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.