1. Apparent Life Threatening Events (ALTE) Adaobi Okobi, M.D. Pediatrics Chief Resident St. Barnabas Hospital

2. Objectives Define an ALTE Recognize key components in the history and physical exam Review work up and differential diagnosis Discuss the use of monitors

3. 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

4. Epidemiology Incidence: 0.6-2.46 per 1,000 live births in children under 1 year Average age: 8 weeks M:F 1:1

5. History Chief complaint Apnea? Respiratory effort? Color change and distribution Change in tone and distribution Choking or gagging? Duration of episode? Vomiting? Relationship to feeds? Eye deviation? Loss of consciousness? Fever? Trauma? State of alertness before the event? Place of occurrence Type of resuscitation and who performed it Review of prehospital record Current condition of the child (in caretaker’s opinion) Presence of a monitor? Medications taken by child or breastfeeding mother Previous history of ALTE and type of evaluation PMHx (including prematurity) FamHx (including SIDS) SocHx

6. Physical Exam Vital signs including pulse oximetry General appearance including any features consistent with a genetic or metabolic syndrome Evaluate for trauma including retinal hemorrohage, hemotympanum, contusions, acute abdomen, etc Evaluate the lungs and assess nasal congestion Evaluate the heart for murmurs, quality of femoral pulses Neuro exam!!

7. 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

8. Differential Diagnosis GI (33%) Gastroesophageal reflux Gastroenteritis Dysphagia Vomiting Neurologic (15%) Seizure Intracranial hemorrhage Central apnea/hypoventilation syndromes Hydrocephalus Brain tumor Vasovagal reflex Meningitis/encephalitis Myopathy Congenital malformation of brainstem

9. Differential Diagnosis (cont’d) Respiratory (11%) RSV Pertussis Aspiration pneumonia Foreign body Other upper or lower resp tract infections Otolaryngologic (4%) Laryngomalacia Subglottic stenosis Cardiac (1%) Arrhythmia (ie Prolonged QTc) Congenital cardiac disease Cardiomyopathy Myocarditis Metabolic or endocrine Electrolyte abnormality Hypoglycemia Inborn Error of Metabolism Infectious Sepsis UTI

10. Differential Diagnosis (cont’d) Other Shaken baby syndrome Intentional Suffocation Munchausen by proxy Physiologic event (ie acrocyanosis, periodic breathing) Breath holding spell Other (cont’d) Anemia Unintentional smothering Toxin ingestion Hypothermia Overfeeding Idiopathic (23%)

11. Work Up Observation with continuous pulse oximetry and cardiorespiratory monitor Dependent on history and physical exam May include: CBC with diff Chemistry panel Metabolic screen Toxin screen Blood culture Urine culture CSF culture Viral respiratory cultures CXR Neuro imaging (CT vs MRI) GI imaging EKG EEG Pneumogram

12. Discharge Criteria Anticipatory Guidance to avoid future events (ie no co-sleeping, back to sleep, no toys or pillows in crib, etc) Consider apnea monitor Teach families: How to recognize events that warrant investigation Appropriate stimulation techniques Cardiopulmonary resuscitation

13. Apnea Monitors Recommended for use in: Preterm infants with high risk of recurrent episodes of apnea, bradycardia, and hypoxemia Infants who are technology-dependent Infants with unstable airways Infants with rare medical conditions that affect their regulation of breathing Infants with symptomatic chronic lung disease

14. Apnea Monitors: Disadvantages No evidence that apnea monitors effectively prevent SIDS Although 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 home Average monthly price of operation per monitor ranges from $300 to $400, excluding physician fees

15. 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

16. 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.

17. 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.

18. 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