Apparent Life- Threatening Event

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Apparent Life- Threatening Event

• K. Myra Lalas, MD
• 7/1

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Definition

• Marked by a combination of the following
  features
• Apnea usually no respiratory effort (central)
  or sometimes effort with difficulty (obstructive)
  
• Color change usually cyanotic or pallid but
  occasionally erythematous or plethoric
• Marked change in muscle tone (usually limpness or
  rarely rigidity)
• Choking or gagging
• Is a manifestation, not a diagnosis

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Etiology

• 0.6 to 2.46 per 1,000 live births and
  representing 0.6 to
• 0.8 of all emergency visits for children younger
  than 1
• year of age.
• Average age of infants experiencing an ALTE is
  approximately 8 weeks.
• Boys girls
• Those at increased risk
• Premature infants
• premature infants with RSV infections
• premature infants who undergo general anesthesia
• Infants who choke during feeding also are at
  increased risk

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Diagnosis

• HISTORY AND PHYSICAL EXAM
• The most important diagnostic tool is a detailed
  description of the event and intervention
  obtained from the caretaker who witnessed the
  episode and any emergency personnel involved in
  the case.

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• Birth History, information about the pregnancy
• Infant's usual behavior, sleep and feeding habits
• Family history (including a history of siblings
  with ALTE, early deaths, genetic, metabolic,
  cardiac, and neurologic problems)

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• Social history (including the presence of
  smoking, alcohol or substance use in the home,
  and a list of medications in the home)
• Possibility of accidental or intentional
  administration of poisons or medications,
  including over-the-counter cold preparations

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• When the episode is assessed to be truly
  life-threatening and an explanation for the ALTE
  is not apparent based on the H P, the initial
  laboratory evaluation may include
• CBC
• Urinalysis
• BMP, Mg
• EKG
• If the infant has a change in sensorium consider
  toxicology screen

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Differential Diagnosis

• Cardiovascular System
•   Anemia
•   Cardiomyopathy
•   Congenital heart disease
•   Dysrhythmia (prolonged QT syndrome,
  Wolff-Parkinson-White syndrome)
• Myocarditis
•   Vascular rings and slings

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• Central Nervous System
•   Apnea of prematurity
•   Congenital brain malformation
•   Head trauma (child abuse)
•   Idiopathic central apnea
•   Increased intracranial pressure (congenital
  hydrocephalus, tumor)
•   Meningitis/encephalitis
•   Seizure

• Respiratory System
•   Breath-holding spell
•   Bronchiolitis (RSV)
•   Congenital malformation (choanal atresia,
  laryngeal cleft, tracheoesophageal fistula)
•   Foreign body
•   Laryngomalacia/tracheomalacia
•   Laryngospasm (choking spell, gastroesophageal
  reflux)
•   Periodic breathing of infancy
•   Pertussis
•   Pneumonia
•   Smothering (intentional or unintentional)
•   Upper airway obstruction (nasal congestion)

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• Metabolic
•   Dehydration
•   Electrolyte abnormality (hyponatremia,
  hypocalcemia, congenital adrenal hyperplasia)
•   Hypoglycemia 
•   Inborn errors of metabolism
•  
•   

• Systemic/ Others
• Hypothermia
• Sepsis
• Factitious (Munchausen's syndrome by proxy)
• Toxins/drugs

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Home Monitors

• Based on strong research evidence, home
  cardiorespiratory monitors should be used only
  for preterm infants or children who are either
  dependent on technology, have unstable airways,
  have medical conditions that involve disordered
  respiratory control, or have symptomatic chronic
  lung disease.

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References

• Corwin Michael J, "Chapter 119. Apparent
  Life-Threatening Events and SIDS" (Chapter).
  Colin D. Rudolph, Abraham M. Rudolph, George E.
  Lister, Lewis R. First, Anne A. Gershon
  Rudolph's Pediatrics, 22e.
• Fu, Linda and R. Moon. Apparent Life-threatening
  Events (ALTEs) and the Role of Home Monitors.
  Pediatr. Rev. 200728203-208
• Hall, K. Evaluation and Management of Apparent
  Life-Threatening Events in Children. Am Fam
  Physician. 2005 Jun 1571(12)2301-2308.
• www.uptodate.com