Apparent Life Threatening Events (ALTE)

Adaobi Okobi, M.D.

Pediatrics Chief Resident

St. Barnabas Hospital

Objectives

Define an ALTE

Recognize key components in the history and physical exam

Review work up and differential diagnosis

Discuss the use of monitors

Definition

An episode that is frightening to the observer and is characterized by a combination of apnea, color change, change in muscle tone, choking or gagging

Epidemiology

Incidence: 0.6-2.46 per 1,000 live births in children under 1 year

Average age: 8 weeks

M:F 1:1

History

Chief complaintApnea?Respiratory effort?Color change and distributionChange in tone and distributionChoking or gagging?Duration of episode?Vomiting?Relationship to feeds?Eye deviation?Loss of consciousness?Fever?Trauma?

State of alertness before the event?Place of occurrenceType of resuscitation and who performed itReview of prehospital recordCurrent condition of the child (in caretaker’s opinion)Presence of a monitor?Medications taken by child or breastfeeding motherPrevious history of ALTE and type of evaluationPMHx (including prematurity)FamHx (including SIDS)SocHx

Physical Exam

Vital signs including pulse oximetryGeneral appearance including any features consistent with a genetic or metabolic syndromeEvaluate for trauma including retinal hemorrohage, hemotympanum, contusions, acute abdomen, etcEvaluate the lungs and assess nasal congestionEvaluate the heart for murmurs, quality of femoral pulsesNeuro exam!!

Apnea

Central- lack of brainstem-mediated respiratory effort; abnormal if >20 sec or shorter duration with physiologic compromise

Obstructive- attempts to breathe against a blocked airway; always abnormal!

Mixed- combination of central and obstructive apnea in the same episode

Differential Diagnosis

GI (33%)Gastroesophageal refluxGastroenteritisDysphagiaVomiting

Neurologic (15%)SeizureIntracranial hemorrhageCentral apnea/hypoventilation syndromesHydrocephalusBrain tumorVasovagal reflexMeningitis/encephalitisMyopathyCongenital malformation of brainstem

Differential Diagnosis (cont’d)

Respiratory (11%)RSVPertussisAspiration pneumoniaForeign bodyOther upper or lower resp tract infections

Otolaryngologic (4%)LaryngomalaciaSubglottic stenosis

Cardiac (1%)Arrhythmia (ie Prolonged QTc)Congenital cardiac diseaseCardiomyopathyMyocarditis

Metabolic or endocrineElectrolyte abnormalityHypoglycemiaInborn Error of Metabolism

InfectiousSepsisUTI

Differential Diagnosis (cont’d)

OtherShaken baby syndromeIntentional SuffocationMunchausen by proxyPhysiologic event (ie acrocyanosis, periodic breathing)Breath holding spell

Other (cont’d)AnemiaUnintentional smotheringToxin ingestionHypothermiaOverfeeding

Idiopathic (23%)

Work Up

Observation with continuous pulse oximetry and cardiorespiratory monitorDependent on history and physical exam

May include:CBC with diffChemistry panelMetabolic screenToxin screenBlood cultureUrine cultureCSF cultureViral respiratory culturesCXRNeuro imaging (CT vs MRI)GI imaging EKGEEGPneumogram

Discharge Criteria

Anticipatory Guidance to avoid future events (ie no co-sleeping, back to sleep, no toys or pillows in crib, etc)Consider apnea monitorTeach families:

How to recognize events that warrant investigationAppropriate stimulation techniquesCardiopulmonary resuscitation

Apnea Monitors

Recommended for use in:Preterm infants with high risk of recurrent episodes of apnea, bradycardia, and hypoxemiaInfants who are technology-dependentInfants with unstable airwaysInfants with rare medical conditions that affect their regulation of breathingInfants with symptomatic chronic lung disease

Apnea Monitors: Disadvantages

No evidence that apnea monitors effectively prevent SIDSAlthough parents report feeling more secure with apnea monitors, psychological testing revealed that they report increased depression and hostility in the first 2 weeks of their infants coming homeAverage monthly price of operation per monitor ranges from $300 to $400, excluding physician fees

Summary

ALTE is a constellation of symptoms and not a true diagnosis

The history and physical exam give important clues to the diagnosis

The work up can be extensive if the history and physical do not correlate

Apnea monitor use can be helpful in a specific population however its use in the setting of ALTE can be controversial

Questions

A young couple brings their 4-week-old daughter to the emergency department because she stopped breathing while feeding. They report that they initiated cardiopulmonary resuscitation but were unable to get a response from her. The infant is apneic, cyanotic, and limp. You also note on physical examination that her left arm and left leg are bruised. After you intubate her and gain intravenous access, you consider the differential diagnosis of apnea. Of the following, the test that is most important to obtain to determine the cause of the infant’s apneic event is:A. Ammonia measurement.B. Chest radiography.C. Computed tomography scan of the head.D. Electrocardiography.E. Upper gastrointestinal radiographic series.

Questions

You are evaluating a 6-week-old boy who was brought to your clinic by his mother after a choking episode several hours earlier. She reports that shortly after feeding, he coughed and appeared to be choking and gasping for breath for 5 seconds. The episode resolved, and he has been breathing normally since. He is a well-appearing, alert infant who has normal vital signs and no fever. Except for mild nasal congestion, his physical examination findings are normal. His mother reports that he spits up occasionally. Of the following, the most appropriate management of this patient’s ALTE is:A. Admission to the hospital for a 48-hour observation without laboratory evaluation.B. Admission to the short-stay unit for 24 hours of continuous cardiorespiratory and pulse oximetry monitoring.C. Discharge from the clinic with an apnea monitor for 2 months.D. Education of the mother and discharge from the clinic with gastroesophageal reflux precautions.E. Full sepsis evaluation, including lumbar puncture, and admission to the hospital for administration of intravenous antibiotics.

References

DeWolfe, C. and Chidekel, A. Apparent Life-Threatening Event, Infant Apnea, and Pediatric Obstructive Sleep Apnea Syndrome. Pediatric Hospitalist Medicine. Pg. 453-459

Fu, L and Moon, R. Apparent Life-Threatening Events (ALTEs) and the Role of Home Monitors. Pediatrics in Review. 2007;28: 203-208