Pediatric Emergency Medicine Core Education Module2010

CMC Department of Emergency MedicineDivision of Pediatric Emergency Medicine

ObjectivesAt the end of this module you will be able to:

Define ALTE and Pathologic APNEADiscuss basic epidemiology of ALTE and list high risk

characteristicsDiscuss the most common etiologies of ALTEDiscuss an appropriate emergency department

evaluation of ALTE.

What is an ALTE?“An episode that is frightening to the observer and

that is characterized by some combination of apnea (central or obstructive), color change (usually cyanotic or pallid, but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking or gagging, and in some cases, the observer fears that the infant has died.”1

1. Infantile apnea and home monitoring. National Institutes of Health Consensus Statement. Sep 29-Oct 1 1986;6(6):1-10.

BackgroundALTE is NOT a Diagnosis

It is a description of symptomsIt is subjective and has heterogeneous etiologies

No association demonstrated with SIDS2 ALTE manifests 10 weeks earlier Back-to-Sleep campaign affected SIDS, but not ALTE

incidence

2. Kahn A. Recommended clinical evaluation of infants with an apparent life-threatening event. Consensus document of the European Society for the Study and Prevention of Infant Death, 2003. Eur J Pediatr. Feb 2004;163(2):108-115.

EpidemiologyDifficult to nail down due to heterogeneity

Since 1997 studies using the NIH definition show: Incidence from 0.2% to 6% of all infants5

45% classified as idiopathic6

5. Davies F, Gupta R. Apparent life threatening events in infants presenting to an emergency department. Emerg Med J. Jan 2002;19(1):11-16.6. Kiechl-Kohlendorfer U, Hof D, Peglow UP, Traweger-Ravanelli B, Kiechl S. Epidemiology of apparent life threatening events. Arch Dis Child. Mar 2005;90(3):297-300.

Morbidity/MortalityIs related to the specific etiology

But, even Idiopathic ALTE has associated M&M There have been documented long-term neuro sequelaeMortality between 0-6%

Important to attempt to stratify patients to help determine risk

a Data from Oren J, Kelly D, Shannon DC. Identification of a high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea. Pediatrics. Apr 1986;77(4):495-499

High Risk CharacteristicsApnea during sleep requiring resuscitation and a

prior similar episode a

Sibling who was the victim of SIDSa

Development of a seizure disorder during monitoringa

Premature infantsInfants less than 1 month of ageInfants who present with inconsistent or changing

histories concerning for abuse

The ProblemThe history is often incomplete, misleading, or

inaccurateParental reporting can over- or underestimate the

severity 3,4

The physical exam is often normal

The differential is VAST

3. Steinschneider A, Santos V. Parental reports of apnea and bradycardia: temporal characteristics and accuracy. Pediatrics. Dec 1991;88(6):1100-1105.4. Brooks JG. Apparent life-threatening events and apnea of infancy. Clin Perinatol. Dec 1992;19(4):809-838.

Broad Categories to ConsiderGastrointestinal: 30-50%Neurological: 15-30%Respiratory: 10-20%Cardiovascular: 1-5%Metabolic/Endo: 1-5%Abuse: 3-5%Idiopathic: ~50%

Some SpecificsHorses

GERD, Intussusception, VolvulusSeizures Infections (Bronchiolitis, Pertussis, Meningitis, pneumonia)Dehydration (electrolyte disturbances)Hypoglycemia

ZebrasCardiac arrhythmia, Prolonged QT, Myocarditis, tamponadeLaryngeal obstruction by arytenoid massesOndine’s Curse (congenital central hypoventilation syndrome) Inborn Errors of MetabolismBrain Tumors, Chiari Malformation

MonstersChild AbuseMunchausen by proxy

ED EvaluationWith such a vast DDx, Start with the Basics = ABCDEs

Address the most life-threatening etiologies first

Believe the parent Even if their reports don’t seem to match the exam

MOST Important evaluation tool is the History and Physical! Otherwise you are left with the whole DDX in Nelson’s Textbook to sort through.

Description of event• Timing (while awake or asleep)• Position (prone, supine)• Location (crib, car seat, co-sleeping)• Associated activity (feeding, coughing)• Breathing efforts (none, increased, weak)• Color• Movement and Tone• Duration

Interventions used to resolve event • None• Gentle stimulation• Vigorous stimulation• Mouth-to-mouth rescue breaths• CPR by trained person

Past Medical History• Prenatal history• Gestational age• Birth history (trauma, hypoxia, infection)• Developmental milestones• Prior hospitalizations• Prior ALTE

Family Medical History• Sudden infant death syndrome• Neonatal deaths• Infant deaths• Congenital problems• Seizure disorders• Arrhythmias

HPI• Antecedent illnesses• Fevers• Trouble feeding• Rashes• Lethargy or irritability• Recent medications • Recent injuries / trauma

History Points of InterestDescription of event by all witnesses

What actions taken (CPR?)Signs of respirations? Description of Apnea.

h/o co-sleeping, type of beddingh/o previous events; similar/differentTiming is critical

While asleep; while eating?Birth hx, wght gain, recent illnessesRecent new medications

APNEANormal apneic episodes can occur

Periodic breathing

Pathologic apnea is associated with:CyanosisBradycardiaAbrupt and marked pallor or hypotoniaGreater than 20 seconds duration

APNEA: Central vs Obstructive Central = disruption of autonomic receptors

Lack of effort

Obstructive = appropriate neuromuscular response, but airway can’t accommodateChoking, gaggingChest wall excursionsAbd wall contractions

Mixed Picture GERD can lead to decreased drive while also causing laryngospasm

Physical ExamPrimary survey = ABCDEsSecondary survey

Use it to focus the evaluationOften completely normal… but be diligentSigns of trauma?Abnormal Upper Airway Anatomy? Stridor?Fundoscopic exam!!

>50% have documented “normal” exams7

7. Perkins RM, Cabinum-Foeller E. Apparent Life-threatening Events. Pediatric Emergency Medicine Reports. February 2005;10(2):13-24.

Labs anyone?Wide DDx = Extensive W/U = Great Controversy

Need to be responsible (Base on H+P)Numerous studies can prove to be beneficial when

based on the H+P~70% have H+Ps that can direct studies 8

<4 weeks full sepsis w/u→ Significant murmur echo→ URI symps nasal swabs for RSV→

8. Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. Apr 2005;115(4):885-893.

What about an inconclusive H+P?Account for ~30% of the ALTEs 9

WBCU/AUCxCXRGER screeningBrain Imaging

ID’d all occult cases of ALTE’s in this study.

9. Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. Apr 2005;115(4):885-893.

In the ED…1. First goal, stabilize2. Classify as an ALTE or Not not an ALTE3. Continuous monitoring4. Check bedside glucose!5. Thorough H+P6. Resist reflexive lab ordering7. Consider abuse

FUNDOSCOPIC EXAM! +/- Head CT

DispoThe final Dx correlates poorly with presenting

symptomsHome vs Admission

Most support admission 7.8% with negative ED eval required subsequent medical

intervention while in the hospital 11

Consider the emotional strain on the familyConsider D/C only in those who may not even be

ALTE’s. Newer study may define population safe for D/C, but needs

more investigation12

11. De Piero AD, Teach SJ, Chamberlain JM. ED evaluation of infants after an apparent life-threatening event. Am J Emerg Med. Mar 2004;22(2):83-86.

12. Claudius, Irene et al. Do All Infants with Apparent Life-Threatening Events need to be Admitted? Pediatrics. April 2007; 119(4):679-683.

High Yield PointsALTE is not a Diagnosis! DDx is vast!Pathologic Apnea:

lasts >20 secs or is associated with bradycardia or change in color or tone

Screen for high risk characteristicsBase evaluation on H+P. Rule out life-

threatening etiologies first.Check the Glucose!Consider abuse!

Parental concerns should be taken seriously, despite a child’s normal appearance.

Please contact Sean M. Fox, MD with any questions or comments.

Carolinas Medical CenterMedical Education Building, 3rd Floor

1000 Blythe BlvdCharlotte, NC 28270

Office: (704) 355-7205Email: sean.fox@carolinashealthcare.org