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Understanding Apparent Life-Threatening Events in Infants

Discover the characteristics, evaluations, and potential underlying causes of ALTE in infants. Learn about related conditions like GER, seizures, and metabolic disorders. Find out how to differentiate ALTE from breath-holding spells and provide proper care.

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Understanding Apparent Life-Threatening Events in Infants

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  1. Apparent life-threatening event Muhammad Waseem, MD Lincoln Hospital Bronx New York

  2. ALTE • Terrifying episodes for both the family and the ED physician • Observer fears that the infant has died

  3. Apparent life-threatening event • An episode that is frightening to the observer • Apnea • Color change (cyanosis) • Change in muscle tone  limp • Choking or gagging

  4. ALTE • Not a diagnosis • Description of a characteristic presentation

  5. ALTE • 0.5 -0.6% of all infants • True frequency & prevalence unknown • Peak incidence 2-3 months

  6. ALTE • Apnea • Cessation of respiration for 20 seconds or more • Bradycardia • Pallor or cyanosis

  7. ALTE • Periodic breathing • Rhythmic respiration with short pauses (3-10 s) • Not associated with bradycardia, pallor or cyanosis • Should not be confused with apnea

  8. ALTE • No typical presentation • “Stopped breathing” (most common) • Stable condition in ED (most common)

  9. ALTE • Can occur during sleep, wakefulness or feeding

  10. ALTE • Relation with SIDS (major fear) • 1-2% (mild) • 8-10% (severe) • Identification of cause does not necessarily eliminate the risk

  11. ALTE • Does a life threatening condition exist? • Was the episode clinically significant? • Can an underlying cause be determined?

  12. 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”

  13. ALTE-Physical Examination • Fever or hypothermia • Tachypnea • Poor feeding, irritability or  sleepiness • Tone • Fontanels & fundi

  14. ALTE • Can be a symptom of many specific disorder • Specific identifiable cause (50%)

  15. ALTE • GER • Infections (CNS, pulmonary, sepsis) • Hypocalcemia, hypoglycemia, anemia • Seizure •  ICP • Dysrhythmia • Child abuse

  16. GER • Physiologic versus pathologic • Infantile versus childhood • Infantile reflux resolve by first birthday

  17. GER • Awake apnea • Usually reflux related • Sleep apnea? • Nocturnal reflux is uncommon

  18. GER • Sandifer syndrome

  19. GER • Intraesophageal pH study • Gold standard • Difficult to prove

  20. Infections • RSV  apnea • < 3 months • Non obstructive • During quiet sleep • Sepsis • Pertussis

  21. Seizure • 4-7% of all infants with ALTE •  risk of SIDS • Clinical diagnosis • Neonatal seizure  apnea

  22. Inborn Error of Metabolism • Medium chain acyl CoA dehydrogenase deficiency (MCADD) • 4% of severe ALTE • 5% of SIDS

  23. Inborn Error of Metabolism • Only apparent during metabolic stress • Fasting • Non ketotic hypoglycemia in previously healthy infant

  24. Inborn Error of Metabolism • First episode is severe • Family history of ALTE &/or SIDS

  25. Child abuse • Up to 5% of SIDS deaths • Most difficult to diagnose • Key to diagnosis is high index of suspicion

  26. 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

  27. ALTE • CBC? • EKG? • Chest X-ray? • Upper GI? • EEG? • pH probe?

  28. 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

  29. ALTE • Admit any child with ALTE criteria • Further evaluation & monitoring • Parent education

  30. 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

  31. Breath holding Spells • Frightening experience for the parents • 3% of all children • Ages1 and 5 years • May begin before 6 months (25%)

  32. Breath holding Spells • Always provoked by pain, angeror frustration (unpleasant stimulus) • Prolonged expiratory apnea • Rapid development of cyanosis • Normal physical & neurological exam

  33. Breath holding Spells • Prolonged expiratory efforts without inspiratory efforts • Interruption in favorite activity cry red & blue

  34. 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

  35. 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

  36. 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

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