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Good Morning!. July 24 th , 2012. Apparent Life-Threatening Events (ALTE)*. Definition An episode that is frightening to the observer and that is characterized by some combination of: Apnea (central or occasionally obstructive)

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  1. Good Morning! July 24th, 2012

  2. Apparent Life-Threatening Events (ALTE)* • Definition • An episode that is frightening to the observer and that is characterized by some combination of: • Apnea (central or occasionally obstructive) • Color change (usually cyanotic or pallid but occasionally erythematous or plethoric) • Marked change in muscle tone (usually marked limpness) • Choking • Gagging

  3. Central vs obstructive apnea

  4. **

  5. Illness Script • Predisposing Conditions • Age, gender, preceding events (trauma, viral illness, etc), medication use, past medical history (diagnoses, surgeries, etc) • Pathophysiology • What is physically happening in the body, organisms involved, etc. • Clinical Manifestations • Signs and symptoms • Labs and imaging

  6. Predisposing Conditions (ALTE) • Average age: 8 weeks • Boys = Girls • Maternal smoking • ?prematurity (conflicting evidence) • Prone sleeping is not associated with ALTE (but it is a significant risk factor for SIDS**)

  7. Pathophysiology • ALTE is a diagnosis based on SYMPTOMS not necessarily on pathophysiology • 50% of cases→ no apparent cause is ever found • Other 50%: a co-morbid condition is found • 3 most common: • GER • Seizure • Lower respiratory tract infection

  8. Clinical Manifestations** • Apnea • Color change • Marked change in muscle tone • Choking • Gagging • Concerning to caregiver

  9. Evaluation** • History • Physical • Diagnostic Studies • No randomized, controlled trials • Based on clinician’s own degree of suspicion and comfort • History and physical should direct additional testing

  10. Admit vs Send home

  11. Evaluation** • Based on history and physical exam • But, if non-suggestive presentation • Top 5 highest yield studies • Screening for GER • Urine analysis, urine cx • Brain neuroimaging • Pneumogram • WBC count • Think about severity of event, patient discomfort, and cost analysis • Remember underlying cause is never found in 50%!

  12. Evaluation** • Evaluation may expand to include: • CRP • Electrolytes • Blood gas • Ammonia, lactate, pyruvate • Blood culture • Tox screen • EKG, Echo • EEG • RSV, pertussis

  13. Apnea monitors • Alert caregivers to episodes of apnea and bradycardia • Infants wear at all times or at least when sleeping • False alarms if sensors shift

  14. Recognize the limitations** • Widespread use began in 1970’s when it was thought apnea was a precursor to SIDS • No convincing evidence has linked prolonged apnea to SIDS • No evidence that apnea monitors effectively prevent SIDS • Studies demonstrate apnea and bradycardia lasting more than 20 seconds are common even in healthy children • Episodes are as frequent among healthy infants as those with idiopathic ALTE

  15. Do parents feel better? • One study showed it made them feel more secure • HOWEVER, in same study, psychological testing showed an emotional toll • Increased depression and hostility within 2 weeks vs those discharged without a monitor • What about cost? • $300-$400 per month (not including physicians fees)

  16. Recommendations** • AAP recommends monitoring for 2 groups: • 1) Preterm infants who are at high risk of recurrent episodes of apnea, bradycardia, and hypoxemia after hospital discharge (limited to 43 weeks post-menstrual age or until no recorded episodes) • 2) Infants who are technology-dependent, have unstable airways, have rare medical conditions affecting regulation of breathing, or have symptomatic chronic lung disease

  17. PRognosis • Will it happen again? • 10% have additional events that are considered clinically significant • Risk factors • Prematurity • History of multiple ALTE prior to admission • Viral respiratory infection • What to do? • Parents should get CPR training • Back to sleep • Safe sleep environments

  18. Thank you!! Linda Y. Fu and Rachel Y. Moon. Apparent Life-threatening Events (ALTEs) and the Role of Home Monitors. Pediatrics in Review June 2007; 28:203-208 Noon Conference: Inpatient ID (Dr. Begue)

  19. Predisposing Conditions (SIDS)** • Male gender • Low birthweight or prematurity • Maternal smoking during pregnancy • Seasonal distribution with a peak in winter months, lower socioeconomic status • Young maternal age • Higher parity • Single parenthood • Multiple gestation • **NOT associated with history of apnea**

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