1. Apparent Life Threatening Event
Condition noted for over 50 years under other terms…
Isolated observations of condition just began over last 20 years…
Philip J, Froman, MD, FACEP
EMS Medical Director
Edited from a presentation by Jim Morehead; Oklahoma EMSC Resource Center; OU Health Sciences Center
2006

2. Objectives Define ALTE Describe common demographic data
Discuss challenges associated with ALTE
Describe common symptomatology of ALTE
List common etiology associated w/ALTE
2006

3. Objectives (Continued)
Discuss ALTE vs SIDS
Explain importance of medical history
Explain necessity for taking this clinical situation seriously
Describe necessity for definitive evaluation
2006

4. ALTE Defined ALTE defined in 1986 by NIH
Consensus Development Conference
New definition replaced existing terms
“Near miss SIDS”
“Aborted cot death”
Older terminology potentially misleading as implied close association with SIDS, yet research continues to discount this increasingly.
2006

5. EMS Encounter Statistics
7.5% of infant encounters
Mean age was 3 months, 55% males
83.3% in NAD, 13.3% in mild, 3.3% in moderate
Appearance, respirations, VS were normal
35% had significant pathology
2006

6. Hospital Demographic Data
True incidence unknown
Only data = cases admitted hospital or ED
Reported incidence = 0.5-8%
Most commonly children <1 yr age
Peak at 1-10 weeks age
Males > females
2006

7. Demographic Data (Continued)
Increased risk children
Premature infants (+)
Undergo general anesthesia
RSV
Rapid feeding infants
Choking during feeding infants
Frequently coughing infants
2006

8. Definition ALTE Episode frightens observer
Exhibits some combination of symptoms
APNEA
COLOR CHANGE
MARKED MUSCLE TONE CHANGE
CHOKING or GAGGING
2006

9. Definition of Apnea of Infancy
Unexplained episode
Cessation of breathing >20 seconds
Associated with
Bradycardia
Cyanosis
Pallor
Marked hypotonia
2006

10. Challenges Accurate episode description often unreliable
Pt often appears well at presentation to EMS
Events are non-specific
It is a complaint, not a diagnosis
Describes cluster of symptoms
Many possible causes w/alarming risks
2006

11. Possible Symptoms Usually infant appears well
Observer describes event as frightening
Often thinks infant died
May say “Appeared funny; not right”
Possible only one observer views symptoms
Good & thorough history is essential
2006

12. Possible Symptoms (Continued)
APNEA
Central
Obstructive (less frequently)
COLOR CHANGE
Usually cyanosis or pallor
Occasionally erythematous or plethoric
MARKED MUSCLE TONE CHANGE
Usually marked floppiness
Occasionally rigidity
CHOKING, COUGHING, or GAGGING
2006

13. Etiology Manifestation of other underlying condition(s)
Chief Complaint, NOT a Diagnosis
Finding underlying cause(s) important
Approx 50% definitive etiology discovered
Intervention may eliminate future events
Approx 50% definitive etiology unknown
ALTE Idiopathic
2006

14. Etiology Dx’d GI most common in up to 50% cases
Gastroesophageal Reflux Disorder (GERD)
Gastric Volvulus
Intussusception
Swallowing Abnormalities
Other GI Abnormalities
2006

15. Etiology Dx’d (Continued)
Neurologic - 30% cases
Seizure Disorder (including Febrile)
CNS Bleeding or Infection
Neuro conditions affecting respiratory
Budd-Chiari syndrome
Hindbrain or Brainstem malformation
Vasovagal reflexes or Malignancies
VP shunt malfunction
2006

16. Etiology Dx’d (Continued)
Respiratory - approx 20% cases
Respiratory compromise by infection
RSV
Pertussis
Mycoplasma
Croup
Other Pneumonias
2006

17. Etiology Dx’d (Continued)
Obstructive Sleep Apnea (OSA)
Breath holding spells
Conditions affecting respiratory control
Prematurity
Central hypoventilation
2006

18. Etiology Dx’d (Continued)
Vocal cord abnormalities
Laryngotracheomalacia
FBAO
Airway obstruction by congenital abnormalities
2006

19. Etiology Dx’d (Continued)
Cardiac - up to 5% cases
Arrhythmia
Prolong QT syndrome
W-P-W syndrome
Congenital Heart Disease (CHD)
Myocarditis
Cardiomyopathy
2006

20. Etiology Dx’d (Continued)
Metabolic abnormalities less than 5% cases
Inborn metabolic errors
Endocrine, electrolyte disorders
Other infections
UTI
Sepsis
2006

21. Etiology Dx’d (Continued)
Child Abuse less than 5% cases
Munchausen syndrome by proxy
Suffocation
Intentional salt poisoning
Medication OD
Physical Abuse
Head Injury
Smothering
Intentional or Unintentional
2006

22. Etiology Dx’d (Continued)
Other
Food allergy (uncommon)
Anaphylaxis
Medication
Prescription
Over-the-counter (O-T-C)
Herbal remedies
2006

23. Normal – Misinterpreted as Abnormal
Irregular breathing of REM sleep
Periodic breathing
Respiratory pauses (5-15 seconds) & longer pauses after sighing
Transient choking, gagging, coughing during feeding
2006

24. Periodic Breathing Brief, cyclic episodes
Intermittent apnea (5-10 secs) followed by
Burst of rapid breathing (10-15 secs)
No color change or significant change in HR
Usually resolves by 36 weeks gestational age
2006

25. GERD & ALTE
Acid reflux → respiratory pause → airway closure → swallowing
This can explain an awake apneic event
Menon/Thach. J Pediatrics 1985;106:
2006

26. GERD & ALTE (Continued)
Regurgitation: → increased mucosal adhesive forces → upper airway collapse
Hypothesis:
Infants w/more pliable upper airways, w/increased laryngeal inflammation due to chronic regurgitation have increased risk for obstructive apnea
2006

27. GERD & ALTE (Continued)
Most infants w/GERD do not have ALTE
No epidemiologic relationship between GERD & SIDS established
2006

28. ALTE vs SIDS Relationship UNKNOWN ALTE: benign to near fatal
Heterogeneous group of problems
82% occur between 8 a.m. and 8 p.m.
SIDS: fatal
80% occur between midnight and 6 a.m.
2006

29. ALTE vs SIDS (Continued)
Increased incidence both central & obstructive sleep apnea (OSA) w/ALTE
Strong family hx ALTE & SIDS show higher incidence OSA
Sudden unexpected death beyond 1st year of life is NOT SIDS
2006

30. ALTE vs SIDS (Continued)
SIDS prevention interventions
Such as “Back to Sleep”
Not resulted in decreased incidence of ALTE
Risk factors for different for each
Not different diseases of same condition
2006

31. Detailed History Detailed description of event
Appearance at time of discovery
Color change – how much, where, what color
Muscle & body movements
Resuscitation/stimulation & response
Home monitoring present
2006

32. Detailed History (Continued)
Muscle tone
Eye movement
General responsiveness after event
Relationship to feeding
Fever, URI
Any other medical problems
2006

33. Additional History Pregnancy/perinatal care
Infant behavior/sleep/feeding
Social history
Smoking
Alcohol or substance use
Medications
2006

34. Additional History (Continued)
Family history
Including siblings or ALTE in other siblings
Early deaths
Genetic disease
Cardiac or neurological problems
2006

35. Examination Obtain detailed hx Age/development characteristics
Vital signs
Upper airway/facial evaluation
Overall appearance
2006

36. Diagnostic Evaluation
Thorough hx & physical exam essential
Diagnosis made in 21%
Confirmation testing based on hx & physical exam brings total to 49%
Entirely normal physical exam (50%)
2006

37. Management Considerations
Is this immediate life-threatening situation?
Was episode truly life-threatening or merely frightening?
Is this over-reaction to normal event?
Is this abnormal phenomenon?
Detailed history of event?
2006

38. Protocol ACTION/TREATMENT: • ABCs
• If needed: IV access, rate titrated to perfusion as needed.
• Leave the child in caretaker’s arm in position of comfort for evaluation, then car seat for transport.
• Provide blow-by oxygen as tolerated; pulse oximetry • Cardiac monitor.
• Refer to appropriate treatment protocols for specific intervention.
2006

39. Protocol (Continued) TRANSPORT:
• There are different transport protocols
Need to be conservative
Transport to nearest appropriate facility via EMS!
• Private transport acceptable for asymptomatic patients IF:
• Transportation is available now
• The parents / caretaker are reliable
• Parents / caretaker understand the importance of evaluation
2006

40. Summary ALTE frightening event to observer Underlying cause in 50%
Idiopathic in remaining 50%
Detailed hx mandatory
Always take described events seriously
Detailed examination & definitive evaluation mandatory
2006

41. Suggested References
Stratton S & Taves A “Apparent Life-Threatening Events in Infants: High Risk in the Out-of-Hospital Environment.” Annals of EM. 2004; 43:6;
Hall K & Zalman B. “Evaluation and Management of Apparent Life-Threatening Events in Children.” Am Acad Fam Phys;Vol 71;Num 12;June 2005.
Kiechl-Kohlendorfer U, et al. “Epidemiology of apparent life threatening events.” Arch Dis Child. 2005;90;
Davies F & Gupta R. “Apparent life threatening events in infants presenting to an emergency department.” Emerg Med. 2002;19;11-16.
2006

42. References (Continued)
Brand D, et al. “Yield of Diagnostic Testing in Infants Who Have Had an Apparent Life-Threatening Event.” Pediatrics. Vol 115;Num 4;April 2005.
Harrington C, et al. “Altered Autonomic Function and Reduced Arousability in Apparent Life-Threatening Event Infants with Obstructive Sleep Apnea.” Am J Respir Care Med. Vol 165;pp ;2002.
De Piero A, et al. “ED Evaluation of Infants After an Apparent Life-Threatening Event.” Am J Emerg Med;Vol 22;Num 2;March 2004.
McGovern M & Smith M. “Causes of apparent life threatening events in infants: a systematic review.” Arch Dis Child. 2004;89;
2006