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ALTEs , SIDS, and Prems

ALTEs , SIDS, and Prems. Russell Lam September 1, 2011 Special thanks to Bela Sztukowski for her help on this presentation. Objectives. Discuss the history of ALTEs , diagnostic work-up, and follow-up Review risk factors for SIDS

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ALTEs , SIDS, and Prems

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  1. ALTEs, SIDS, and Prems Russell Lam September 1, 2011 Special thanks to BelaSztukowski for her help on this presentation

  2. Objectives • Discuss the history of ALTEs, diagnostic work-up, and follow-up • Review risk factors for SIDS • Review some conditions commonly encountered in the ED relevant to prematurely born patients

  3. Case 1 • 2 mo male brought in after a choking episode • Grandmother picked up baby after a nap, 2 hours post feed • Baby made choking noise and turned off-colour. Back blows given • Vitals in ED: P120 R45 T 37 BP 95/60 Sp02 100% room air • Exam unremarkable

  4. What investigations do you want (if any)? • How long will you monitor in the ED? • What do you tell this grandmother?

  5. A historical perspective

  6. “The hypothesis implicating prolonged apnea during sleep is causally related to SIDS underscores the need for further research directed toward a greater understanding of the variables influencing the occurrence of sleep apnea…” • 2 decades later – evidence of infanticide for all 5 infants became known

  7. Definitions • Apparent Life Threatening Event • Frightening to the observer • Combination of • Apnea • Color change • Tone change • Cough or gagging Infantile Apnea and Home Monitoring. NIH Consensus Statement 1986 Sep 29-Oct 1;6(6):1-10.

  8. Definitions • Sudden infant death syndrome • Death of infant or child unexplained by history • Post mortem fails to demonstrate adequate explanation • Less than 1 year • Case investigation and death scene examination fail to demonstrate adequate explanation Infantile Apnea and Home Monitoring. NIH Consensus Statement 1986 Sep 29-Oct 1;6(6):1-10. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. PediatrPathol. 1991;11:677–684

  9. Definitions • Apnea of infancy • Unexplained cessation in breathing > 20s or < 20s if • Bradycardia • Cyanosis • Pallor • Hypotonia • Apnea of prematurity • Same as above but < 37 weeks GA Infantile Apnea and Home Monitoring. NIH Consensus Statement 1986 Sep 29-Oct 1;6(6):1-10.

  10. Who gets ALTEs? • 0.5-6% of all infants • Difficult to estimate true incidence as: • Subjective nature of definition • Not all ALTEs will visit the ED • Retrospective data Brooks JG. Apparent life-threatening events and apnea of infancy. ClinPerinatol 1992;4:809 – 838.

  11. Who gets ALTEs? • Prospective study (1993-2001) • 2.46/1000 live births • Average age of ALTE = 8 weeks • 55% of ALTEs had diagnoses • Respiratory (RSV/pneumonia) (29%) • GI (GERD/Feeding aspiration) (22%) • Congenital cardiac (2%) • Metabolic/Neuro (2%)

  12. ALTE Risk Factors • Family history of infant death, single parenthood, profuse night sweating, smoking, repeated cyanotic episodes, pallor, apnea, feeding difficulties

  13. Typical History

  14. Typical physical General physical appearance, work of breathing, circulatory signs, respiratory rate, pulse rate not clinically abnormal Stratton SJ, Taves A, Lewis RJ, et al. Ann Emerg Med 2004; 43:711–717

  15. Differential of the cause of an ALTE?

  16. Causes of ALTEs? • N = 643 pts (1991-2002) • Most common diagnoses • GERD (31%) • Seizure (11%) • LRTI (8%) • Unknown (23%)

  17. Serious Bacterial Infection? • Altman (2008) – Retrospective chart review N=243 • 5% had occult bacterial infection • 26% had obvious bacterial infection • Mittal (2009) – Prospective cohort N=198 • 22.2% had cultures • 0% had serious bacterial infection • Zuckerbraun (2009) – Retrospective chart review N=182 • 61.5% had cultures • 2.7% had serious bacterial infection • Premature patients more likely to have SBI (6.7 v 0.8%)

  18. A reasonable work-up?

  19. Back to the case… • Would you admit this 2 month old patient? • History = consistent with ALTE definition • Physical = normal • Risk Factors • None (no smoke at home, usually feeds well, married parents)

  20. 3 year prospective study N = 59 • 8 patients met “hospital required” outcome criteria • Multiple ALTEs and prematurity (<37 weeks) SD from “hospital not required patients” • Most common demographic features were age < 1mos and multiple ALTEs • From this study, 2 criterion features developed: • age < 1mos and/or multiple ALTEs yields 100% NPV 100% Sens for need for hospital admission

  21. Mortality? Recurrence? • 9 year prospective study N = 563 • 3 deaths (0.5%) • 2 SIDS and 1 from child abuse • Recurrence • 37.9% had recurrent episodes • 8.9% would return visit for ALTE

  22. How is ALTE different from SIDS?

  23. Take home points on ALTE • Scary+ Apnea/Colour Change/Tone/Choking • Broad differential but mostly GER/LRTI/CNS • Likely need admission + broad work-up • Low mortality rate (0.5%) • ALTE ≠ SIDS

  24. Case 2 • 6 mo male brought in because of cough x 3 days • You diagnose URTI and discharge the patient • On the way out, mother asks: “By the way, a mother from book club just got an apnea monitor. Should I get one too?”

  25. A little about SIDS • Most common cause of death in 1mos-1y (20-25% of all deaths < 1 year) • 2006 = 0.54 per 1000 live births in the US • Most will occurs age 2-4 months, almost all by 6 months

  26. SIDS versus SUDI • Sudden Unexpected Death of Infancy (SUDI) • Umbrella term which includes SIDS but also other causes of sudden infant death (CVS, Abuse, Metabolics) • SIDS requires autopsy and death scene examination

  27. Pathophysiology of SIDS Filiano and Kinney. Biol Neonate 1994;65(3-4): 194-7

  28. Long QT? Schwartz et al. 1998. New Eng J Med. 338 (24):1709-1714

  29. Risk factors?

  30. Risk factors? • Sleeping prone • Maternal smoking during and after pregnancy • Bed-sharing, especially if EtOH or very tired parent • Soft bedding, pillow, covers over the head • Prematurity (<37 weeks) • Low birth weight (<2500g)

  31. A safe sleeping environment • CPS 2004 Guidelines • 1st six months babies should sleep in own crib in parent’s room • Sleep on back in an approved crib • No quilts/comforters, pillows • Room-sharing is protective, bed-sharing is not • No sleeping on couch, water bed, air mattress, car seats

  32. Pacifiers? Huack et al. Pediatrics (2005). 116 (5):716-722

  33. CPS (2004) • Does not recommend pacifier use to reduce risk of SIDS • Caution before routinely advising against pacifier use • AAP (2005) • Pacifier for 1st year of life when putting down to sleep • Delay until 1 month of age ifexclusive breastfeeding

  34. Apnea Monitors? • CHIME study (1994-1998) • 1079 infants in 4 groups • Healthy Term, Idiopathic ALTE, SIDS-Sibling, Preterm • All given plethysmography • All groups had similar numbers of apnea/bradycardia on monitors • Extreme apneas in 10% of all infants • Significantly more AsBs in Preterm infants • But all resolved by 43 weeks post conceptual age • 6 deaths, none on monitors

  35. Apnea Monitors? • AAP 2005 • Many infants get Apneas/Bradycardia and do not die • Apnea resolves prior to when most SIDS deaths occur • Does not prevent SUDI • Possible groups who need apnea monitors • Preterm infants • CPAP/Trach’dpatients

  36. Twins? • Malloy (1995) • N = 23464 single SIDS deaths and 1056 twin SIDS deaths • RR 1.13 (95%CI 0.97-1.31) for twins when adjusted for birth weight • RR 8.17 (90%CI 1.18-56.67) if 1 twin died of SIDS • Getahun (2004) • N = 501 SIDS deaths overall • RR 1.9 (95%CI 1.68-2.01) but not matched for birth weight • RR 4.7 (95%CI not reported) if 1 twin died of SIDS

  37. Take home points on SIDS • Different from ALTE • Two most important risk factors are prone sleeping and maternal smoking • Back to sleep in their own crib • Don’t discourage pacifiers • Apnea monitors don’t help • If a twin already died of SIDS, other twin at way higher risk. Admission debatable…

  38. Case 3 • 2 month old ex 24 week male comes in with wheeze and cough • Mom hands you a summary from the NICU that she was given • ELBW and SGA • RDS/BPD • NEC • Grade III IVH • ROP Zone 2 Stage 1 • GERD with Fundo • G-Tube Fed

  39. The Lingo • Prematurity = <37 weeks gestational age • Birth weight • Low birth weight = < 2500g • Very low birth weight = < 1500g • Extremely low birth weight = < 1000g

  40. The Lingo Age Terminology During Perinatal Period. Pediatrics. 114 (5):1362-1364

  41. Bronchopulmonary Dysplasia • Defined by oxygen needs beyond 28 days of life • Initial respiratory disease (RDS/Meconium Aspiration) then chronic lung disease that develops afterwards • 3 big risk factors • Oxygen toxicity • Mechanical ventilation • Exaggerated inflammatory response Lacy Gomella. Neonatology. 2004

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