ALTE Basics

 ALTE is NOT a diagnosis. It is a collection of symptoms.

 ALTE is defined as an episode that is “frightening” to the care provider and is characterized by
some combination of pathologic apnea, color change, change in muscle tone, choking,
orgagging.

 It is frequently difficult to decide whether there has been a true life threatening
event. Usually occurs in infants between 1 week and 10 months and most prior to 10
weeks.

 Pathologic Apnea = apnea associated with cyanosis, pallor, hypotonia, or bradycardia(which

would only be known if on a monitor really) OR apnea of greater than 20 seconds in duration
(which is a really long time for a parent to count when their kid is not breathing).

 The rather broad “definition” of ALTE leads to some difficulty in researching it and in
interpreting the results of the research.

Incidence and Relationship to Sudden Infant Death Syndrome (SIDS)

 0.05-1.0 % of normal children experiences an ALTE.

 1-2% risk of subsequent death. The incidence is higher if the infant required CPR or event
occurred during sleep and also increased if greater than one severe episode.
 Approximately 5% of SIDS occurred with a history of severe ALTE
 Not a predictor of SIDS and incidence of SIDS has decreased as incidence of ALTEs has increased.
 Interventions to prevent SIDS (e.g. supine sleeping) have not resulted in a decreased incidence
of ALTE
ALTE Differential Diagnosis is VAST

 Since ALTE represents a collection of symptoms, numerous conditions can be responsible.

 A thorough H+P often points toward a diagnosis and directs the work-up.

 GERD, Seizures, and Lower Respiratory Tract Infections are the most common diagnosesfound
after evaluation of ALTE.

 Many ominous conditions have been associated with ALTE as well:

 Serious Bacterial Infections- Pertussis, CNS infections

 Congenital Heart Disease

 Inborn Errors of Metabolism

 Ondine’s Curse (Congenital Central Hypoventilation Syndrome)

 Abuse

 Poisoning

 Many times no diagnosis is found (idiopathic ALTE).

1.Normal variation. No significant color changes or bradycardia.

 Short periods of apnea
 Periodic breathing
 Minor airway obstruction- Increased because of floppy airways in neonates and
infants
ALTE Evaluation

 In general, it is known that broad and expansive testing is often of limited value.

 It is best to tailor the evaluation based on a thorough history and physical exam.

 Currently there are investigations to better determine who benefits from admission; however,
there is currently no validated study that reliably identifies this group of children.

ALTE in the NEONATE

 Neonates are tough to figure out!

 They can’t tell you what really happened.

 They’re repertoire to demonstrate any illness is limited.

 Neonates who are seriously ill may only demonstrate that fact by being
hypothermic.

 We all know that the “well appearing” neonate can still be hiding serious illness.

 Your physical exam is less helpful in determining an etiology of the event.

 You cannot rely on finding meningismus.

 Even paradoxical irritability can be difficult to discern in the neonate.

 Neonates often have a different breathing pattern that can alarm care providers.

 Periodic Breathing is a normal variation of breathing.

 It is characterized by pauses of breathing for less than 20 seconds (more

typically less than 10 seconds).

 Often followed by some increased respiratory rate.

 There is no change in color or tone.

 This is NOT pathologic apnea, but often catches the attention of the care giver.

 Neonates that do Weird Things Make Me Nervous!

 Yes, the literature would argue that the overall incidence of serious bacterial infections
in all cases of ALTE is low.

 Meningitis 0-1.6%

 Bacteremia 0-2.5%
  UTI 0-7.6%

 Respiratory Tract Infection 0-10%

 If the story fits neither a simple gagging episode with feeding nor periodic breathing,
then I have to ask myself why did this neonate have Pathologic Apnea.

 While the numbers may not favor a serious bacterial infection… I have a hard
time proving that to myself in a neonate.

 Perhaps it was a seizure… hmmm… why did the neonate have a seizure… once
again infection is high on that list.

 Therefore, I still vote for the “worst first” approach and look to have someone
tell me in two days that the neonate did not have a serious bacterial infection.

 In short, these neonates I perform a full sepsis work-up on.

 ALTE in Neonate = Full Sepsis Work-up!

 If the story is a little odd… you know the one where you just can’t seem to get your
hands around what happened.

 Then I would favor a cautious, but reasonable approach.

 Sepsis screen with Urine studies and Urine Culture and admission for close
observation.

 Naturally, a conversation with the admitting team to develop a joint plan is

always appreciated.

 Aside from serious bacterial infections… don’t forget other badness in neonates!!

 Inborn Errors of Metabolism

 Abuse

 Congenital Heart Disease

EVALUATION -SUMMARY
1. History
1. Duration of spell and resuscitative measures used
2. Was the infant awake or asleep?
3. Relationship to feeds and were there any noises.
4. Position the infant was in when spell occurred.
5. Color change?
6. Was the infant trying to breathe?
7. What was the infant's condition following the spell? If they were back to normal, less
 likely to be a metabolic disease, CNS infection, trauma, or seizure.
8. Are there discrepancies in the story?
9. Sick contacts at home and immunization status of family members (DPT)
2. Family History
1. Seizures
2. Unexplained deaths
3. Arrhythmia
3. Medical/Birth History
1. Prematurity
2. BPD
3. History of reflux and using medications
4. History of seizures
4.Physical examination -Thorough physical examination including fundoscopic exam
5.LABOROTARY EVALUATIONS
1. CBC- anemia, lymphocytosis (Pertussis)
2. BMP- acidosis, glucose
3. CSF fluid analysis and culture.
4. Other appropriate cultures
5. ECG
6. Barium swallow and pH probe
7. EEG

So, in the end, when evaluating the neonate for an ALTE, don’t just resort to the common approach of
“that’s an easy admission” and admit for “obs.” Rather, be a little fearful… and start looking for those
needles in the haystack of disease.

Treatment

1. Specific for the etiology of ALTE

2. Monitoring

1. Avoid monitoring transient episodes that are not life threatening.

2. One or more episodes requiring mouth-mouth resuscitation or vigorous

stimulation

3. Preterm and symptomatic

4. 2 or more siblings who died of SIDS

5. Serious central hypoventilation.

3. Pneumograms have no predictive value

References

Claudius I1, Mittal MK2, Murray R3, Condie T3, Santillanes G4. Should infants presenting with an
apparent life-threatening event undergo evaluation for serious bacterial infections and respiratory
pathogens? J Pediatr. 2014 May;164(5):1231-1233. PMID: 24484770. [PubMed] [Read by QxMD]

Kadivar M1, Yaghmaie B1, Allahverdi B1, Shahbaznejad L2, Razi N1, Mosayebi Z1. Apparent life-
threatening events in neonatal period: clinical manifestations and diagnostic challenges in a pediatric
referral center. Iran J Pediatr. 2013 Aug;23(4):458-66. PMID: 24427501. [PubMed] [Read by QxMD]