After evaluating this article, participants will be able to:
1. Incorporate strategies into practice to identify at risk children with ALTEs
2. Develop effective diagnostic strategies for patients that present with ALTEs
Apparent life-threatening events (ALTEs) are a common presenting complaint to the emergency department. According to the National Institutes of Health 1986 definition – which remains the current definition – an ALTE is an episode that is frightening to the observer and is characterized by some combination of apnea (central or obstructive), color change (cyanotic, pallid, erythematous or plethoric), change in muscle tone (usually diminished), and choking or gagging. In pediatrics, the observer sometimes fears that the infant has died.
While up to 50% of cases remain unexplained after medical evaluation, Davies and Gupta found the following diagnoses to be most commonly associated with an ALTE (1):
- Gastroesophageal reflux disease - 26%
- Pertussis - 9%
- Lower respiratory tract infection - 9%
- Seizure - 9%
- Urinary tract infection - 8%
- Factitious illness - 3%
This article will review some recent articles on apparent life-threatening events in children and answer some important questions on the need for hospitalization, extent of evaluation, and diagnoses to consider in these patients.
Q. If you think an infant has gastresopheal reflux and presents with an apparent life-threatening event as a consequence, is hospitalization still required?
A. In this study by Doshi et al, even patients for whom there was a high concordance with admission and discharge diagnosis were at risk for in-hospital events, recurrent ALTEs on discharge and the possibility of a new diagnosis after discharge.
Citation: Doshi A, Bernard-Stover L, Kuelbs C, Castillo E, Stucky EApparent life-threatening event admissions and gastroesophageal reflux disease: the value of hospitalization. Pediatr Emerg Care. 2012 Jan;28(1):17-21.
BACKGROUND: No standard management plan for infants with an apparent life-threatening event (ALTE) currently exists. These infants are routinely hospitalized. Benefits of hospitalization of ALTE patients with gastroesophageal reflux disease (GERD) need definition.
OBJECTIVES: The study’s objectives were to determine the accuracy of a working diagnosis of GERD in infants admitted with ALTE and to describe the history and hospital course of infants with both working and discharge diagnoses of GERD.
METHODS: Authors retrospectively reviewed records from a large children’s hospital of infants aged 1 year old and younger hospitalized from January 1, 2004, to March 1, 2007, with an admission diagnosis of ALTE. Demographics, clinical presentation, testing, hospital course, and 6-month postdischarge visits were abstracted. Intensive care admissions were excluded. Univariate and multivariate analyses identified factors associated with a discharge diagnosis of GERD.
RESULTS: Three hundred thirteen infants met inclusion. Mean age was 2.1 months; mean length of stay was 2.5 days. A discharge diagnosis of GERD was most common (n = 154, 49%); 138 (89%) were initially well appearing, 10 (6%) had in-hospital events, and only 20 (13%) had upper gastrointestinal series performed. Concordance of initial working to discharge diagnosis of GERD was 96%. Nonconcordant diagnoses evolved within 24 hours. Rescue breaths and calling 911 were independently associated with a discharge diagnosis of GERD. Within 6 months, 14 patients (9%) with a discharge diagnosis of GERD had recurrent ALTE, and 5 (3%) had significant new diagnoses.
CONCLUSIONS: Concordance of initial working diagnosis with discharge diagnosis of GERD in ALTE patients is high. However, in hospital events, evolution to new diagnoses and recurrent ALTE suggest that hospitalization of these patients is beneficial. Diagnostic studies should not be routine but should target concerns from the history, examination, and hospital course
Q. Do you have to do a full work-up on every infant who presents with an ALTE?
A. This study supports performing a focused evaluation rather than a gunshot approach to laboratory evaluation.
Citation De Piero AD, Teach SJ, Chamberlain JMED evaluation of infants after an apparent life-threatening event. Am J Emerg Med. 2004 Mar;22(2):83-6.
OBJECTIVE: The objective of this study was to determine the rate of positive ED diagnostic evaluations and significant interventions during the hospitalization of infants after an apparent life-threatening event (ALTE). The study was performed at a single, tertiary care children’s hospital.
METHODS: Patients under 6 months of age were identified for a potential ALTE from the ED chief complaint log. The charts of patients meeting the definition of an ALTE were abstracted for data pertaining to the patient’s history, physical examination, ED diagnostic evaluation, and admission.
The yield of the ED diagnostic evaluation and hospitalization was noted. A positive ED evaluation was defined as a diagnostic intervention that resulted in a specific treatment for a defined condition.
Significant medical interventions were derived from a validated instrument assessing the risk of admission for pediatric patients presenting to an ED. Such interventions included, but were not limited to, parenteral antibiotics for documented infections, supplemental oxygen, endotracheal intubation, airway suctioning, and intensive-care unit admission.
RESULTS: Over a 5-year period with 253,408 patient visits, 523 patents met the initial search criteria for a potential ALTE. From this group, 483 charts were reviewed (92.4%) and 150 patients met the definition for an ALTE. The mean age of the patients was 61.7 days and 115 (76.7%) were admitted. Of the patients with an ALTE, 122 patients had ED diagnostic tests performed and three had a positive result (2.5%; 95% confidence interval [CI]; 0.5-7.0). The rate of significant medical interventions among admitted patients was 7.% (9 of 115, 95% CI, 3.6-14.3). No patients with a positive ED diagnostic evaluation were discharged from the ED. Risk factors for significant medical interventions included prematurity, a positive medical history, and age >60 days.
CONCLUSION: The overall rate of either positive ED diagnostic evaluations or significant medical interventions during hospitalizations of infants after an ALTE is low. A majority of these patients can be best managed with a limited ED diagnostic evaluation and a period of observation
Q. Can over-the-counter cough medications result in ALTEs and are caregivers forthcoming when asked about medication use?
A. This study revealed that 13 of 274 (4.7%) toxicology screen results were positive for an over-the-counter cold preparation No parent admitted to having given his or her child an over-the-counter cold preparation. A substantial number of children presenting to the emergency department with an apparent life-threatening event had a positive toxicology screen result and therefore a toxicology screens should be considered when evaluating these patients
Citation Pitetti RD, Whitman E, Zaylor A.Accidental and nonaccidental poisonings as a cause of apparent life-threatening events in infants. Pediatrics. 2008 Aug;122(2):e359-62.
BACKGROUND: Apparent life-threatening events are a relatively common event in children for which there may be a number of causes. Previous reports have suggested that poisonings, either accidental or intentional, may be causes of some events. However, this theory has not been systematically studied.
METHODS: We conducted a prospective, descriptive study of infants under two years of age presenting to a pediatric emergency department of a large, urban tertiary care children’s hospital with signs and symptoms of an apparent life-threatening event. All of the children presenting with an apparent life-threatening event were to undergo a standardized evaluation, which included obtaining a comprehensive urine toxicology screen. A positive toxicology screen result was defined as follows: a clinically insignificant screen result (identification of a medication that would not cause an apparent life-threatening event) or a clinically significant screen result (identification of a medication that could cause apnea or other event consistent with an apparent life-threatening event, even if it was a medication that the child was known to be taking).
RESULTS: During the study period, 596 children presented to the emergency department with an apparent life-threatening event, and 274 (46.0%) had a toxicology screen performed. Of 274 toxicology screen results, 50 were considered truly positive (18.2%), and 23 positive screen results were considered clinically significant (23 of 274 [8.4%]). Thirteen toxicology screen results were positive for an over-the-counter cold preparation (13 of 274 [4.7%]). No parent admitted to having given his or her child an over-the-counter cold preparation.
CONCLUSIONS: A substantial number of children presenting to the emergency department with an apparent life-threatening event had a positive toxicology screen result. In particular, a number of children were found to have been given an over-the-counter cold preparation. We would recommend that toxicology screens be included as part of the routine evaluation of children who present with an apparent life-threatening event.
Q. What is a common cause of death in a child who presents with an apparent life threatening event?
A. In this study, while the overall rate of death in children with ALTEs is low, child abuse was identified as a case of death and therefore should be considered in the evaluation and management of children who present with an ALTE.
Citation: Parker K, Pitetti R.Mortality and child abuse in children presenting with apparent life-threatening events. Pediatr Emerg Care. 2011 Jul;27(7):591-5.
BACKGROUND: Children who present to the emergency department following an apparent life-threatening event (ALTE) often appear well, have a normal physical examination, and usually do well. The incidence of mortality following an event appears to occur infrequently, but has not been well described. However, it has been our experience that children who are victims of occult child abuse have a high mortality rate.
METHODS: Children younger than 24 months who presented to the emergency department following an apparent life-threatening event (ALTE) were prospectively enrolled and followed up for a period of 12 months. Mortality rate was recorded.
RESULTS: During the study period of 9 years, 563 patients were enrolled. The mean age of the patients was 2.6 months. Eleven patients (2%) were diagnosed with child abuse. Those diagnosed with child abuse were more likely to have focal findings on physical examination (54% vs 17%, P < 0.01). Three children died; the overall mortality rate was 0.5% (3/563). One of the 3 deaths was secondary to child abuse. The other 2 deaths were reported at autopsy to be secondary to sudden infant death syndrome. One of the 11 cases of child abuse ended in a death, which is a 9% mortality rate of child abuse victims who present with an ALTE.
CONCLUSIONS: Although the subsequent mortality rate for children who present with an apparent life-threatening event (ALTE) is low, child abuse was one of the identifiable causes of death and should be considered during evaluation of all children who present with an ALTE.
Q. Are premature, afebrile infants at greater risk for serious bacterial illness when they present with an ALTE?
A. In this study, serious bacterial infection was found in 2.7% of well-appearing, afebrile infants aged 60 days or younger with an ALTE. Prematurity was associated with having an SBI. Therefore, in premature infants aged 60 days or younger who present with an ALTE, evaluation for SBI should be strongly considered
Citation: Zuckerbraun NS, Zomorrodi A, Pitetti RD.Occurrence of serious bacterial infection in infants aged 60 days or younger with an apparent life-threatening event. Pediatr Emerg Care. 2009 Jan;25(1):19-25
OBJECTIVE: To describe the occurrence of serious bacterial infections (SBIs) in well-appearing, afebrile infants aged 60 days or younger with an apparent life-threatening event (ALTE).
STUDY DESIGN: We retrospectively reviewed microbiologic testing in a cohort of well-appearing, afebrile infants aged 60 days or younger who presented with an ALTE to a children’s hospital emergency department between January 2002 and July 2005. All patients were admitted and followed up for 6 months. Comparisons were made among those who did and did not undergo microbiologic testing and full sepsis evaluation (blood, urine, and cerebrospinal fluid) and those who did and did not have an SBI.
RESULTS: Of 182 patients, 112 (61.5%) underwent microbiologic testing, and 53 (29.1%) had a full sepsis evaluation. Five patients (2.7%; 95% confidence interval, 0.9%-6.3%) had an SBI including 3 positive results in blood cultures, 1 positive result in urine culture, and 1 positive result for pertussis by polymerase chain reaction. No patient had a positive result in cerebrospinal fluid culture (95% confidence interval, 0%-5.7%). Patients with a history of prematurity were more likely to have an SBI (6.7% vs. 0.8%, P = 0.04).
CONCLUSIONS: Serious bacterial infection occurred in 2.7% of well-appearing, afebrile infants aged 60 days or younger with an ALTE. Prematurity was associated with having an SBI. For premature infants aged 60 days or younger who present with an ALTE, an evaluation for SBI should be strongly considered
(1) Davies F, Gupta R. Apparent life threatening events in infants presenting to an emergency department. Emerg Med J. Jan 2002;19(1):11-6.
Dr. Ghazala Sharieff is the Director of Pediatric Emergency Medicine. Palomar Health, San Diego, CA, and a Clinical Professor, University of California, San Diego
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