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SIDS/ALTE

SIDS/ALTE. Tintinalli Chap. 112. Sudden Infant Death Syndrome. Unexpected death of infants < 1 year Leading cause of death of infants between 1 month and 1 year 0.8/1000 live births Diagnosis of exclusion. Risk Factors. Triple-risk model Underlying vulnerability Genetic factors

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SIDS/ALTE

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  1. SIDS/ALTE Tintinalli Chap. 112

  2. Sudden Infant Death Syndrome • Unexpected death of infants < 1 year • Leading cause of death of infants between 1 month and 1 year • 0.8/1000 live births • Diagnosis of exclusion

  3. Risk Factors • Triple-risk model • Underlying vulnerability • Genetic factors • Male gender • Race • Poverty • Prenatal exposure • Critical period of development • First 6 months • Exogenous stressors • Prone sleeping • Soft/adult bedding • Bed sharing • Minor infection (RSV)

  4. Clinical Presentation • Either • Not amenable to resuscitation • Or • Potentially responsive to resuscitation measures • Infants with rigor mortis, livedoreticularis, pH < 6 and significantly reduced core temp in the absence of environmental hypothermia should not be resuscitated

  5. History • Complete description of circumstances • Caretakers • Recent illness • Prenatal/birth history • History of other infant deaths • Family history of metabolic dz • Sleep position • Sleep location • When/who last saw baby alive • Position baby was found • Bed sharing

  6. Exam • Signs of trauma • Facial bruising • Petechiae • Blood in nose/mouth • Rectal temp • Rigor mortis/lividity

  7. Management • Notify, educate, and counsel family • Notify coroner • Notify PCP • Notify hospital chaplain

  8. Apparent Life-threatening Event • A symptom not a diagnosis • Episode that is frightening to a caregiver and involves some combination of the following: • Apnea • Color change • Change in muscle tone, choking, or gagging • Peak incidence between 1 week and 2 months of age • Most before 10 weeks

  9. Risk Factors • RSV infection • Prematurity • Recent anesthesia • Known gastroesophageal reflux/maxillofacial anomalies

  10. Apnea • Pauses of > 20 seconds or those with changes in color, tone, or heart rate are considered pathologic • Central • Cessation of respiratory effort • Obstructive • Attempting to breathe through an occluded airway • Mixed

  11. Color Change • Cyanosis • May be seen in the normal infant • Perioral • Acrocyanosis • Plethoric • “purple” coloring in the crying infant • Pallor • Vasovagal response • GERD

  12. Change in Tone • Seizures • Hypoxia • Severe GERD (Sandifer syndrome)

  13. Choking, Gagging, or Coughing • GERD • Overfeeding • Incoordination of suck-swallow-breath sequence • Exacerbated by URI • Congenital anatomic malformations • Tracheoesophageal fistula

  14. Differential Common Less Common Pertussis Inflicted injury Poisoning Serious bacterial infection Electrolyte abnormality • Seizure • GERD • Respiratory tract infection • Benign periodic breathing • Vomiting/choking episode

  15. Workup • Urine Toxicology • Consider in all patient’s in whom another diagnosis is not likely • Full sepsis workup • All infants < 2 months presenting with ALTE • CBC, UA, urine culture, blood culture, LP

  16. Disposition • 83% are admitted • Stable with a clear diagnosis • Unstable without a clear diagnosis • Stable without a clear diagnosis

  17. Indications for Admission • < 48 weeks post-conceptual age • Ill appearing • Concerning findings on PE • Bronchiolitis or pertussis with apnea • Suspected non-accidental trauma • More than one event in 24 hours • Multiple ALTEs • Significant PMH • Prolonged central apnea • ALTE requiring resuscitation • Poor follow-up • Family history of SIDS

  18. Prior to Discharge • Talk with PCP • CPR instruction • Education • Cough and cold preparations are contraindicated in infancy!

  19. Question 1 • A mother brings in her 3 week old, found him floppy and not breathing during a nap. Given rescue breaths by the mother and then returned to normal. EMS reports No abnormalities. Child is alert appears well without distress and no obvious focal findings on primary survey. What is the next most appropriate step? • A. Head CT • B. H&P • C. CBC, UA, CXR • D. RSV Swab • E. Admit

  20. Question 2 • 2 week old is brought in by parents who concern when she stopped breathing and turned blue. Parents note she has not been feeding well. The infant is alert, jittery, tachycardic, irritable, and tachypneic. You should do which of the following first? • A. Ask RN draw variety of blood samples and hold spare tubes • B. Administer broad spectrum Antibiotics? • C. Full Vital signs and a Fingerstick? • D. Bolus with 10ml/kg of 3% saline • E. Administer Prostaglandin E?

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