ALTE DEFINE, DIAGNOSE, DISPO Riham Alwan, MD, MPH Henry Ford Hospital Department of Emergency Medicine inspiration 10 wk old ex-28wk M (corrected GA 37w1d) presents to Kaiser Permanente with frightened Mom at 9:21 PM with DIB. Patients mom states she bottle fed him and laid him down to sleep. Ten mins later, she heard a gagging noise that alarmed her. She found his lips slightly blue and his face red, and he was stiff. She does not recall if it was seconds or minutes, but she is certain he wasnt breathing. Mom states she picked him up and hit his back because she thought he had choked on something. She was screaming for her sisters help in the meantime. Sister arrived from downstairs, and patient was back to baseline. - just discharged from NICU 5 days ago - no fevers, cough, congestion, abdominal distension, vomiting, or rash - vitals remarkable for mild tachypnea - physical exam wnl - what is this? why did it happen? what do I need to do? goals and objectives o Recognize ALTE in a child presenting to the ED o Learn the key historical elements of ALTE o Know the differential diagnosis of ALTE o Recognize the limitation and utility of work up o Learn criteria for admission o Understand the risks of discharge define o In 1986, an expert panel sponsored by the National Institutes of Health developed the now widely accepted definition of ALTE Apparent Life Threatening Event: an episode that is frightening to the observer and that is characterized by some combination of: o Apnea o Change in color: red, white, or blue o Change in muscle tone: hyper or hypotonicity o Choking or gagging epidemiology o 0.6 to 10 per 1,000 live births o 0.6% to 1 % of all emergency visits for children younger than age 1 yo o 2% of pediatric hospitalizations o median age of ALTE 1-3 mo o 29% of premies experience ALTE vs 13% of term infants etiology No consensus currently exists about the most likely culprit of an ALTE o Is it GERD? o Is it URIs? o Is it seizures? o Is it abusive head trauma? o Is it congenital cardiac lesion? o Is it central sleep apnea? etiology The history and physical exam 21-49% of cases reveal etiology based on hx and PE Note the feeding history Delve into the pregnancy, delivery, or previous hospitalizations Preform a thorough physical exam including Plotting the height, weight, and head circumference of infants Neuro exam appropriate for age Careful cardiac exam to detect murmurs etiology Apparent life threatening events in infants presenting to an emergency department F Davies and R Gupta, Royal London Hospital, Emerg Med J 2002;19,11-16 Study Design: 12 mo prospective study of pts 2mo, abnormal clinical exam, and recurrent ALTE diagnosis GERD? Testing the association between GERD and apnea in infants Mousa, et al, Columbus Childrens Hospital, in J Pediatr Gastroenterol Nutr 2005; 41: Study Design: prospective study of pts 50% of basal tone lost progressively retrograde over 2 or more channels Acid reflux: when pH of the esophagus decreased