APPARENT LIFE-THREATENING EVENT (ALTE)

Definition

ALTE is not a specific diagnosis, but a description of the acute event.

NIH definition

“An episode that is frightening to the observer and that is characterized by some combination of apnea, color change,(usually cyanotic or pallid but can be erythematous or plethoric) marked change in muscle tone, (usually limpness), choking, or gagging.”

These are frightening events for families and are diagnostic challenges for the physicians caring for these infants. It is frequently difficult to decide whether there has been a true life threatening event. Usually occurs in infants between 1 week and 10 months and most prior to 10 weeks.

Incidence and Relationship to Sudden Infant Death Syndrome (SIDS)

1.     0.05-1.0 % of normal children experiences an ALTE.

2.     1-2% risk of subsequent death. The incidence is higher if the infant required CPR or event occurred during sleep and also increased if greater than one severe episode.

3.      Approximately 5% of SIDS occurred with a history of severe ALTE

a.     Not a predictor of SIDS and incidence of SIDS has decreased as incidence of ALTEs has increased.

b.     Interventions to prevent SIDS (e.g. supine sleeping) have not resulted in a decreased incidence of ALTE.

Etiology

1.     Normal variation. No significant color changes or bradycardia.

a.     Short periods of apnea

b.     Periodic breathing

c.     Minor airway obstruction- Increased because of floppy airways in neonates and infants

2.     Infectious- RSV, Pertussis, CNS infections

3.     Drugs

4.     Gastroesophageal reflux- may be diagnosed and not the cause of the ALTE.

5.     Seizures

6.     Cardiac- congenital malformations or arrhythmia

7.     Non-Accidental trauma

8.     Munchhausen Syndrome

9.     Idiopathic- majority of cases.

Evaluation

1.     History

a.     Duration of spell and resuscitative measures used

b.     Was the infant awake or asleep?

c.     Relationship to feeds and were there any noises.

d.     Position the infant was in when spell occurred.

e.     Color change?

f.      Was the infant trying to breathe?

g.     What was the infant's condition following the spell? If they were back to normal, less likely to be a metabolic disease, CNS infection, trauma, or seizure.

h.     Are there discrepancies in the story?

i.      Sick contacts at home and immunization status of family members (DPT)

2.     Family History

a.     Seizures

b.     Unexplained deaths

c.     Arrhythmia

3.     Medical/Birth History

a.     Prematurity

b.     BPD

c.     History of reflux and using medications

d.     History of seizures

4.     Physical examination

a.     Thorough physical examination including fundoscopic exam

5.     Laboratory and other tests - dependent on history and findings

a.     CBC- anemia, lymphocytosis (Pertussis)

b.     BMP- acidosis, glucose

c.     CSF fluid analysis and culture.

d.     Other appropriate cultures

e.     ECG

f.      Barium swallow and pH probe

g.     EEG

Treatment

1.     Specific for the etiology of ALTE

2.     Monitoring

a.     Avoid monitoring transient episodes that are not life threatening.

b.     One or more episodes requiring mouth-mouth resuscitation or vigorous stimulation

c.     Preterm and symptomatic

d.     2 or more siblings who died of SIDS

e.     Serious central hypoventilation.

3.     Pneumograms have no predictive value

4.     Reassure and discuss issues with parents. Teach CPR

References

1.     Brooks John G. Apparent Life-Threatening Events Pediatrics in Review July 1996

2.     Palfrey Sean Overcoming ALTEphobia. A rational approach to "spells" in infants. Contemporary Pediatrics May 1999

3.     Palfrey Sean. When and how to manage infants who have "spells" Contemporary Pediatrics. June 1999

4.     Farrell Paula.ALTE, Apnea and the use of Home Monitors. Pediatrics in Review January 2002

5.     Brand D. et al. Yield of Diagnostic Testing in Infants Who Have Had an Apparent Life-Threatening Event. Pediatrics April 2005.

6.     Claudius I. Do All Infants With Apparent Life-Threatening Events Need to Be AAdmitted? Pediatrics April 2007