Brief resolved unexplained event: Difference between revisions

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Background3% of infants experience ALTEs
==Background==
*3% of infants experience ALTEs
*Mean age of ALTE:  8-16 wks
**<6mo-1yr


Mean age of ALTE:  8-16 wks
===Maternal Risk Factors===
 
#Smoking in pregnancy
<6mo-1yr
#Parity greater than 2
 
#Mom's age < 20yrs
#Decreased number of prenatal visits
#Crowding in home
#Mom not finish High School
#Illicit drugs in pregnancy
#Unmarried
#Anemia in Pregnancy
#< 20lbs wt gain in pregnancy
#UTI in pregnancy


==Diagnosis==
==Diagnosis==
Definition - episode, frightening to observer with witnessed apnea, color change, or change in tone, choking or gagging
Definition - episode, frightening to observer with witnessed apnea, color change, or change in tone, choking or gagging


===History===
 
#Central question: did heart/respirations stop?
History
#position, activity before, during event, asleep vs. awake
 
#previous hx of apnea
- Central question: did heart/respirations stop?
#relation to eating
 
#change in color
- position, activity before, during event, asleep vs. awake
#change in tone
 
#any intervention done? Duration, CPR? rescue breathes?
- previous hx of apnea
#social history/screen for abuse
 
- relation to eating
 
- change in color
 
- change in tone
 
- any intervention done? Duration, CPR? rescue breathes?
 
- social history/screen for abuse
 


==Work-Up==
==Work-Up==
===ED===
#CBC, U/A, Lytes
#CXR, EKG, EEG,


 
===Inpt===
ED
#pH probe, barium swallow
 
#CVR monitoring
-CBC, U/A, Lytes
#Pneumogram
 
#Metabolic studies (Lac/pyruv/NH4, urine AA and OAs)
-CXR, EKG, EEG,
#Imaging
 
 
Inpt
 
pH probe, barium swallow
 
-CVR monitoring
 
-Pneumogram
 
-Metabolic studies (Lac/pyruv/NH4, urine AA and OAs)
 
-Imaging
 
 
Prognosis is generally excellent--only 10% have repeat events
 
 
==Maternal Risk Factors==
 
 
Smoking in pregnancy
 
Parity greater than 2
 
Mom's age < 20yrs
 
Decreased # prenatal visits
 
Crowding in home
 
Mom not finish High School
 
Illicit drugs in pregnancy
 
Unmarried
 
Anemia in Pregnancy
 
< 20lbs wt gain in pregnancy
 
UTI in pregnancy
 


==DDX==
==DDX==
#idiopathic (50%)... Apnea of infancy
#infectious... PNA, RSV, Sepsis, Meningitis, encephalitis, botulism, UTI
#CNS... Sz, ICH
#Cardiac... CHD, dysrhythmias, CHF
#GI... GERD, TE Fistula
#Metabolic... hypoglycemia, hyponatremia, anemia
#Child abuse
#Toxic ingestions/fb
#Breath Holding Spell
##usu 6mo to 3-4yr!!
##in awake pt, begins w/ crying, stops breathing in end expiration, w/resultant cyanosis & LOC
##resumes breathing spontaneously
#Cyanotic Heart Dz
##difficulty feeding w/ diaphoresis & poor wt. gain
#Apnea
##central vs obstructive or mixed
##short (< 15 s) can be normal
##is pathologic if > 20 sec, or w/ cyanosis, bradycardia, pallor or hypotonia
#Periodic Breathing
## 3 or more resp pauses of > 3 sec
#Apnea of Prematurity


===Obstructive Apnea===
#Stridor - vascular ring, FB, croup, epiglottitis
#Prematurity - position, laryngomalacia, web, tracheomalacia etc.
#Airway anatomy abnormalities


-idiopathic (50%)... Apnea of infancy
===Mixed Apnea===
# shock, dysrhythmias, cong heart dz, prolonged QT
# sepsis, pertussis, RSV, meningitis, PNA, infant botulism
#Trauma, anemia, poisoning, NM d/o, metabolic d/o


-infectious... PNA, RSV, Sepsis, Meningitis, encephalitis, botulism, UTI
===Specified Etiology (50%)===
 
#Neuro: Seizure, breath-holding spell
-CNS... Sz, ICH
#GE reflux (Sandifer's sign: arching back to get comfortable), TEF
 
#Infection: sepsis, meningitis, PNA, bronchiolits, Apnea of prematurity
-Cardiac... CHD, dysrhythmias, CHF
#15% are CNS: sz, ventricular hemorrhage, hydrocephalus
 
#Cardiac: Duct-dependent lesion, long QT, arrhythmias
-GI... GERD, TE Fistula
#Metabolic, electrolytes, abuse
 
-Metabolic... hypoglycemia, hyponatremia, anemia
 
-Child abuse
 
-Toxic ingestions/fb
 
Breath Holding Spell
 
- usu 6mo to 3-4yr!!
 
- in awake pt, begins w/ crying, stops breathing in end expiration, w/resultant cyanosis & LOC
 
- resumes breathing spontaneously
 
Cyanotic Heart Dz
 
- difficulty feeding w/ diaphoresis & poor wt. gain
 
Apnea
 
- central vs obstructive or mixed
 
- short (< 15 s) can be normal
 
- is pathologic if > 20 sec, or w/ cyanosis, bradycardia, pallor or hypotonia
 
Periodic Breathing
 
- 3 or more resp pauses of > 3 sec
 
Apnea of Prematurity
 
 
==DDx of Obstructive Apnea==
 
 
-Stridor - vascular ring, FB, croup, epiglottitis
 
- Prematurity - position, laryngomalacia, web, tracheomalacia etc.
 
- Airway anatomy abnormalities
 
 
Mixed Apnea
 
- shock, dysrhythmias, cong heart dz, prolonged QT
 
- sepsis, pertussis, RSV, meningitis, PNA, infant botulism
 
- Trauma, anemia, poisoning, NM d/o, metabolic d/o
 
 
50% have specified etiology:
 
-Neuro: Seizure, breath-holding spell
 
-GE reflux (Sandifer's sign: arching back to get comfortable), TEF
 
-Infection: sepsis, meningitis, PNA, bronchiolits, Apnea of prematurity
 
-15% are CNS: sz, ventricular hemorrhage, hydrocephalus
 
-Cardiac: Duct-dependent lesion, long QT, arrhythmias
 
-Metabolic, electrolytes, abuse
 


==Disposition==
==Disposition==
at least 48 hrs for r/o sepsis
at least 48 hrs for r/o sepsis


==Prognosis==
generally excellent--only 10% have repeat events


==Source==
==Source==
Adapted from Pani  
Adapted from Pani  


[[Category:Peds]]
[[Category:Peds]]

Revision as of 18:58, 21 May 2011

Background

  • 3% of infants experience ALTEs
  • Mean age of ALTE: 8-16 wks
    • <6mo-1yr

Maternal Risk Factors

  1. Smoking in pregnancy
  2. Parity greater than 2
  3. Mom's age < 20yrs
  4. Decreased number of prenatal visits
  5. Crowding in home
  6. Mom not finish High School
  7. Illicit drugs in pregnancy
  8. Unmarried
  9. Anemia in Pregnancy
  10. < 20lbs wt gain in pregnancy
  11. UTI in pregnancy

Diagnosis

Definition - episode, frightening to observer with witnessed apnea, color change, or change in tone, choking or gagging

History

  1. Central question: did heart/respirations stop?
  2. position, activity before, during event, asleep vs. awake
  3. previous hx of apnea
  4. relation to eating
  5. change in color
  6. change in tone
  7. any intervention done? Duration, CPR? rescue breathes?
  8. social history/screen for abuse

Work-Up

ED

  1. CBC, U/A, Lytes
  2. CXR, EKG, EEG,

Inpt

  1. pH probe, barium swallow
  2. CVR monitoring
  3. Pneumogram
  4. Metabolic studies (Lac/pyruv/NH4, urine AA and OAs)
  5. Imaging

DDX

  1. idiopathic (50%)... Apnea of infancy
  2. infectious... PNA, RSV, Sepsis, Meningitis, encephalitis, botulism, UTI
  3. CNS... Sz, ICH
  4. Cardiac... CHD, dysrhythmias, CHF
  5. GI... GERD, TE Fistula
  6. Metabolic... hypoglycemia, hyponatremia, anemia
  7. Child abuse
  8. Toxic ingestions/fb
  9. Breath Holding Spell
    1. usu 6mo to 3-4yr!!
    2. in awake pt, begins w/ crying, stops breathing in end expiration, w/resultant cyanosis & LOC
    3. resumes breathing spontaneously
  10. Cyanotic Heart Dz
    1. difficulty feeding w/ diaphoresis & poor wt. gain
  11. Apnea
    1. central vs obstructive or mixed
    2. short (< 15 s) can be normal
    3. is pathologic if > 20 sec, or w/ cyanosis, bradycardia, pallor or hypotonia
  12. Periodic Breathing
    1. 3 or more resp pauses of > 3 sec
  13. Apnea of Prematurity

Obstructive Apnea

  1. Stridor - vascular ring, FB, croup, epiglottitis
  2. Prematurity - position, laryngomalacia, web, tracheomalacia etc.
  3. Airway anatomy abnormalities

Mixed Apnea

  1. shock, dysrhythmias, cong heart dz, prolonged QT
  2. sepsis, pertussis, RSV, meningitis, PNA, infant botulism
  3. Trauma, anemia, poisoning, NM d/o, metabolic d/o

Specified Etiology (50%)

  1. Neuro: Seizure, breath-holding spell
  2. GE reflux (Sandifer's sign: arching back to get comfortable), TEF
  3. Infection: sepsis, meningitis, PNA, bronchiolits, Apnea of prematurity
  4. 15% are CNS: sz, ventricular hemorrhage, hydrocephalus
  5. Cardiac: Duct-dependent lesion, long QT, arrhythmias
  6. Metabolic, electrolytes, abuse

Disposition

at least 48 hrs for r/o sepsis

Prognosis

generally excellent--only 10% have repeat events

Source

Adapted from Pani

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