1. STEP BY STEP MANAGEMENT OF ALTE Dr. D. Alvarez September 2006

2. ALTE An episode that is frightening to the observer and is characterized by some combination of: –Apnea –Color change –Marked change in muscle tone –Choking or gagging In some instant the observer fears that the infant has died. Recovery occurs only after stimulation or ressuscitation. Recurrence of ALTE is very frequent and occurs in 30- 60% of all ALTE. True frequency of recurrence is probably even higher since many true documented apnea not leading to full blown ALTE go undetected by parents.

3. ALTE – Definition (Other) Episode frightening to the observer plus 1 or more of the following –Apnea central > obstructive –Color changes: blue or pale –Sudden limpness) –Chocking – gagging Recurrence 13 %

4. INITIAL PROCES 1.Call from the ED/4-B requesting bed for a patient with Diagnosis of ALTE 2.Resident / Supervisor (if applicable) obtains information on patients condition, on the phone or going to the ED/4-B, (as activity in the unit warrants). 3. Information needed: Detail history from the observer (who was with the infant during the “episode”)

5. ALTE - History should include 1.Duration of the event 2.Time of the day 3.Time after feeding (any changes in feeding if any) 4.Adequacy of lighting 5.Infant position within his / her surroundings (soft bedding, pillows?) 6.Did episode began while awake or asleep 7.Changes in Color 8.Changes in muscle tone 9.Need for any type of resuscitation (describe) 10.Was any blood or pink frothing coming from infants mouth or nose 11.Appropriateness of caregiver’s concerns 12.Fly. Hx of SIDS or serious illness with coma 13.Any associated respiratory symptoms.(URI – Coughs)

6. Focus PE (ALTE) Alertness Tone Bruising Scalp swelling Disuse of extremities Fundoscopy, retinal hemorrhages Chest exam, stridor.

7. Selected Causes of ALTE RSV, Pertusis Sepsis with apnea Syndromes compromising the upper airway (Pierre-Robin) Breath holding spells Seizures Intracraneal hemorrhages, vascular abnormalities, child abuse, Vit K deficiency. Exaggerated laryngeal chemoreceptor with or without GER Drug. (Phenothyazede) Tachyarreithmias, SVT, prolongued QT intervale. Inborn errors of metabolism Hypoventilation during bed sharing.,soft bedding

8. Apnea of Infancy An ALTE episode with no found cause. Unexplained episode of cessation of breathing for > 20 sec, or shorter respiratory pause associataed with bradycardia, cyanosis, pallor, and/or marked hypotonia in an infant whose age during initial event is > 37 wks postconceptional age.

9. ED Events. 4.- Review of ED-Events –Assessment on presentation to ED –Intervention / therapies and response –Studies / labs done (Start laboratory flow sheets record) CBC with diff and Electrolytes. »Look for hypoglycemia, metabolic acidosis. Source of infection: UA, blood cultures. CxR Look for any lung pathology and heart side EKG 5.- Communicate with PICU Attending and inform on patient’s condition. 6.- Inform PICU Nurses that patient was accepted and up-date them on patient’s condition.

10. ASSESSMENT & MANAGEMENT

11. OVERALL ASSESSMENT / FOCAL SIGNS INTERVENTIONS Patient’s looks well at baseline condition Afebrile -No Focal signs Observe /monitor F/U initial studies CBC, Lytes, Cultures, EKG, RSV Identify/investigate and such as: RSV, Pneumonia, GER, etc.** Treat the identifiable causes. Ill, sick looking with no indefinable causes. ? Sepsis / Management ? Metabolic workup –ABG, LFT, Amonia level, – Lactic and Pirubic Acid – Urine metabolic screening, INITIAL MANAGEMENT

12. GENERAL / OVERALL ASSESSMENT AND FOCAL FINDINGS Identify/investigate and treat focal abnormalities such as: Possible bacterial infection early sepsis? Respiratoy symptoms –Close respiratory monitoring –CxR –Respiratory therapy according to pathology: URI?, LRI Cardiovascular abnormalitis –Cardiomegaly, EKG abnormalities Continue investigations according to physical exam –R/O CNS infections >LP ? Head CT –Metabolic screening: ABG, Lactic Acid, LFT, ammonia level

13. Basic Recommended Evaluation for ALTE Admit to observation and cardiorespiratory monitoring Careful history, physical and neurologic examination Complete blood count Blood glucose, electrolytes, Calcium CxR, ECG, Arterial Blood gases EEG Multichannel recording including oxygenation.

14. Evaluation of ALTE in Selected Cases: Septic workup (blood, urine, CSF cultures) Barium Swallow Lateral neck x Rays Milk scan PH probe U/S or CT scan of brain Echocardiogram Blood amonia and urine Amino acid if recurrent.

15. “Indication” for home C-R monitoring History of ALTE Multichanel documentation of clinical significant Apnea Twin of SIDS Apnea of Prematurity Periodic breathing associadited with hypoxia Feeding associated with apnea and bradycardia Technology dependent children ISAM (Selected cases) Sibling of SIDS (Selected Cases)

16. Home Monitor Settings: Heart Rate Alarm –High: 220 bpm –Low: 70 bpm (< 2 mo) 60 bpm (2-8 mo) 50 bpm (> 8 mo) Apnea: –> 15 sec – record –> 20 sec – alarm If SaO2 is monitored: Alarm set at < 85 %

17. ALTE Begin Monitor 2-3 months no true alarms Event Record Normal Abnormal Event Recording True Alarms Discontinue Monitor Continue Monitoring