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Apparent life-threatening event. Muhammad Waseem, MD Lincoln Hospital Bronx New York. ALTE. Terrifying episodes for both the family and the ED physician Observer fears that the infant has died. Apparent life-threatening event. An episode that is frightening to the observer Apnea
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Apparent life-threatening event Muhammad Waseem, MD Lincoln Hospital Bronx New York
ALTE • Terrifying episodes for both the family and the ED physician • Observer fears that the infant has died
Apparent life-threatening event • An episode that is frightening to the observer • Apnea • Color change (cyanosis) • Change in muscle tone limp • Choking or gagging
ALTE • Not a diagnosis • Description of a characteristic presentation
ALTE • 0.5 -0.6% of all infants • True frequency & prevalence unknown • Peak incidence 2-3 months
ALTE • Apnea • Cessation of respiration for 20 seconds or more • Bradycardia • Pallor or cyanosis
ALTE • Periodic breathing • Rhythmic respiration with short pauses (3-10 s) • Not associated with bradycardia, pallor or cyanosis • Should not be confused with apnea
ALTE • No typical presentation • “Stopped breathing” (most common) • Stable condition in ED (most common)
ALTE • Can occur during sleep, wakefulness or feeding
ALTE • Relation with SIDS (major fear) • 1-2% (mild) • 8-10% (severe) • Identification of cause does not necessarily eliminate the risk
ALTE • Does a life threatening condition exist? • Was the episode clinically significant? • Can an underlying cause be determined?
ALTE -History • Asleep or awake • Red, pale or blue • Relation to feeding • Spontaneous recovery or CPR • Associated movements/ change in tone • “difficult to take care”
ALTE-Physical Examination • Fever or hypothermia • Tachypnea • Poor feeding, irritability or sleepiness • Tone • Fontanels & fundi
ALTE • Can be a symptom of many specific disorder • Specific identifiable cause (50%)
ALTE • GER • Infections (CNS, pulmonary, sepsis) • Hypocalcemia, hypoglycemia, anemia • Seizure • ICP • Dysrhythmia • Child abuse
GER • Physiologic versus pathologic • Infantile versus childhood • Infantile reflux resolve by first birthday
GER • Awake apnea • Usually reflux related • Sleep apnea? • Nocturnal reflux is uncommon
GER • Sandifer syndrome
GER • Intraesophageal pH study • Gold standard • Difficult to prove
Infections • RSV apnea • < 3 months • Non obstructive • During quiet sleep • Sepsis • Pertussis
Seizure • 4-7% of all infants with ALTE • risk of SIDS • Clinical diagnosis • Neonatal seizure apnea
Inborn Error of Metabolism • Medium chain acyl CoA dehydrogenase deficiency (MCADD) • 4% of severe ALTE • 5% of SIDS
Inborn Error of Metabolism • Only apparent during metabolic stress • Fasting • Non ketotic hypoglycemia in previously healthy infant
Inborn Error of Metabolism • First episode is severe • Family history of ALTE &/or SIDS
Child abuse • Up to 5% of SIDS deaths • Most difficult to diagnose • Key to diagnosis is high index of suspicion
ALTE Evaluation • Whether the event represents an ALTE or not? • Not every infant needs all these tests • No routine evaluation • Should be guided by history & physical
ALTE • CBC? • EKG? • Chest X-ray? • Upper GI? • EEG? • pH probe?
ALTE • Most important is accurate history • Absolute determination of significant episode may not be possible in ED • Often the best investigation is a short period in hospital with monitoring
ALTE • Admit any child with ALTE criteria • Further evaluation & monitoring • Parent education
Quiz -ALTE • 2 year old with c/o “stopped breathing” • Screaming after toy taken by playmate • Stopped breathing limp & blue 15 sec • Resolved spontaneously • Now alert & normal exam
Breath holding Spells • Frightening experience for the parents • 3% of all children • Ages1 and 5 years • May begin before 6 months (25%)
Breath holding Spells • Always provoked by pain, angeror frustration (unpleasant stimulus) • Prolonged expiratory apnea • Rapid development of cyanosis • Normal physical & neurological exam
Breath holding Spells • Prolonged expiratory efforts without inspiratory efforts • Interruption in favorite activity cry red & blue
Quiz -ALTE • 5 month-old male infant couldn’t breath about an hour after feeding • Mother describes “Struggling or gasping to breath” • Well on arrival • Afebrile, HR 110, RR 24, BP 74/46 • Wt 4.3 kg & oral thrush
Quiz -ALTE • 16 month old girl with cerebral palsy • Stiff limp (almost 5 minutes) • Mother described as “she was dead” • “Out of it” for next hour • No fever, trauma or other recent ill contacts
Quiz -ALTE • A 3 month old infant “stopped breathing while sleeping”. Mother describes as weak and blue and “looked dead” • Improved with mouth to mouth breathing • Well appearing in ED