ALTE

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 childs 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 1980s 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/ Infants 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

• Infectious
• Sepsis
• Meningitis/Encephalitis
• RSV/Pertussis/Other respiratory
• GI
• GER
• Volvulus
• Intussusception
• Swallowing dysfunction
• Cardiovascular
• Prolonged QT
• Arrythmia
• Myocarditis
• Vacular Ring
• Metabolic
• Primary Inborn Error of Metabolism Secondary to
  other endocrine, electrolyte, or metabolic
  disorder
• Toxic Exposure
• Carbon monoxide

• Neurologic
• Seizure
• 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 old6 0.45
sec in infants lt6 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 1571011)
• 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. 26108-9, 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.