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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

Apparent life-threatening event

Muhammad Waseem, MD

Lincoln Hospital Bronx New York

slide2
ALTE
  • Terrifying episodes for both the family and the ED physician
  • Observer fears that the infant has died
apparent life threatening event3
Apparent life-threatening event
  • An episode that is frightening to the observer
  • Apnea
  • Color change (cyanosis)
  • Change in muscle tone  limp
  • Choking or gagging
slide4
ALTE
  • Not a diagnosis
  • Description of a characteristic presentation
slide5
ALTE
  • 0.5 -0.6% of all infants
  • True frequency & prevalence unknown
  • Peak incidence 2-3 months
slide6
ALTE
  • Apnea
    • Cessation of respiration for 20 seconds or more
    • Bradycardia
    • Pallor or cyanosis
slide7
ALTE
  • Periodic breathing
    • Rhythmic respiration with short pauses (3-10 s)
    • Not associated with bradycardia, pallor or cyanosis
    • Should not be confused with apnea
slide8
ALTE
  • No typical presentation
  • “Stopped breathing” (most common)
  • Stable condition in ED (most common)
slide9
ALTE
  • Can occur during sleep, wakefulness or feeding
slide10
ALTE
  • Relation with SIDS (major fear)
    • 1-2% (mild)
    • 8-10% (severe)
  • Identification of cause does not necessarily eliminate the risk
slide11
ALTE
  • Does a life threatening condition exist?
  • Was the episode clinically significant?
  • Can an underlying cause be determined?
alte history
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
ALTE-Physical Examination
  • Fever or hypothermia
  • Tachypnea
  • Poor feeding, irritability or  sleepiness
  • Tone
  • Fontanels & fundi
slide14
ALTE
  • Can be a symptom of many specific disorder
  • Specific identifiable cause (50%)
slide15
ALTE
  • GER
  • Infections (CNS, pulmonary, sepsis)
  • Hypocalcemia, hypoglycemia, anemia
  • Seizure
  •  ICP
  • Dysrhythmia
  • Child abuse
slide16
GER
  • Physiologic versus pathologic
  • Infantile versus childhood
    • Infantile reflux resolve by first birthday
slide17
GER
  • Awake apnea
    • Usually reflux related
  • Sleep apnea?
    • Nocturnal reflux is uncommon
slide18
GER
  • Sandifer syndrome
slide19
GER
  • Intraesophageal pH study
    • Gold standard
    • Difficult to prove
infections
Infections
  • RSV  apnea
    • < 3 months
    • Non obstructive
    • During quiet sleep
  • Sepsis
  • Pertussis
seizure
Seizure
  • 4-7% of all infants with ALTE
  •  risk of SIDS
  • Clinical diagnosis
  • Neonatal seizure  apnea
inborn error of metabolism
Inborn Error of Metabolism
  • Medium chain acyl CoA dehydrogenase deficiency (MCADD)
  • 4% of severe ALTE
  • 5% of SIDS
inborn error of metabolism23
Inborn Error of Metabolism
  • Only apparent during metabolic stress
    • Fasting
    • Non ketotic hypoglycemia in previously healthy infant
inborn error of metabolism24
Inborn Error of Metabolism
  • First episode is severe
  • Family history of ALTE &/or SIDS
child abuse
Child abuse
  • Up to 5% of SIDS deaths
  • Most difficult to diagnose
  • Key to diagnosis is high index of suspicion
alte evaluation
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
slide27
ALTE
  • CBC?
  • EKG?
  • Chest X-ray?
  • Upper GI?
  • EEG?
  • pH probe?
slide28
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
slide29
ALTE
  • Admit any child with ALTE criteria
    • Further evaluation & monitoring
    • Parent education
quiz alte
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
Breath holding Spells
  • Frightening experience for the parents
  • 3% of all children
  • Ages1 and 5 years
  • May begin before 6 months (25%)
breath holding spells32
Breath holding Spells
  • Always provoked by pain, angeror frustration (unpleasant stimulus)
    • Prolonged expiratory apnea
    • Rapid development of cyanosis
  • Normal physical & neurological exam
breath holding spells33
Breath holding Spells
  • Prolonged expiratory efforts without inspiratory efforts
  • Interruption in favorite activity cry red & blue
quiz alte34
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 alte35
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 alte36
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