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

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

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

ALTE ALTE u Not a diagnosis u Description of a characteristic presentation

ALTE ALTE u % of all infants u True frequency & prevalence unknown u Peak incidence 2-3 months

ALTE ALTE u Apnea u Cessation of respiration for 20 seconds or more u Bradycardia u Pallor or cyanosis

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

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

ALTE ALTE u Can occur during sleep, wakefulness or feeding

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

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

ALTE -History ALTE -History u Asleep or awake u Red, pale or blue u Relation to feeding u Spontaneous recovery or CPR u Associated movements/ change in tone u “difficult to take care”

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

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

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

GER GER u Physiologic versus pathologic u Infantile versus childhood u Infantile reflux resolve by first birthday

GER GER u Awake apnea u Usually reflux related u Sleep apnea? u Nocturnal reflux is uncommon

GER GER u Sandifer syndrome

GER GER u Intraesophageal pH study u Gold standard u Difficult to prove

Infections Infections u RSV  apnea u < 3 months u Non obstructive u During quiet sleep u Sepsis u Pertussis

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

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

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

Inborn Error of Metabolism Inborn Error of Metabolism u First episode is severe u Family history of ALTE &/or SIDS

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

ALTE Evaluation ALTE Evaluation u Whether the event represents an ALTE or not? u Not every infant needs all these tests u No routine evaluation u Should be guided by history & physical

ALTE ALTE u CBC? u EKG? u Chest X-ray? u Upper GI? u EEG? u pH probe?

ALTE ALTE u Most important is accurate history u Absolute determination of significant episode may not be possible in ED u Often the best investigation is a short period in hospital with monitoring

ALTE ALTE u Admit any child with ALTE criteria u Further evaluation & monitoring u Parent education

Quiz -ALTE Quiz -ALTE u 2 year old with c/o “stopped breathing” u Screaming after toy taken by playmate u Stopped breathing  limp & blue 15 sec u Resolved spontaneously u Now alert & normal exam

Breath holding Spells Breath holding Spells u Frightening experience for the parents u 3% of all children u Ages 1 and 5 years u May begin before 6 months (25%)

Breath holding Spells Breath holding Spells u Always provoked by pain, anger or frustration (unpleasant stimulus) u Prolonged expiratory apnea u Rapid development of cyanosis u Normal physical & neurological exam

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

Quiz -ALTE Quiz -ALTE u 5 month-old male infant couldn’t breath about an hour after feeding u Mother describes “Struggling or gasping to breath” u Well on arrival u Afebrile, HR 110, RR 24, BP 74/46 u Wt 4.3 kg & oral thrush

Quiz -ALTE Quiz -ALTE u 16 month old girl with cerebral palsy u Stiff  limp (almost 5 minutes) u Mother described as “she was dead” u “Out of it” for next hour u No fever, trauma or other recent ill contacts

Quiz -ALTE Quiz -ALTE u A 3 month old infant “stopped breathing while sleeping”. Mother describes as weak and blue and “looked dead” u Improved with mouth to mouth breathing u Well appearing in ED