Transcript Apparent Life Threatening Events

ALTE
Danielle Cherian, MD
Morning Report
July 2005
DEFINITION
– “ALTE refers to an episode that is frightening to the
observer and that is characterized by some
combination of apnea (central or occasionally
obstructive), color change (cyanotic or pale), marked
change in muscle tone (limpness, rarely rigidity),
choking or gagging. Prompt intervention is usually
associated with normalization of the child’s
appearance.”
National Institutes of Health Consensus Development
Conference on Infantile Apnea and Home Monitoring
Pediatrics1987
Association to SIDS
• Prior to 1986, a sudden, near fatal event was referred to
as a “near-miss SIDS” because of the perceived close
relationship to SIDS
• The term ALTE coined in the late 1980’s to distinguish it
more clearly from SIDS as it became evident that no
definite link could be established b/w apnea and SIDS.
(NIH Consensus Development Conference on Infantile Apnea and
Home Monitoring)
• Less than 10% of future SIDS victims had presented a
cyanotic or pale episode prior to death. Eur J Pediatr 2004
HISTORY
• A detailed and precise description of the event is of
paramount importance
– Events immediately preceding event (recent illness,
immunizations, daily activities)
– Usual sleep conditions (position, bedding, bed-sharing)
– Precise time when event occurred and association with time of
last feed, presence of fever
– Place where event occurred (parents arms, crib, bed, car etc)
– State of infant when found (awake or asleep; position of sleep,
face covered or uncovered)
– If awake, activities during event (feeding, bathing, crying)
– Reason that led to discovery of the infant (abnormal cry)
– Caretakers who discovered or witnessed event
Description of Event
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How did the child look and what was the
lighting in the room?
– Consciousness, muscle tone, color,
respiratory effort, choking, gasping, emesis,
sweating, limb or eye movements, skin
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Any intervention/ Infant’s response
Estimated time of recovery
Estimated duration of the event
Further History
• Birth History: gestational age, perinatal
complications, neonatal period
• Subsequent medical problems
• History of previous ALTE
• Complete ROS
• Family History: history of SIDS or sudden
unexpected death, genetic or neurologic
disorders, cardiac disease, ALTEs
• SH: caretakers, history of abuse
Physical Exam
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Complete and detailed exam
Plot weight, height, head circumference!
Fundoscopic exam
Facial dysmorphisms
Upper airway obstruction
General tone and appearance
Careful neurologic examination
Attention to respiratory and cardiac exam
Most Common Diagnoses
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50% Gastrointestinal
30% Neurologic
20% Respiratory (including URI)
5% Cardiovascular
5% Metabolic/Endocrine
3-5%+ Non-accidental trauma
Up to 50% Unknown
Differential Diagnosis
Infectious
Sepsis
Meningitis/Encephalitis
RSV/Pertussis/Other respiratory
GI
GER
Volvulus
Intussusception
Swallowing dysfunction
Cardiovascular
Prolonged QT
Arrythmia
Myocarditis
Vacular Ring
Metabolic
Primary Inborn Error of Metabolism Secondary
to other endocrine, electrolyte, or metabolic
disorder
Toxic Exposure
Carbon monoxide
Neurologic
Seizure
Vasovagal syncope
Chiari/hindbrain malformation associated apnea
CNS hemorrhage
Respiratory
Breath-holding spells
Congenital airway abnormalities
Central hypoventilation
Upper airway obstruction
Vocal cord dysfunction
Laryngotracheomalacia
Child abuse
Suffocation
Forced aspiration
Intoxication
Physical Injury
Shaken Baby
Munchausen by proxy
CLINICAL EVALUATION
• Standard Procedures:
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EKG
CXR
BMP
CBC
LFTs
Viral screening, NPAs
Bacterial screening
(urine)
• Ocular exam
• SW/CPS consult
• Specific Procedures:
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LP
EEG
Head CT or MRI
pH probe
UGI
Laryngoscopy
Echocardiography
Metabolic workup
Skeletal survey
Toxicology screen
Polysomnography
Skull films
QT INTERVAL
The QTc is calculated as:
The R-R interval should extend from the R wave in the QRS
complex in which you are measuring QT to the preceding R
wave. Normal values for QTc :
0.440 sec is 97th percentile for infants 3 to 4 days old[6]
≤0.45 sec in infants <6 months old
≤0.44 sec in children
≤0.44 sec in adults
Hospitalization?
• Most infants with ALTE should be hospitalized
for more evaluation and observation
• If there is reliable follow-up and the child is
completely well-appearing and the details of the
event indicate a benign occurrence, it may be
possible to follow as an outpatient. However,
most are admitted at the U of C.
• If resuscitation required was significant, patients
should be monitored closely in a ICU.
• Continuous monitoring is important!
DISCHARGE
• Prior to Discharge
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CPR training for caretakers
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Back to sleep
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Safe sleeping environments
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Elimination of tobacco smoke exposure
ALTE and ABUSE
• An infant who has sustained an abusive head
injury may appear well on presentation, with no
external signs of abuse.
• 2.5% of 243 infants in a prospective study of pts
admitted for ALTE were diagnosed with
nonaccidental head injuries (Altman, RL, Arch Pediatr
Adolesc Med 2003; 157:1011)
• AHT as cause for ALTE occurs frequently
enough to obligate its inclusion in DDx. At very
least, we should do fundoscopic evaluation on
all infants and consider cranial imaging early
unless another cause is readily apparent.
HOME MONITORING
• Uncontrolled studies have not been able to show
effectiveness in preventing SIDS
• No change in incidence of SIDS has been
correlated with the use of home monitors
• CHIME Study (1079 infants) suggests that
prolonged apnea and bradycardia are not
precursors of SIDS
• Prevention of SIDS not acceptable indication for
home monitoring (AAP Policy Statement)
HOME MONITORING
Assumptions inherent in home monitor use
have not been proven:
• No evidence that home monitoring will
warn caregivers in time to intervene
• No evidence that any intervention will
prevent unexpected death
HOME MONITORING
• Suggested to prevent repetition of severe
hypoxic attacks and improve developmental
outcome; no long-term studies
• Cases in which it may be considered:
– Preterm infant who is at high risk for extreme apnea,
this increased risk decreases with time, ceasing at
approx. 43 weeks postmenstrual age. AAP Policy
– Recurrent documented idiopathic ALTEs or those
requiring vigorous resuscitation; again to recognize
episodes and aid in diagnosis
– Tracheostomy or ventilator dependent children
• Events monitors with ECG analysis are preferred
FOLLOW UP
• If home monitoring is started, it is typically
terminated following a 6 week period free
of recurrent events or at least 6 months
old.
• For unexplained ALTE, the outcome is not
predictable.
• FOLLOW UP is EXTREMELY
IMPORTANT!
Review of Literature
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Altman RL. Brand DA. Forman S. Kutscher ML. Lowenthal DB. Franke KA. Mercado VV. Abusive head injury as a cause of
apparent life threatening events in infancy. Archives of Pediatrics & Adolescent Medicine. 157(10): 1011-5, 2003 Oct.
Carroll JL. Apparent Life Threatening Event (ALTE) assessment. Pediatric Pulmonology - Supplement. 26:108-9, 2004.
Davies F and Gupta R. Apparent life threatening events in infants presenting to an emergency department. Emergency
Medicine Journal. 19(1): 11-16, 2002.
DePiero AD. Teach SJ. Chamberlain JM. ED evaluation of infants after an apparent life-threatening event. American
Journal of Emergency Medicine. 22(2): 2004 March.
Farrell PA. Weiner GM. Lemons JA. SIDS, ALTE, apnea, and the use of home monitors. Pediatrics in Review. 23(1):3-9,
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Gray C. Davies F. Molyneux E. Apparent life-threatening events presenting to a pediatric emergency department. [Journal
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Kahn A. European Society for the Study and Prevention of Infant Death. Recommended clinical evaluation of infants with an
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Kahn A. Rebuffat E. Sottiaux M. Blum D. Management of an infant with an apparent life-threatening event. Pediatrician.
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Kairys SW, Alexander RC, Block RW, Everett VD, Hymel KP, Jenny C, Corwin DL, Shelley GA, Reece RM, Krous HF,
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