ALTE: “Your baby did what?!”

Overview and Updates on the Apparent Life Threatening Event

Dominic Lucia M.DAssistant Professor of Emergency Medicine

Texas A&M Health Science CenterMedical Director Emergency Medicine

McClane Children’s HospitalScott and White

“Your baby did what?”

Define ALTE ALTE Relationship to SIDS What could this be? Work-up Disposition

Take home points Discussion

What we will do

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”….

Busy night shift

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

ALTE: Apparent Life Threatening Event

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!

First things first:

Generally talking about under 1 year of age Peak incidence occurs between 1w-2m More common in preemies Male 2:1 Females

ALTE Facts

Am Fam Physician. 2005 Jun 15;71(12):2301-8.Evaluation and management of apparent life-threatening events in children. Hall KL, Zalman B.

Rocker JA, Israel J: emedicine, Pediatrics, apnea

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.

A “Parent” life threatening…

~5% of children who die of SIDs have had an ALTE

Causal relationship has not been established◦ ALTE- heterogenous group of problems◦ SIDs and ALTE event times vary◦ Interventions have not decreased incidence of

ALTE◦ Risk factors vary

ALTE and SIDS

DEFINITION of SIDS

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

Season: winter Socioeconomic status: low Ethnicity: cultural differences Race: higher in African Americans and

Native Americans Male predominance

SIDS Epidemiology

Infant factors and increased risk◦ low birth weight◦ short gestational age◦ IUGR

Maternal factors and increased risk◦ tobacco use pre and post delivery ◦ opiate and cocaine use◦ young age◦ high parity◦ multiple gestation

Epidemiology

Other factors that increase risk◦ thermal stress◦ co-sleeping combined with other factors◦ soft surfaces◦ prone position◦ history of SIDS in prior sibling

Epidemiology

Exogenous Stressor

Vulnerable infant

Development of

Homeostatic Control

Triple Risk Model for SIDS

Despair.com

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

ALTE: HPI

Gastroenterologic (33%) Idiopathic Apnea of Infancy (23%) Neurologic (15%) Respiratory (11%) Otololaryngologic (4%) Cardiovascular (1%)

Metabolic/Endocrine Infectious Other

ALTE: Differential

DeWolfe CC:Apparent Life Threatening Event: a review Pediatr Clin North Am. 2005 Aug;52(4):1127-46, ix.

Gastroesophageal reflux disease Gastroenteritis Esophageal dysfunction Surgical abdomen Dysphagias

Gastroenterologic (33%)

Apparent life-threatening event admissions and gastroesophageal reflux disease: the value of hospitalization.

Pediatr Emerg Care. 2012 Jan;28(1):17-21.

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…

Seizure Central apnea/hypoventilation Meningitis/encephalitis Hydrocephalus Congenital brain malformation Increased ICP: hydrocephalus, tumor Neuromuscular disorders Vasovagal reaction Head trauma

Neurologic (15%)

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.

Abstract BACKGROUND: Apparent life-threatening events (ALTE) and/or prolonged apnoea have been well-

documented 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.

Respiratory syncytial virus Pertussis Congenital malformation Laryngospasm (choking/GERD) Aspiration Respiratory tract infection (obligate nasal

breathers) Reactive airway disease Foreign body

Respiratory (11%)

Laryngomalacia Choanal atresia Laryngeal cleft Tracheoesophageal fistula Subglottic and/or laryngeal stenosis Obstructive sleep apnea

Otololaryngologic (4%)

Anemia Congenital heart disease Cardiomyopathy Vascular rings and slings Cardiac arrhythmias/prolonged QT

syndrome; WPW Myocarditis

Cardiovascular (1%)

Hypoglycemia Electrolyte disturbance Inborn error of metabolism

Metabolic/Endocrine

Sepsis Urinary tract infection

Infectious

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.

Virus Panel?

Insanity is hereditary, you get it from your kids….

Child maltreatment syndrome Shaken baby syndrome Breath-holding spell Choking Drug or toxin reaction Dehydration Unintentional smothering Periodic breathing Munchhausen-by-proxy syndrome

Other….

Children < 24mo with an ALTE btwn 3/97-2/99 opthalmologic exam as well as, lab tests Results:

◦ 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

Prevalence of Retinal Hemorrhages and Child Abuse in Children Who Present with an ALTE

Pediatrics September 2002

Periodic Breathing

Breath holding spells (older)

Standard reflux

*Be sure your history physical and subsequent documentation firmly support your diagnosis

Sheep in Wolf Clothing

Lets try to decide what to do :

Never trust a neonate… “Well appearing” Social Smile…? Feeding issues… Significant episode Under 6 weeks, considerFull sepsis workup(even if afebrile…)

Don’t be fooled…

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.

Things that should be a constant in your ED for an possible ALTE presentation:

Younger…more aggressive Punky…listless…full court press

Let the history and physical exam guide your work-up.

Labs…?

Blood glucose* CBC with diff CMP Mg, Phos, Ca Blood Culture UA Urine Culture UDS VBG RSV Respiratory Virus Panel

Laboratory Considerations:

Chest X-Ray EKG

Abuse? CT, skeletal survey, UDS

Other studies:

All children who have suffered an ALTE should be transported for evaluation by a physician (EMS)

Admission for observation at the least◦ Anyone with cyanosis◦ Apnea◦ Loss of tone◦ Required CPR

Home only if clearly NOT an ALTE

ALTE- disposition

Despair.com

Benefit Pushback What can an inpatient stay offer?

Admission…

Prolonged monitoring Culture monitoring Sleep studies pH probe testing EEG

Parental calming…

Inpatient

More scholarly reading….

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.

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

An update on the approach to apparent life-threatening events.

Curr Opin Pediatr. 2007 Jun;19(3):288-94.

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.

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

AIMS: To determine the most likely diagnoses when infants first present with an apparent life

threatening event (ALTE). METHODS: 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.

RESULTS: 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.

CONCLUSIONS: 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.

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.

Take home points:

Natalie Lane MD

Marisa, Derian, Malaya, and Lillian

Thanks: