Brief resolved unexplained event

Background3% of infants experience ALTEs

Mean age of ALTE: 8-16 wks

<6mo-1yr

Diagnosis

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

History

- Central question: did heart/respirations stop?

- position, activity before, during event, asleep vs. awake

- previous hx of apnea

- relation to eating

- change in color

- change in tone

- any intervention done? Duration, CPR? rescue breathes?

- social history/screen for abuse

Work-Up

ED

-CBC, U/A, Lytes

-CXR, EKG, EEG,

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

-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

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

at least 48 hrs for r/o sepsis

Source

Adapted from Pani