P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO

LWBK822-driver-A LWBK822-Hoffman ch034.xml April 15, 2011 13:20

APPARENT LIFE-THREATENING EVENT

Kevin Ching

ETIOLOGY
BASICS An underlying diagnosis is identified in only 50% of DIAGNOSIS
cases (∼50% are idiopathic):
DESCRIPTION r GI: HISTORY
r According to the NIH, an infant apparent Detailed accounts from witnesses (caretaker) and
– Gastroesophageal reflux
life-threatening event (ALTE) is an unexpected, emergency prehospital personnel may provide
– Intussusception
frightening episode that is characterized by some important insight on nature of event:
– Volvulus r Condition:
combination of (1): – Swallowing incoordination
– Apnea (central, obstructive, or mixed) r Neurologic: – Awake, asleep, crying, position (prone vs. supine)
– Color change (cyanosis, pallor, redness, or r Activity during event:
– Seizure
plethora) – CNS hemorrhage – Coughing, feeding, vomiting, gagging
– Marked change in muscle tone (limpness or r Respiratory effort:
– Hydrocephalus
rigidity) – Chiari malformation – Fast, slow, shallow, stridor, gasping, choking, none
– Choking or gagging – Central hypoventilation syndrome r Color:
– Fear (in some cases) that the infant has died – Vasovagal syncope – Red, blue, purple, pale
r An ALTE may prompt the caregiver to stimulate or r Respiratory: r Tone and movement:
resuscitate the infant before recovery. – Laryngotracheomalacia – Limp, rigid, convulsions
EPIDEMIOLOGY – Vocal cord dysfunction r Duration:
Incidence – Vascular ring – Time to recovery (eg, normal respiratory pattern or
Unknown, though estimates range from 0.5–6% – Obstructive sleep apnea tone)
(2): – Foreign body aspiration r Interventions (and duration):
r Most occur in infants <1 yr of age, peaking at 1 wk – Congenital airway anomalies – None, gentle or vigorous stimulation, artificial
– Stimulation of laryngeal chemoreceptors respirations, CPR
to 2 mo of age (3).
– Breath-holding spell r Recent illnesses
RISK FACTORS r Cardiac: r Past medical history:
r Prematurity
– Congenital heart disease (eg, ductal-dependent – Prenatal care
r Infection with respiratory syncytial virus (RSV) lesion) – Prematurity
r Male gender – Dysrhythmia (eg, long QT, Wolff-Parkinson-White – Developmental history
r Prone sleeping position syndrome) – Feeding history
r Feeding difficulties – Cardiomyopathy – Sleep habits
r History of apnea, cyanosis, or pallor – Myocarditis – Prior events
r Metabolic/Endocrine: r Family/Social history:
PATHOPHYSIOLOGY – Inborn error of metabolism – Siblings with sudden infant death syndrome (SIDS)
r The pathophysiology of ALTE in infants is unclear.
– Endocrine disorder – Dysrhythmias
r Apnea (1): r Infection:
– Medications in home
– Cessation of respiratory airflow for any reason: – Sepsis or meningitis – Smoking, alcohol, or substance abuse
◦ In central apnea, respiratory pauses may be – RSV
caused by CNS immaturity, seizures, or tumors. – Pertussis PHYSICAL EXAM
◦ In obstructive apnea, breathing may be r Infants may appear well without any signs or
– Croup
obstructed by a laryngeal web, vascular ring, – Pneumonia symptoms of pathology:
tracheoesophageal fistula, or foreign body. r Child abuse: – In 1 study, 83% of infants evaluated by
– In pathologic apnea, there is a respiratory pause paramedics had unremarkable physical exams
– Physical abuse
>20 sec accompanied by bradycardia, cyanosis, – Munchausen by proxy (eg, suffocation, intentional
after an ALTE (4).
pallor, hypotonia, or other signs of compromise. poisoning, head trauma)
– In apnea of infancy, there is an unexplained r Normal:
respiratory pause >20 sec, or <20 sec when – Respiratory pauses
accompanied by bradycardia, cyanosis, pallor, – Periodic breathing
hypotonia, or other signs of compromise.
– Periodic breathing is a normal respiratory pattern
involving ≥3 brief pauses interrupted by <20 sec
of normal respirations in between (no bradycardia,
cyanosis, or hypotonia).

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P1: OSO/OVY P2: OSO/OVY QC: OSO/OVY T1: OSO
LWBK822-driver-A LWBK822-Hoffman ch034.xml April 15, 2011 13:20

APPARENT LIFE-THREATENING EVENT

A
r Thorough exam: PROGNOSIS
r Highly variable: Dependent on underlying condition
– General: TREATMENT r The recurrence rate for severe ALTE is as high as
◦ Height, weight, head circumference (compared
to norms) INITIAL STABILIZATION/THERAPY 68%.
◦ Dysmorphisms r Assess and stabilize airway, breathing, and r Overall risk of death is <1% (2).
◦ Vital signs circulation.
– Neurologic assessment: r Management is dependent on presentation and
◦ Muscle tone, posture condition. REFERENCES
– Developmental assessment: r Most infants appear well on presentation, and
◦ Age-appropriate milestones 1. Infantile apnea and home monitoring. NIH
minimal stabilization and therapy will be required. Consensus Statement. 1986;6:1–10.
– Respiratory and cardiac:
◦ Stridor, wheezes, rales DISPOSITION 2. Brooks JG. Apparent life-threatening events and
◦ Murmurs Admission Criteria apnea of infancy. Clin Perinatol. 1992;19:809–838.
◦ BP differential r Admission criteria vary: Some institutions routinely 3. Davies F, Gupta R. Apparent life threatening events
– Signs of trauma: admit patients with ALTE and perform extensive in infants presenting to an emergency department.
◦ Consider dilated funduscopy. workup; others do not admit patients and do not Emerg Med J. 2002;19:11–16.
routinely conduct lab testing or imaging: 4. Stratton SJ, Taves A, Lewis RJ, et al. Apparent
DIAGNOSTIC TESTS & INTERPRETATION
– It is unclear if there is any superiority of routine life-threatening event in infants: High risk in the
Lab admission or routine discharge. out-of-hospital environment. Ann Emerg Med.
r Lab testing should be guided by the history and
r Any infant who has required resuscitation or whose 2004;43:711–717.
physical exam findings.
r No standard for the minimum lab and radiographic history, exam, or diagnostic studies suggest any 5. Kahn A. Recommended clinical evaluation of
potential abnormalities should be hospitalized for infants with an apparent life threatening event.
testing exists (5). further workup and monitoring. Consensus document of the European Society for
Initial Lab Tests the Study and Prevention of Infant Death, 2003.
r High-yield studies include: Discharge Criteria
Patients with normal physical exam and no apparent Eur J Pediatr. 2004;163:108–115.
– Bedside glucometry
underlying medical problem requiring treatment are
– CBC
potential candidates for discharge:
– Urinalysis r In particular, children >30 days old with a single ADDITIONAL READING
– Electrolytes, BUN, calcium, magnesium r American Academy of Pediatrics Task Force on
– Serum bicarbonate ALTE may be discharged safely from the hospital.
– Serum lactate Issues for Referral Sudden Infant Death Syndrome. The changing
r Other tests to consider: Subspecialty referral is determined by historical and concept of sudden infant death syndrome:
– Toxicology screen physical exam findings as well as lab and radiographic Diagnostic coding shifts, controversies regarding the
– Metabolic screening (eg, ammonia) findings. sleeping environment, and new variables to consider
– Respiratory virus screens (eg, RSV, pertussis) in reducing risk. Pediatrics. 2005;116:1245–1255.
r Shah S, Sharieff GQ. An update on the approach to
– CSF analysis
– Blood and urine cultures FOLLOW-UP apparent life-threatening events. Curr Opin Pediatr.
2007;19:288–294.
Imaging FOLLOW-UP RECOMMENDATIONS
r CXR: High yield Discharge instructions and medications:
r Neuroimaging r If there is any problem for which medication
r Skeletal survey
CODES
prescription is required, take the prescription
Diagnostic Procedures/Other compliantly. ICD9
r ECG r Use a supine sleep position.
799.82 Apparent life threatening event in infant
r Screen for gastroesophageal reflux (eg, esophageal r Discourage cosleeping.
pH probe or upper GI series) r Avoid overheating (overbundling).
r Echo r Encourage breast-feeding. PEARLS AND PITFALLS
r Multichannel polysomnography r Avoid overfeeding. r Infants typically are well appearing with a normal
r Ensure timely vaccinations.
DIFFERENTIAL DIAGNOSIS physical exam after ALTE.
r Eliminate any exposure to tobacco smoke. r There is a lack of evidence supporting or refuting
See Etiology. r Seek training in CPR. management styles. The range of appropriate
Patient Monitoring management is a spectrum from no lab or imaging
r Cardiopulmonary monitoring, such as an apnea evaluation and routine discharge to routine
alarm, is of no proven benefit. admission and lab investigations.
r Parents should monitor for recurrent episodes of r Children >30 days old with a single ALTE and
ALTE or other illness. normal exam are particular candidates for safe
home discharge.
r Child abuse can present as an ALTE.
r Studies have not confirmed a link between ALTE and
SIDS.

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