ALTE: Apparent Life Threatening Event

1. ALTE:Apparent Life Threatening Event Désirée Michelle Seeyave, MB.BS Clinical Assistant Professor April 28th, 2011

2. Objectives • Define ALTE • Discuss the incidence, morbidity and mortality of ALTE • Discuss causes and symptoms of ALTE • Distinguish between ALTE and SIDS • Discuss management of a patient presenting with an ALTE

3. Case #1 A woman calls 911 because her 14 day old term infant stopped breathing. According to his distraught mother, 1 hour after breast feeding he gasped for breath and became blue around his lips. He was not breathing for about 10 seconds and was limp. She picked him up and blew on his face, then he gasped and started crying. On arrival to the home, you find:

5. Or you may find this baby....

7. Apparent Life-threatening Event (ALTE) Definition An episode that is frightening to the observerand characterized by some combination of • apnea • color change • marked change in muscle tone • choking, gagging or coughing • AND observer may fear the infant has died - National Institutes of Health Consensus Panel on Infantile Apnea and Home Monitoring, 1986

8. ALTE • New definition replaced existing terminology: • “Near miss SIDS” • “Aborted cot death”

9. ALTE • True incidence unknown • Demographic data from admissions and ED visits: • 0.6-9/1000 live births • 0.6-0.8% of ED visits for children < 1 yr • Peak incidence: 1 wk-2 mo • Most occur < 10 wks • Mortality < 1 % cases

10. ALTE • Risk factors • Prematurity, especially with RSV infection • Rapid feeders • Frequent coughing • Choking with feeds • Boys > girls • Significant disorder more likely if > 2 months and recurrent episodes

11. EMS Statistics • 7.5% of infant encounters • Mean age 3 months • 55% males • Distress: • None: 83.3% • Mild: 13.3% • Moderate: 3.3 • 1/3 had significant pathology

12. Challenges in diagnosing ALTE • Caregiver(s) usually distraught • Description of event may be unreliable • Patient often appears well • Events are non-specific: • It is a complaint, not a diagnosis • Many possible causes • Many cases never find underlying cause (25-50%)

13. Symptoms of ALTE • APNEA • Central, obstructive, mixed • COLOR CHANGE • Cyanotic, pale, red/plethoric • MUSCLE TONE CHANGE • Floppy • Rigid (think seizure) • CHOKING, GAGGING or COUGHING

14. Etiology of ALTE • Many underlying causes • Approx. 50% definitive etiology found • Intervention may eliminate future events

15. Etiology - GI • GI most common cause (30-50% cases) • Gastroesophageal Reflux Disorder (GERD) • Pain causes respiratory pause or gasping • Sandifer’s syndrome – mimics seizures • Gastric volvulus • Intussusception • Swallowing abnormalities • Other GI abnormalities

16. Etiology - Neurologic 10-25% of cases • Seizure disorder • Febrile seizure • Vasovagal reflexes or malignancies • Neuro conditions affecting respiration • Budd-Chiari syndrome • Hindbrain or brainstem malformations • VP shunt malfunction • CNS bleed or infection

17. Etiology - respiratory 8-20% of cases • Infections: • RSV • Pertussis • Mycoplasma • Croup • Pneumonia

18. Etiology - respiratory • Conditions affecting respiratory control • Prematurity • Central hypoventilation • Breath-holding spell • Pallid form • Loss of consciousness +/- Seizure • Laryngotracheomalacia

19. Etiology - respiratory • Foreign body aspiration

20. Etiology - respiratory • Obstructive Sleep Apnea (OSA) • Vocal cord abnormalities • Adenoid vegetations • Airway obstruction from congenital abnormalities

21. Etiology - Cardiac 1-5% cases • Arrhythmia • Long QT syndrome • WPW syndrome • Myocarditis • Congenital heart disease • Cardiomyopathy

22. Etiology - Metabolic abnormalities < 5% cases • Inborn errors of metabolism • Endocrine, electrolyte disorders • UTI • Sepsis • Other infections

23. Etiology – Nonaccidental injury (Child abuse) < 5% cases • Munchausen by proxy • suffocation • salt poisoning • medication overdose • physical abuse • head injury • Smothering • unintentional or intentional

24. Etiology – other • Food allergies • Anaphylaxis • Medications • Prescription • OTC • Herbal remedies

25. Normal but misinterpreted as abnormal • Irregular breathing of REM sleep • Periodic breathing • Normal breathing pattern with 3 or more pauses, each > 3 seconds, with < 20 seconds of normal respiration between pauses • No change in color or tone • Respiratory pauses (5-15 seconds) and longer pauses after sighing • Transient choking, gagging, coughing during feeding

26. Abnormal apnea • Apnea • cessation of respiratory airflow for any reason - central, obstructive, or mixed • < 15 seconds can be normal at all ages • Pathologic apnea • lasts ≥ 20 seconds with bradycardia, cyanosis, hypotonia, or other signs of compromise

27. ALTE vs SIDS • Relationship unknown • ALTE – usually benign • 80% occur between 8 am-8 pm • SIDS – fatal • sudden death in a child < 1 year without historical, physical, laboratory, or thorough postmortem findings that explain cause of death • 80% occur between MN-6 am

28. ALTE vs SIDS • SIDS campaign (1994) “Back to Sleep” • Resulted in decreased SIDS incidence by 50% • No change in incidence of ALTE • Likely 2 separate entities

29. ALTE – Evaluation • Event should be taken seriously • Immediate evaluation • Work-up may be extensive • Careful history of • the event • circumstances surrounding event • resuscitative measures • may be unreliable given the emotional state of caregiver

30. ALTE – History Description of event: • Condition of child: • Awake or asleep • Position: prone, supine, on side • Location of child: crib, parent's bed, baby seat, other • Bedclothes, blankets, pillows

31. ALTE – History Description of event: • Activity during event • feeding, coughing, gagging, choking, vomiting • Breathing efforts • none, shallow, gasping, increased, color of infant

32. ALTE – History Description of event • Color • pallor, red, purple, blue, peripheral, whole body, circum-oral • Movement and tone • rigid, tonic-clonic, decreased, floppy • Coughing, vomiting • productive, mucus, blood, or noise (silent, cough, gag, wheeze, stridor, crying) • Duration: • Length of time to reinstate regular breathing and normal behavior or tone or time of resuscitation

33. ALTE – History • Description of event: • Interventions: • None • Gentle stimulation • Blowing air in face • Vigorous stimulation • Mouth-to-mouth breathing • CPR by parent or medically trained person

34. ALTE – History •  HPI • Any illness in days or hrs leading up to event • Fever • Poor feeding • Weight loss • Rash • Irritability, lethargy • Sick contacts, medications administered, immunization

35. ALTE – History • Prenatal: use of drugs, tobacco, or alcohol during pregnancy • Birth: SGA, prematurity, birth trauma, hypoxia, presumed sepsis • Feeding: gagging, coughing, poor weight gain • Dev. history: appropriate milestones

36. ALTE – History • Previous admissions, surgery, ALTE’s, accidents (being dropped or tossed; possibility of trauma) • Family History: • congenital problems, neurologic conditions, neonatal and child deaths • smoking in the home • cardiac arrhythmia • ALTE’s in siblings • SIDS

37. ALTE - History • Environment: • Sleeping environment • Medications/drugs of abuse/paraphernalia/cigarettes

38. ALTE – Physical examination Look for: • Dysmorphic features • Vital signs • Weight - ?failure to thrive • Abdomen: signs of trauma • Neuro: pupils, muscle tone, developmental stage

39. ALTE - Diagnosis • Thorough history essential to make a diagnosis • Normal physical exam found in most cases

40. ALTE – management considerations • Is this immediately life-threatening? • Is it just frightening and not life-threatening? • Is this over-reaction to a normal event? • Is this truly abnormal behavior?

41. ALTE - management • ABCs • IV access if indicated • Blood sugar • If needed: O2, pulse ox, cardiac monitor, EKG

42. ALTE - management • Leave the baby in caregiver’s arm for evaluation, car seat for transport • Transport • Protocols may vary • All babies should be evaluated by medical personnel • May allow private transport if baby is stable and parents are reliable

43. First, short, self-correcting episode with feeding? Yes No

44. ALTE – management • Manage immediate event • Find underlying cause and treat • Educate and reassure parents • Determine need for admission • CPR classes • Home monitoring • controversial, false alarms, parental anxiety, efficacy • Only recommended for infants with severe ALTEs requiring mouth-mouth, symptomatic preterm infants, siblings of 2 or more SIDS victims, central hypoventilation

45. ALTE Summary • ALTE frightening to observer who may fear death • Cause found in ~50% • Detailed history essential • Take event seriously, even if baby appears well • ABCs as needed • ALTE ≠ SIDS • Remember non-accidental injury

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47. References • Infantile Apnea and Home Monitoring, National Institutes of Health Consensus Development Conference StatementSept 29-Oct 1, 1986 • McGovern MC, Smith MBH, Causes of apparent life threatening events in infants: a systematic review Arch Dis Child 2004;89:1043-1048 • Hall KL, Zalman B. Evaluation and management of apparent life-threatening events in children. Am Fam Physician. 2005 Jun 15;71(12):2301-8