Apparent life-threatening event

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Apparent life-threatening event

• Muhammad Waseem, MD
• Lincoln Hospital Bronx New York

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ALTE

• Terrifying episodes for both the family and the
  ED physician
• Observer fears that the infant has died

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Apparent life-threatening event

• An episode that is frightening to the observer
• Apnea
• Color change (cyanosis)
• Change in muscle tone ? limp
• Choking or gagging

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ALTE

• Not a diagnosis
• Description of a characteristic presentation

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ALTE

• 0.5 -0.6 of all infants
• True frequency prevalence unknown
• Peak incidence 2-3 months

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ALTE

• Apnea
• Cessation of respiration for 20 seconds or more
• Bradycardia
• Pallor or cyanosis

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ALTE

• Periodic breathing
• Rhythmic respiration with short pauses (3-10 s)
• Not associated with bradycardia, pallor or
  cyanosis
• Should not be confused with apnea

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ALTE

• No typical presentation
• Stopped breathing (most common)
• Stable condition in ED (most common)

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ALTE

• Can occur during sleep, wakefulness or feeding

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ALTE

• Relation with SIDS (major fear)
• 1-2 (mild)
• 8-10 (severe)
• Identification of cause does not necessarily
  eliminate the risk

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ALTE

• Does a life threatening condition exist?
• Was the episode clinically significant?
• Can an underlying cause be determined?

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ALTE -History

• Asleep or awake
• Red, pale or blue
• Relation to feeding
• Spontaneous recovery or CPR
• Associated movements/ change in tone
• difficult to take care

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ALTE-Physical Examination

• Fever or hypothermia
• Tachypnea
• Poor feeding, irritability or ? sleepiness
• Tone
• Fontanels fundi

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ALTE

• Can be a symptom of many specific disorder
• Specific identifiable cause (50)

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ALTE

• GER
• Infections (CNS, pulmonary, sepsis)
• Hypocalcemia, hypoglycemia, anemia
• Seizure
• ? ICP
• Dysrhythmia
• Child abuse

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GER

• Physiologic versus pathologic
• Infantile versus childhood
• Infantile reflux resolve by first birthday

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GER

• Awake apnea
• Usually reflux related
• Sleep apnea?
• Nocturnal reflux is uncommon

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GER

• Sandifer syndrome

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GER

• Intraesophageal pH study
• Gold standard
• Difficult to prove

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Infections

• RSV ? apnea
• lt 3 months
• Non obstructive
• During quiet sleep
• Sepsis
• Pertussis

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Seizure

• 4-7 of all infants with ALTE
• ? risk of SIDS
• Clinical diagnosis
• Neonatal seizure ? apnea

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Inborn Error of Metabolism

• Medium chain acyl CoA dehydrogenase deficiency
  (MCADD)
• 4 of severe ALTE
• 5 of SIDS

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Inborn Error of Metabolism

• Only apparent during metabolic stress
• Fasting
• Non ketotic hypoglycemia in previously healthy
  infant

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Inborn Error of Metabolism

• First episode is severe
• Family history of ALTE /or SIDS

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Child abuse

• Up to 5 of SIDS deaths
• Most difficult to diagnose
• Key to diagnosis is high index of suspicion

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ALTE Evaluation

• Whether the event represents an ALTE or not?
• Not every infant needs all these tests
• No routine evaluation
• Should be guided by history physical

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ALTE

• CBC?
• EKG?
• Chest X-ray?
• Upper GI?
• EEG?
• pH probe?

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ALTE

• Most important is accurate history
• Absolute determination of significant episode may
  not be possible in ED
• Often the best investigation is a short period in
  hospital with monitoring

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ALTE

• Admit any child with ALTE criteria
• Further evaluation monitoring
• Parent education

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Quiz -ALTE

• 2 year old with c/o stopped breathing
• Screaming after toy taken by playmate
• Stopped breathing ? limp blue 15 sec
• Resolved spontaneously
• Now alert normal exam

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Breath holding Spells

• Frightening experience for the parents
• 3 of all children
• Ages 1 and 5 years
• May begin before 6 months (25)

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Breath holding Spells

• Always provoked by pain, anger or frustration
  (unpleasant stimulus)
• Prolonged expiratory apnea
• Rapid development of cyanosis
• Normal physical neurological exam

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Breath holding Spells

• Prolonged expiratory efforts without inspiratory
  efforts
• Interruption in favorite activity ?cry ?red blue

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Quiz -ALTE

• 5 month-old male infant couldnt breath about an
  hour after feeding
• Mother describes Struggling or gasping to
  breath
• Well on arrival
• Afebrile, HR 110, RR 24, BP 74/46
• Wt 4.3 kg oral thrush

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Quiz -ALTE

• 16 month old girl with cerebral palsy
• Stiff ? limp (almost 5 minutes)
• Mother described as she was dead
• Out of it for next hour
• No fever, trauma or other recent ill contacts

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Quiz -ALTE

• A 3 month old infant stopped breathing while
  sleeping. Mother describes as weak and blue and
  looked dead
• Improved with mouth to mouth breathing
• Well appearing in ED