1. ALTE Danielle Cherian, MD Morning Report July 2005

2. DEFINITION –“ALTE refers to 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.” National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring Pediatrics1987

3. Association to SIDS Prior to 1986, a sudden, near fatal event was referred to as a “near-miss SIDS” because of the perceived close relationship to SIDS The term ALTE coined in the late 1980’s to distinguish it more clearly from SIDS as it became evident that no definite link could be established b/w apnea and SIDS. (NIH Consensus Development Conference on Infantile Apnea and Home Monitoring) Less than 10% of future SIDS victims had presented a cyanotic or pale episode prior to death. Eur J Pediatr 2004

4. HISTORY A detailed and precise description of the event is of paramount importance –Events immediately preceding event (recent illness, immunizations, daily activities) –Usual sleep conditions (position, bedding, bed-sharing) –Precise time when event occurred and association with time of last feed, presence of fever –Place where event occurred (parents arms, crib, bed, car etc) –State of infant when found (awake or asleep; position of sleep, face covered or uncovered) –If awake, activities during event (feeding, bathing, crying) –Reason that led to discovery of the infant (abnormal cry) –Caretakers who discovered or witnessed event

5. Description of Event How did the child look and what was the lighting in the room? –Consciousness, muscle tone, color, respiratory effort, choking, gasping, emesis, sweating, limb or eye movements, skin character Any intervention/ Infant’s response Estimated time of recovery Estimated duration of the event

6. Further History Birth History: gestational age, perinatal complications, neonatal period Subsequent medical problems History of previous ALTE Complete ROS Family History: history of SIDS or sudden unexpected death, genetic or neurologic disorders, cardiac disease, ALTEs SH: caretakers, history of abuse

7. Physical Exam Complete and detailed exam Plot weight, height, head circumference! Fundoscopic exam Facial dysmorphisms Upper airway obstruction General tone and appearance Careful neurologic examination Attention to respiratory and cardiac exam

8. Most Common Diagnoses 50% Gastrointestinal 30% Neurologic 20% Respiratory (including URI) 5% Cardiovascular 5% Metabolic/Endocrine 3-5%+ Non-accidental trauma Up to 50% Unknown

9. Differential Diagnosis InfectiousSepsisMeningitis/Encephalitis RSV/Pertussis/Other respiratory GI GIGERVolvulusIntussusception Swallowing dysfunction Cardiovascular Prolonged QT ArrythmiaMyocarditis Vacular Ring Metabolic Primary Inborn Error of Metabolism Secondary to other endocrine, electrolyte, or metabolic disorder Toxic Exposure Carbon monoxide NeurologicSeizure Vasovagal syncope Chiari/hindbrain malformation associated apnea CNS hemorrhage Respiratory Breath-holding spells Congenital airway abnormalities Central hypoventilation Upper airway obstruction Vocal cord dysfunction Laryngotracheomalacia Child abuse Suffocation Forced aspiration Intoxication Physical Injury Shaken Baby Munchausen by proxy

10. CLINICAL EVALUATION Standard Procedures: EKG CXR BMP CBC LFTs Viral screening, NPAs Bacterial screening (urine) Ocular exam SW/CPS consult Specific Procedures: LP EEG Head CT or MRI pH probe UGI Laryngoscopy Echocardiography Metabolic workup Skeletal survey Toxicology screen Polysomnography Skull films

11. QT INTERVAL The QTc is calculated as: The R-R interval should extend from the R wave in the QRS complex in which you are measuring QT to the preceding R wave. Normal values for QTc : 0.440 sec is 97th percentile for infants 3 to 4 days old[6]6 ≤0.45 sec in infants <6 months old ≤0.44 sec in children ≤0.44 sec in adults

12. Hospitalization? Most infants with ALTE should be hospitalized for more evaluation and observation If there is reliable follow-up and the child is completely well-appearing and the details of the event indicate a benign occurrence, it may be possible to follow as an outpatient. However, most are admitted at the U of C. If resuscitation required was significant, patients should be monitored closely in a ICU. Continuous monitoring is important!

13. DISCHARGE Prior to Discharge CPR training for caretakers Back to sleep Safe sleeping environments Elimination of tobacco smoke exposure

14. ALTE and ABUSE An infant who has sustained an abusive head injury may appear well on presentation, with no external signs of abuse. 2.5% of 243 infants in a prospective study of pts admitted for ALTE were diagnosed with nonaccidental head injuries (Altman, RL, Arch Pediatr Adolesc Med 2003; 157:1011) AHT as cause for ALTE occurs frequently enough to obligate its inclusion in DDx. At very least, we should do fundoscopic evaluation on all infants and consider cranial imaging early unless another cause is readily apparent.

15. HOME MONITORING Uncontrolled studies have not been able to show effectiveness in preventing SIDS No change in incidence of SIDS has been correlated with the use of home monitors CHIME Study (1079 infants) suggests that prolonged apnea and bradycardia are not precursors of SIDS Prevention of SIDS not acceptable indication for home monitoring (AAP Policy Statement)

16. HOME MONITORING Assumptions inherent in home monitor use have not been proven: No evidence that home monitoring will warn caregivers in time to intervene No evidence that any intervention will prevent unexpected death

17. HOME MONITORING Suggested to prevent repetition of severe hypoxic attacks and improve developmental outcome; no long-term studies Cases in which it may be considered: –Preterm infant who is at high risk for extreme apnea, this increased risk decreases with time, ceasing at approx. 43 weeks postmenstrual age. AAP Policy –Recurrent documented idiopathic ALTEs or those requiring vigorous resuscitation; again to recognize episodes and aid in diagnosis –Tracheostomy or ventilator dependent children Events monitors with ECG analysis are preferred

18. FOLLOW UP If home monitoring is started, it is typically terminated following a 6 week period free of recurrent events or at least 6 months old. For unexplained ALTE, the outcome is not predictable. FOLLOW UP is EXTREMELY IMPORTANT!

19. Review of Literature 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, 2003 Oct. Carroll JL. Apparent Life Threatening Event (ALTE) assessment. Pediatric Pulmonology - Supplement. 26:108-9, 2004. Davies F and Gupta R. Apparent life threatening events in infants presenting to an emergency department. Emergency Medicine Journal. 19(1): 11-16, 2002. DePiero AD. Teach SJ. Chamberlain JM. ED evaluation of infants after an apparent life-threatening event. American Journal of Emergency Medicine. 22(2): 2004 March. Farrell PA. Weiner GM. Lemons JA. SIDS, ALTE, apnea, and the use of home monitors. Pediatrics in Review. 23(1):3-9, 2002 Jan. 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, 1999 Jun. 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, 2004 Feb. Kahn A. Rebuffat E. Sottiaux M. Blum D. Management of an infant with an apparent life-threatening event. Pediatrician. 15(4):204-11, 1988. 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. 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, 2002 Jun. 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. Samuels, M P. The Management of ALTE. Pediatric Research. 45(5) (PART 2 OF 2):1A, May 1999.Sheikh S, Stephen TC, and Fraser A. Risk Factors for Apparent Life Threatening Episodes (ALTE) in Infants. Chest. 114(4) (Supplement):256S, October 1998. Steinschneider A. Prolonged apnea and the sudden infant death syndrome: clinical and laboratory observations. Pediatrics.1972; 50 :646 –654 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. 2004; 42(6): 711-717. Tirosh E. Colin AA. Tal Y. Kolikovsky Z. Jaffe M. Practical approach to the diagnosis and treatment of apnea of infancy. Israel Journal of Medical Sciences. 26(8):429-33, 1990 Aug. Touvenot, Valerie. Dynamic Etiology of Acute Life-Threatening Episodes (ALTE). Pediatric Research. 45(5) (PART 2 OF 2):33A, May 1999. Tsukada K. Kosuge N. Hosokawa M. Umezu R. Murata M. Etiology of 19 infants with apparent life- threatening events: relationship between apnea and esophageal dysfunction. Acta Paediatrica Japonica. 35(4):306-10, 1993 Aug.