Brief resolved unexplained event

Background

• Peak incidence: 1wk - 2mo
• ALTE is a symptom, not a dx
• Only 10% have repeat events
• ALTE is not related to SIDS

Risk Factors

• RSV infection
• Prematurity
• Recent anesthesia
• GERD
• Airway/maxillofacial anomalies
• Age < 10 wks
• Hx of apneas
• Pallor, cyanosis, feeding difficulties

Clinical Features

Episode that is frightening to caregiver and involves combination of:

• Apnea
• Color change
• Muscle tone change
• Choking or gagging

History

• PMH
  • Prematurity, history of apnea, prior resp/feeding difficulties
  • Immunization status (pertussis)
• FH
  • History of SIDS, cardiac, seizure, metabolic disease
• Event
  • Duration, resus required
  • Temporal relationship with feeding, sleeping, crying, vomiting, choking
  • Central versus obstructive pattern of apnea
  • Episodic versus sustained change in mental status
• ROS
  • Respiratory symptoms
  • Medication use

Differential Diagnosis

Common

• Idiopathic (~50%)
• GERD
• Seizure
• Respiratory tract infection
• Misinterpretation of benign process (e.g. periodic breathing)
• Vomiting/choking episode

Less Common

• Pertussis
• Inflicted injury
• Poisoning
• Serious bacterial infection
  • Must consider in all febrile pts with ALTE
• Electrolyte abnormality (incl glucose)

Uncommon

• Arrhythmia
• Anemia
• Breath-holding spell (6mo - 4yrs)
• Metabolic disease

Work-Up

(Individualize testing by history and exam)

• CBC
• Chem 10
• UA
• CXR
• Pertussis nasal swab
• RSV nasal swab
• Consider:
  • UCx/BC
  • ECG
  • LP
  • LFTs
  • MRI Brain

Management

• Stable patients without a clear diagnosis
  • No evidence-based guidelines for proper w/u dispo decision
• Stable patients with a clear diagnosis
  • Manage according to identified disease

Empiric Treatment for Unstable Patients

Medication/Intervention	Indication	Dose/Size (for neonate)
Glucose	Hypoglycemia	5–10 mL/kg of 10% dextrose in water IV
3% normal saline	Symptomatic hyponatremia	3–5 mL/kg bolus IV
Calcium	Hypocalcemia	50–100 milligrams/kg calcium gluconate or 20 milligrams/kg calcium chloride IV
Cefotaxime	Infection	50 milligrams/kg IV
Ampicillin	Infection	50 milligrams/kg IV
Packed red blood cells	Anemia	10 mL/kg IV
Normal saline	Hypotension, dehydration	20 mL/kg IV
10% dextrose in one fourth normal saline	Metabolic disease	1.5 maintenance (6 mL/kg/h for the first 10 kg)
Endotracheal intubation	Hypoventilation or frequent apnea	3mm for preemie; 3mm for term neonate, 4mm for older infant

Disposition

Admission in most cases

Especially for:

• <48wk postconceptual age
• Ill-appearing
• Bronchiolitis or pertussis w/ apnea
• >1 event in past 24hr or multiple ALTEs
• Abnormalities in PMH
• Prolonged central apnea >20s
• ALTE requiring resus
• Family history of SIDS

Current Research

• Neither of these decision rules have been validated

Mittal ALTE Decision Rule

• 300 Infants in a single center with 76% admission rate with 37 (12%) required significant intervention

Predictors for requiring intervention

• Prematurity
• Abnormal physical examination
• Color change to cyanosis,
• Absence of upper respiratory infection symptoms and the absence of choking
• Negative predictive value: 96%
• Specificity of 70.5%
• 7 out of the 184 (3.8%) were incorrectly discharged

Kaji ALTE Decision Rule

• 832 patients from 4 different study sites, with a 79.2% admission rate

Predictors for requiring admission

• Obvious need for admission:
  • Supplemental Oxygen requirement
  • Resuscitation
  • Hemodynamic Instability
  • Positive RSV or Pertussis test
• Significant past medical history
  • Congenital heart disease
  • Down Syndrome
  • Previous Intubation
• Chromosomal abnormaility
• Chronic Lung Disease
• > 1 ALTE in 24 hours
• Negative predictive value of 96.5%
• Sensitivity of 89% , a Specificity of 61.9% , and a calculated
• 14 (2%) patients were incorrectly discharged

Sources

• Fu L. et al. Apparent Life-threatening events: an update. Pediatr Rev. 2012; 33(8(:361-368
• Tieder J et al. Management of apparent life-threatening events: a systemic review. J Pediatr. 2013 Jul;163(1):94-9