1. Is there a way to improve management of ALTE? Danielle Cherian, MD; Nan Walicki, MD; Alyna Chien, MD; Jill Glick, MD University of Chicago Hospitals Background Objective MethodsResults Conclusion References Demographics ALTEALTE-like % Male40%50% Median Age3 weeks6 weeks % Premature60%33% Median Gestational Age34 weeks31 weeks % IDPA40%83% To compare the evaluation and ultimate diagnosis of patients admitted to UCCH meeting the strict definition of ALTE with other patients admitted where the term ALTE was used. ALTE was defined as “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.” Definition from the National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring Pediatrics 1987. Finding patients admitted to UCCH with ALTE presented a challenge since there is no ICD-9 code for ALTE. Patients were identified and data collected through a 2 phase chart review. Initially charts were pulled by medical records meeting the following criteria: 6 months of age or less, admitted for >48 hours to PICU, PINT, or General Pediatric Floor between November 1, 2004 and February 28, 2005 Explicit Review: charts with the term “ALTE” in the Resident’s admission H & P, admission orders, or discharge sheet were included for subsequent review. Implicit Review: A standard chart extraction tool was used to help two 3rd year residents independently code for patient demographics, H&P and ALTE-pertinent elements of the admission and discharge. Identified 182 patients meeting the following criteria: 6 months of age or less, admitted for >48 hours to PICU, PINT, or General Pediatric floor between November 1, 2004 and February 28, 2005 18 patients were identified as patients with ALTE by the use of the term ALTE in the admission H & P, admission orders, or discharge sheet. 17 of the 18 charts were reviewed and data collected. 1 chart missing in medical records 8/17 had obvious symptoms on admission 9/17 were clinically well appearing on admission 2 of these 9 had a history highly suggestive of reflux 2 of these 9 had a history highly suggestive of seizure 5 patients fulfill strict definition of ALTE 1.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, Oct 2003. 2.Carroll JL. Apparent Life Threatening Event (ALTE) assessment. Pediatric Pulmonology - Supplement. 26:108-9, 2004. 3.Davies F and Gupta R. Apparent life threatening events in infants presenting to an emergency department. Emergency Medicine Journal. 19(1): 11-16, 2002. 4.DePiero AD, Teach SJ, Chamberlain JM. ED evaluation of infants after an apparent life-threatening event. American Journal of Emergency Medicine. 22(2): March 2004. 5.Donnelly DF. Developmental aspects of oxygen sensing by the carotid body. Journal of Applied Physiology. 88: 2296-2301, 2000. 6.Farrell PA, Weiner GM, Lemons JA. SIDS, ALTE, apnea, and the use of home monitors. Pediatrics in Review. 23(1):3-9, Jan 2002. 7.Gray C. Davies F. Molyneux E. Apparent life-threatening events presenting to a pediatric emergency department. [Journal Article] Pediatric Emergency Care. 15(3):195-9, June 1999. 8.Kahn A. European Society for the Study and Prevention of Infant Death. Recommended clinical evaluation of infants with an apparent life- threatening event. Consensus document of the European Society for the Study and Prevention of Infant Death, 2003. European Journal of Pediatrics. 163(2):108-15, Feb 2004. 9.Kahn A, Rebuffat E, Sottiaux M, Blum D. Management of an infant with an apparent life-threatening event. Pediatrician. 15(4):204-11, 1988. 10.Kairys SW, Alexander RC, Block RW, Everett VD, Hymel KP, Jenny C, Corwin DL, Shelley GA, Reece RM, Krous HF, Hurley TP. Distinguishing Sudden Infant Death Syndrome from Child Abuse Fatalities. Pediatrics. 107(2):437-441, February 2001. 11.Kiechl-Kohlendorfer U, Hof D, Peglow UP, Traweger-Ravanelli B and Kiechl S. Epidemiology of apparent life threatening events. Archives of Disease in Childhood. 90(3): 297-300, 2005. 12.McGrath NE, DeMasi J, DeMasi M. Infants with an Apparent Life-Threatening Event (ALTE): recognizing the symptoms, the seriousness. Journal of Emergency Nursing. 28(3):255-8, June 2002. 13.Okada K, Miyako M, Honma S, Wakabayashi Y, Sugihara S, Osawa M. Discharge diagnoses in infants with apparent life-threatening event. Pediatrics International. 45(5):560-563, October 2003. 14.Samuels, M P. The Management of ALTE. Pediatric Research. 45(5) (PART 2 OF 2):1A, May 1999. 15.Sheikh S, Stephen TC, and Fraser A. Risk Factors for Apparent Life Threatening Episodes (ALTE) in Infants. Chest. 114(4) (Supplement):256S, October 1998. 16.Steinschneider A. Prolonged apnea and the sudden infant death syndrome: clinical and laboratory observations. Pediatrics.1972; 50 :646 –654 17.Stratton SJ, Taves A, Lewis RJ, Clements H, Henderson D, and McCollough M. Apparent Life-Threatening Events in Infants: High Risk in the Out-of-Hospital. Annals of Emergency Medicine. 42(6): 711-717, 2004. 18.Touvenot V. Dynamic Etiology of Acute Life-Threatening Episodes (ALTE). Pediatric Research. 45(5) (PART 2 OF 2):33A, May 1999. ALTE evaluation may vary depending on how the definition of ALTE is interpreted. The variance in the use of the term may lead to both under-testing and over-testing. Most concerning in the area of under-testing is the relative lack of social work/CPS involvement given the continued concern that abuse may be an important etiology of ALTE. UCCH patients admitted with ALTE or ALTE-like events discharge diagnoses correspond well to that of published data. However, this may not necessarily correspond to the cause of the event. Limitations Our study was limited by the small study group size. Also, the study only included the winter months and patients less than or equal to 6 months of age. Diagnosis on discharge sheet does not always reflect the “cause” of the ALTE Biases: Implicit review whereby the reviewers were very familiar with the patients Figure 3. All discharge diagnoses given (Primary and Secondary) to ALTE patients and ALTE- like patients. Figure 2. The percentage of patients who received a Social Work or CPS Evaluation. Figure 1. The ALTE Workup. Comparison of patients with an ALTE event to those with an ALTE- like event as to the work up done. Also, the percentage of patients in each group that received a “complete” workup investigating for all 3 categories: reflux, arrhythmias and seizures. Table 1. Compare demographics of ALTE patients meeting the strict definition to those of ALTE-like patients who do not meet the strict definition Up to 70% of ALTEs remain unexplained (range from literature 15-70%). Infants included as having ALTEs are a very heterogeneous group. An ALTE may be considered even with an obvious symptom and/or physical exam finding on presentation that may aid in tailoring the diagnosis, i.e. vomiting, diarrhea and/or acute abdomen. ALTE is a difficult condition to study because the term is not used precisely in the literature or by clinicians. Few of the studies in the area sufficiently specify their inclusion/exclusion criteria; clinicians tend to use the term to connote obscurity in the diagnostic process. How the definition is interpreted is critical in the labeling and evaluation of children which in turn is critical to advancing our knowledge regarding the etiology and natural history of ALTE, and may account for the variation of discharge diagnoses. In order to advance our knowledge of ALTE, we must be sure to specify how our patients are labeled “ALTE” or not. Previous studies determined less than 3% of ALTEs to be a result of child abuse[1][8]. It is possible that the percentage of ALTEs due to child abuse is higher due to missed diagnosis and/or a lack of investigation. It is also possible that the percentage of ALTEs linked to abuse may be higher if one excludes as true ALTEs those patients who by initial physical examination have a well recognized etiology for their symptoms