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ALTEs, SIDS, and Prems Russell Lam September 1, 2011 Special thanks to Bela Sztukowski for her help on this presentation.

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Presentation on theme: "ALTEs, SIDS, and Prems Russell Lam September 1, 2011 Special thanks to Bela Sztukowski for her help on this presentation."— Presentation transcript:

1 ALTEs, SIDS, and Prems Russell Lam September 1, 2011 Special thanks to Bela Sztukowski for her help on this presentation

2 Objectives Discuss the history of ALTEs, diagnostic work-up, and follow-up Review risk factors for SIDS Review some conditions commonly encountered in the ED relevant to prematurely born patients

3 Case 1 2 mo male brought in after a choking episode Grandmother picked up baby after a nap, 2 hours post feed Baby made choking noise and turned off-colour. Back blows given Vitals in ED: P120 R45 T 37 BP 95/60 Sp02 100% room air Exam unremarkable

4 What investigations do you want (if any)? How long will you monitor in the ED? What do you tell this grandmother?

5 A historical perspective

6 “The hypothesis implicating prolonged apnea during sleep is causally related to SIDS underscores the need for further research directed toward a greater understanding of the variables influencing the occurrence of sleep apnea…” 2 decades later – evidence of infanticide for all 5 infants became known

7 Definitions Apparent Life Threatening Event Frightening to the observer Combination of Apnea Color change Tone change Cough or gagging Infantile Apnea and Home Monitoring. NIH Consensus Statement 1986 Sep 29-Oct 1;6(6):1-10.

8 Definitions Sudden infant death syndrome Death of infant or child unexplained by history Post mortem fails to demonstrate adequate explanation Less than 1 year Case investigation and death scene examination fail to demonstrate adequate explanation Infantile Apnea and Home Monitoring. NIH Consensus Statement 1986 Sep 29-Oct 1;6(6):1-10. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol. 1991;11:677–684

9 Definitions Apnea of infancy Unexplained cessation in breathing > 20s or < 20s if Bradycardia Cyanosis Pallor Hypotonia Apnea of prematurity Same as above but < 37 weeks GA Infantile Apnea and Home Monitoring. NIH Consensus Statement 1986 Sep 29-Oct 1;6(6):1-10.

10 Who gets ALTEs? 0.5-6% of all infants Difficult to estimate true incidence as: Subjective nature of definition Not all ALTEs will visit the ED Retrospective data Brooks JG. Apparent life-threatening events and apnea of infancy. Clin Perinatol 1992;4:809 – 838.

11 Who gets ALTEs? Prospective study ( ) 2.46/1000 live births Average age of ALTE = 8 weeks 55% of ALTEs had diagnoses Respiratory (RSV/pneumonia) (29%) GI (GERD/Feeding aspiration) (22%) Congenital cardiac (2%) Metabolic/Neuro (2%)

12 ALTE Risk Factors Family history of infant death, single parenthood, profuse night sweating, smoking, repeated cyanotic episodes, pallor, apnea, feeding difficulties

13 Typical History

14 BreathingApnea70% Difficulty breathing62% ColourCyanosis71% Red face29% Pallor51% ToneStiffness46% Floppiness43% Limb Jerking22% GIChoking35% Vomiting18%

15 Typical physical Stratton SJ, Taves A, Lewis RJ, et al. Ann Emerg Med 2004; 43:711–717 General physical appearance, work of breathing, circulatory signs, respiratory rate, pulse rate not clinically abnormal

16 Differential of the cause of an ALTE?

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18 Causes of ALTEs? N = 643 pts ( ) Most common diagnoses GERD (31%) Seizure (11%) LRTI (8%) Unknown (23%)

19 Serious Bacterial Infection? Altman (2008) – Retrospective chart review N=243 5% had occult bacterial infection 26% had obvious bacterial infection Mittal (2009) – Prospective cohort N= % had cultures 0% had serious bacterial infection Zuckerbraun (2009) – Retrospective chart review N= % had cultures 2.7% had serious bacterial infection Premature patients more likely to have SBI (6.7 v 0.8%)

20 A reasonable work-up?

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23 Back to the case… Would you admit this 2 month old patient? History = consistent with ALTE definition Physical = normal Risk Factors None (no smoke at home, usually feeds well, married parents)

24 3 year prospective study N = 59 8 patients met “hospital required” outcome criteria Multiple ALTEs and prematurity (<37 weeks) SD from “hospital not required patients” Most common demographic features were age < 1mos and multiple ALTEs From this study, 2 criterion features developed: age < 1mos and/or multiple ALTEs yields 100% NPV 100% Sens for need for hospital admission

25 Mortality? Recurrence? 9 year prospective study N = deaths (0.5%) 2 SIDS and 1 from child abuse Recurrence 37.9% had recurrent episodes 8.9% would return visit for ALTE

26 How is ALTE different from SIDS?

27 Take home points on ALTE Scary+ Apnea/Colour Change/Tone/Choking Broad differential but mostly GER/LRTI/CNS Likely need admission + broad work-up Low mortality rate (0.5%) ALTE ≠ SIDS

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29 Case 2 6 mo male brought in because of cough x 3 days You diagnose URTI and discharge the patient On the way out, mother asks: “By the way, a mother from book club just got an apnea monitor. Should I get one too?”

30 A little about SIDS Most common cause of death in 1mos-1y (20-25% of all deaths < 1 year) 2006 = 0.54 per 1000 live births in the US Most will occurs age 2-4 months, almost all by 6 months

31 SIDS versus SUDI Sudden Unexpected Death of Infancy (SUDI) Umbrella term which includes SIDS but also other causes of sudden infant death (CVS, Abuse, Metabolics) SIDS requires autopsy and death scene examination

32 Pathophysiology of SIDS Filiano and Kinney. Biol Neonate 1994;65(3-4): 194-7

33 Long QT? Schwartz et al New Eng J Med. 338 (24):

34 Risk factors?

35 Sleeping prone Maternal smoking during and after pregnancy Bed-sharing, especially if EtOH or very tired parent Soft bedding, pillow, covers over the head Prematurity (<37 weeks) Low birth weight (<2500g)

36 A safe sleeping environment CPS 2004 Guidelines 1 st six months babies should sleep in own crib in parent’s room Sleep on back in an approved crib No quilts/comforters, pillows Room-sharing is protective, bed-sharing is not No sleeping on couch, water bed, air mattress, car seats

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39 Pacifiers? Huack et al. Pediatrics (2005). 116 (5):

40 CPS (2004) Does not recommend pacifier use to reduce risk of SIDS Caution before routinely advising against pacifier use AAP (2005) Pacifier for 1 st year of life when putting down to sleep Delay until 1 month of age if exclusive breastfeeding

41 Apnea Monitors? CHIME study ( ) 1079 infants in 4 groups Healthy Term, Idiopathic ALTE, SIDS-Sibling, Preterm All given plethysmography All groups had similar numbers of apnea/bradycardia on monitors Extreme apneas in 10% of all infants Significantly more AsBs in Preterm infants But all resolved by 43 weeks post conceptual age 6 deaths, none on monitors

42 Apnea Monitors? AAP 2005 Many infants get Apneas/Bradycardia and do not die Apnea resolves prior to when most SIDS deaths occur Does not prevent SUDI Possible groups who need apnea monitors Preterm infants CPAP/Trach’d patients

43 Twins? Malloy (1995) N = single SIDS deaths and 1056 twin SIDS deaths RR 1.13 (95%CI ) for twins when adjusted for birth weight RR 8.17 (90%CI ) if 1 twin died of SIDS Getahun (2004) N = 501 SIDS deaths overall RR 1.9 (95%CI ) but not matched for birth weight RR 4.7 (95%CI not reported) if 1 twin died of SIDS

44 Take home points on SIDS Different from ALTE Two most important risk factors are prone sleeping and maternal smoking Back to sleep in their own crib Don’t discourage pacifiers Apnea monitors don’t help If a twin already died of SIDS, other twin at way higher risk. Admission debatable…

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46 Case 3 2 month old ex 24 week male comes in with wheeze and cough Mom hands you a summary from the NICU that she was given ELBW and SGA RDS/BPD NEC Grade III IVH ROP Zone 2 Stage 1 GERD with Fundo G-Tube Fed

47 The Lingo Prematurity = <37 weeks gestational age Birth weight Low birth weight = < 2500g Very low birth weight = < 1500g Extremely low birth weight = < 1000g

48 The Lingo Age Terminology During Perinatal Period. Pediatrics. 114 (5):

49 Bronchopulmonary Dysplasia Defined by oxygen needs beyond 28 days of life Initial respiratory disease (RDS/Meconium Aspiration) then chronic lung disease that develops afterwards 3 big risk factors Oxygen toxicity Mechanical ventilation Exaggerated inflammatory response Lacy Gomella. Neonatology. 2004

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51 BPD pearls for the ED Examines like asthma Increased RR, wheeze, crackles Treat like asthma SABA, Inhaled Corticosteroids, Oxygen Consider diuretics Special consideration: RSV If RSV and BPD, more likely to develop apnea and a more severe course = admit! Passive RSV immunoglobulin upon NICU discharge? Fleisher et al. Textbook of Pediatric Emergency Medicine. 2010

52 Necrotizing Enterocolitis Spectrum of acquired neonatal disease with end expression of serious intestinal injury Etiology is multifactorial Infectious/Ischemic/Feeds Mostly in preterms in first few weeks of life but can present in term babies in first 10 days of life Presents as Septic infant Lower GI Bleeding Abdominal distension and feed intolerence/vomiting Hackam. Necrotizing Enterocolitis: A leading cause of death and disability

53 Hackam. Necrotizing Enterocolitis: A leading cause of death and disability

54 Hackam. Necrotizing Enterocolitis: A leading cause of death and disability

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56 Hackam. Necrotizing Enterocolitis: A leading cause of death and disability

57 NEC pearls for the ED Treatment Broad spectrum antibiotics (Amp/Gent ± Flagyl) NPO NG decompression Serial X-rays Consult surgery Lacy Gomella. Neonatology. 2004

58 Apnea of prematurity Apnea of infancy Unexplained cessation in breathing > 20s or < 20s if Bradycardia Cyanosis Pallor Hypotonia Apnea of prematurity Same as above but < 37 weeks GA Infantile Apnea and Home Monitoring. NIH Consensus Statement 1986 Sep 29-Oct 1;6(6):1-10.

59 Apnea of prematurity More common with younger GA Etiology is multifactorial Combination of central/obstructive apnea Treatment in NICU Caffeine, though should be discontinued by discharge CPAP

60 AOP pearls in the ED Typically, NICUs keep babies 8 days after last apnea episode If truly AOP, should resolve by 43 weeks PCA SIDS is not prolongation of apnea of prematurity Apnea in someone who was previously discharged from the NICU a few days ago requires careful consideration AOP or not? ALTE?

61 Post-hemorrhagic Hydrocephalus Results from intraventricular hemorrhage Risk of IVH goes up with lower GA Screening protocols Secondary to bleeding from germinal matrix in lateral ventricles

62 Agamanolis. Neuropathology

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67 VP Shunt Dysfunction/Infection Symptoms = non specific but may include headache/vomiting/mental status/fever Diagnosis = Push the valve (operation varies on the valve) CT/MRI head to rule out worsening ventriculomegaly Shunt Series (Skull x-ray, CXR, AXR) Shunt Tap Treatment Neurosurgery consult for ± shunt revision

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69 Take home points about prems They come with lots of comorbid diseases BPD, NEC, Apnea of Prematurity, VP Shunt Dysfunction are just a few Parents often know more about their child’s conditions than you do

70 Objectives Discuss the history of ALTEs, diagnostic work-up, and follow-up Review risk factors for SIDS Review conditions commonly encountered in the ED relevant to prematurely born patients


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