oxygen saturation, heart rate, and impedance
pneumography giving respiratory rate) should occur for a minimum of 24 hours.
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Continuous monitoring must be continued for an additional 12 hours after any episode of
apnoea, bradycardia, or desaturation.
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Patient:nurse ratio assignment of 3:1 is recommended (lower patient:nurse ratios can be
ordered as deemed appropriate on a case by case basis). The patient:nurse ratio may
increase for short time periods as a result of staff coverage, but patient care will continue to
emphasize response to the patient/monitor in a timely fashion.
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Placement of patients in rooms across from or close to the nursing station during the
24-hour continuous monitoring period is recommended to ensure visual and audible contact
with the patient and their monitor. The door of the patient room should remain open whenever
possible during the 24-hour continuous monitoring period.
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Equipment:
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An auto-inflating bag, appropriately sized mask, and suction equipment are easily
accessible in every patient room. All healthcare providers should review the
equipment and its use regularly.
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A physician or nurse may order or choose to have the equipment set up at the
bedside.
“Educational STEP consult” for all infants:
Custodian (developed by): Simon Parsons, Pediatric Intensivist
Authorized by (departmental areas): Section of Critical Care, ACH
Effective Date: June 2013
Review Date: June 2015
Page 3 of 5
APPARENT LIFE THREATENING EVENTS GUIDELINE
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Order: MD to nurse clinical communication to be entered by the most responsible
physician (MRP) or delegate in SCM as “Educational STEP Consult” upon patient
arrival on the unit. The “Educational STEP Consult” can also be requested by nursing
staff without an MD to nurse clinical communication order.
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The receiving Unit (bedside/charge RN or unit clerk) will need to text page the STEP
Team to initiate the “educational STEP Consult” (i.e. education consult pt---- on Unit--).
NB: An SCM MD to nurse clinical communication order will NOT result in notification of
the STEP Team of the consult.
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The consult will offer “on-the-spot” staff education about apnoea monitoring and
management, as well as airway equipment setup. The MRP will be text paged by the
charge nurse or delegate of the receiving unit with "STEP education call on pt. ---", to
let them know the educational consult was initiated.
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Once the consult is complete, unless there are clinical concerns (in which case, the
STEP team will remain involved and liaise with the MRP), the STEP team will sign off.
For any patient concerns/deterioration, standard processes including notification of
MRP/delegate (Resident or Fellow), activation of STEP, and/or calling a Code Blue should be
followed.
HIGH RISK INFANTS
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Pre-term (< 37 weeks gestation) infants who are still < 44 weeks CGA.
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> 1 ‘real’ event (within 24 hrs), with at least one witnessed in ER or by health care provider.
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Severe event requiring CPR.
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Unwell at presentation e.g. signs of sepsis.
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Single seizure in neonate.
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History strongly suggestive of/or observed repeated or prolonged seizure(s) in older infants
and children.
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True apnoea duration > 15-20 sec, or hyopnoea, associated with bradycardia or oxygen
desaturation < 85%, requiring more than oxygen for recovery e.g. requiring stimulation or bag
and mask ventilation, witnessed in ER or by health care provider.
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Periodic breathing pattern with oxygen desaturations to < 85%, not responsive to oxygen
therapy, witnessed in ER or by health care provider.
THESE INFANTS REQUIRE PICU CONSULTATION AND ADMISSION
Custodian (developed by): Simon Parsons, Pediatric Intensivist
Authorized by (departmental areas): Section of Critical Care, ACH
Effective Date: June 2013
Review Date: June 2015
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APPARENT LIFE THREATENING EVENTS GUIDELINE
DURATION OF MONITORING
Infants should not be removed from CRM, even if ‘well’, until a 24 hr period event free has been
documented. If the final diagnosis is apnoea of prematurity, local policy indicates that 5 days of event
free monitoring is required before its discontinuation.
REFERENCES
1
Up To Date. Apparent Life Threatening Events. http://www.uptodate.com/contents/apparent-lifethreatening-event-in-infants?source=search_result&search=ALTE&selectedTitle=1%7E18
2
A Thickened Formula Does Not Reduce Apneas Related to Gastroesophageal Reflux in Preterm
Infants. Corvaglia L, Spizzichino M, Aceti A, Legnani E, Mariani E, Martini S, Battistini B, Faldella G.
Neonatology. 2012 Nov 20;103(2):98-102.
3
Gastroesophageal reflux disease in neonates and infants : when and how to treat. Czinn SJ,
Blanchard S. Paediatr Drugs. 2013 Feb;15(1):19-27.
4
Metoclopramide, H2 blockers, and proton pump inhibitors: pharmacotherapy for gastroesophageal
reflux in neonates. Malcolm WF, Cotten CM. Clin Perinatol. 2012 Mar;39(1):99-109.
5
Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North
American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the
European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). Vandenplas
Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, Sondheimer J, Staiano A, Thomson M,
Veereman-Wauters G, Wenzl TG, North American Society for Pediatric Gastroenterology Hepatology
and Nutrition, European Society for Pediatric Gastroenterology Hepatology and Nutrition. J Pediatr
Gastroenterol Nutr. 2009 Oct;49(4):498-547.
6
Assessment and treatment of gastroesophageal reflux in healthy infants with apneic episodes: a
retrospective analysis of 87 consecutive patients. Koivusalo AI, Pakarinen MP, Wikström A, Rintala
RJ. Clin Pediatr (Phila). 2011 Dec;50(12):1096-102.
7
Risk factors for extreme events in infants hospitalized for apparent life-threatening events.
Al-Kindy HA, Gélinas JF, Hatzakis G, Côté A.
J Pediatr. 2009 Mar;154(3):332-7
8
Apparent life-threatening event admissions and gastroesophageal reflux disease: the value of
hospitalization. Doshi A, Bernard-Stover L, Kuelbs C, Castillo E, Stucky E. Pediatr Emerg Care. 2012
Jan;28(1):17-21.
9
Cardiorespiratory events recorded on home monitors: Comparison of healthy infants with those at
increased risk for SIDS. Ramanathan R, Corwin MJ, Hunt CE, Lister G, Tinsley LR, Baird T, Silvestri
JM, Crowell DH, Hufford D, Martin RJ, Neuman MR, Weese-Mayer DE, Cupples LA, Peucker M,
Willinger M, Keens TG; Collaborative Home Infant Monitoring Evaluation (CHIME) Study Group.
JAMA. 2001 May 2;285(17):2199-207.
Custodian (developed by): Simon Parsons, Pediatric Intensivist
Authorized by (departmental areas): Section of Critical Care, ACH
Effective Date: June 2013
Review Date: June 2015
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