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Apparent Life Apparent Life Threatening Events:Threatening Events:

Actual Life Threatening Events?Actual Life Threatening Events?

Erich C. Maul, DO, FAAPErich C. Maul, DO, FAAPAssociate Program Director, Pediatric Residency Associate Program Director, Pediatric Residency Associate Program Director, Pediatric Residency Associate Program Director, Pediatric Residency

Assistant Professor of PediatricsAssistant Professor of PediatricsUniversity of Kentucky College of MedicineUniversity of Kentucky College of Medicine

This is an This is an ActualActual Life Threatening EventLife Threatening Event

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This has This has great great

potential…potential…

Apparent Life Apparent Life Threatening Events:Threatening Events:

A th L th TiA th L th Ti iiAnother Lengthy TimeAnother Lengthy Time--consuming consuming Evaluation?Evaluation?

Erich C. Maul, DO, FAAPErich C. Maul, DO, FAAPAssociate Program Director, Pediatric Residency Associate Program Director, Pediatric Residency Associate Program Director, Pediatric Residency Associate Program Director, Pediatric Residency

Assistant Professor of PediatricsAssistant Professor of PediatricsUniversity of Kentucky College of MedicineUniversity of Kentucky College of Medicine

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DisclosuresDisclosures

No financial disclosuresNo financial disclosures No conflicts of interestNo conflicts of interest

ObjectivesObjectives

Define ALTE and associated clinical Define ALTE and associated clinical titititientitiesentities

Discuss etiology and evaluation of Discuss etiology and evaluation of ALTEsALTEs

Examine future directions of ALTE Examine future directions of ALTE management and researchmanagement and researchmanagement and researchmanagement and research

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Road MapRoad Map

Opening ThoughtsOpening ThoughtsE id i lE id i l EpidemiologyEpidemiology

PathophysiologyPathophysiology Differential DiagnosisDifferential Diagnosis History and Physical ExaminationHistory and Physical Examination EvaluationEvaluation Discharge PlanningDischarge Planning Areas of Contention/Random ThoughtsAreas of Contention/Random Thoughts

Couple of Couple of CasesCases

Case 1Case 13 week old “lost his breath ” cyanosis “got 3 week old “lost his breath ” cyanosis “got •• 3 week old “lost his breath,” cyanosis, “got 3 week old “lost his breath,” cyanosis, “got stiff and arched his back for 1 minute,” after stiff and arched his back for 1 minute,” after that was “that was “lifeless”lifeless”

•• Got CPR for one minute at home while waiting Got CPR for one minute at home while waiting for EMSfor EMS

•• EMS arrives to find child crying in parent’s EMS arrives to find child crying in parent’s d ED i di i d d ED i di i d arms, transported to ED in same condition and arms, transported to ED in same condition and

you are called to evaluate them for possible you are called to evaluate them for possible admissionadmission

•• What do you do?What do you do?

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Couple of Couple of CasesCases

Case 2Case 21 m/o female who 10 minutes after a “normal 1 m/o female who 10 minutes after a “normal •• 1 m/o female who 10 minutes after a “normal 1 m/o female who 10 minutes after a “normal feed” spitfeed” spit--up, choked, gagged, turned blue, up, choked, gagged, turned blue, and became and became limplimp

•• Formula noted in mouthFormula noted in mouth•• Dad blew in child’s face and was about to call Dad blew in child’s face and was about to call

911 when child started crying again911 when child started crying again•• Parents bring to local ER where you are Parents bring to local ER where you are

evaluating themevaluating them•• What do you do?What do you do?

Thoughts about ALTEThoughts about ALTE

Not a diagnosisNot a diagnosis A constellation of signs and A constellation of signs and

symptoms that are a result of symptoms that are a result of underlying pathologyunderlying pathology•• ALTE and shock simileALTE and shock simile

An ALTE has a cause as does shockAn ALTE has a cause as does shockAn ALTE has a cause as does shockAn ALTE has a cause as does shock The skill is stabilizing patient until cause of The skill is stabilizing patient until cause of

either condition is foundeither condition is found

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Thoughts about ALTEThoughts about ALTE

Anxiety provokingAnxiety provoking•• Parents just saw child “die”Parents just saw child “die”Parents just saw child dieParents just saw child die•• We generally see a normal childWe generally see a normal child

So what do I do?So what do I do?

A point of consternationA point of consternation•• Hard to tell who’s sick sometimesHard to tell who’s sick sometimes•• Who gets big workWho gets big work--up?up?•• Who gets big workWho gets big work--up?up?•• Who can go home from office or ED?Who can go home from office or ED?•• Can breed complacency and missed Can breed complacency and missed

diagnosesdiagnoses

Thoughts about ALTEThoughts about ALTE “Remember that when there is nothing “Remember that when there is nothing

wrong, there is nothing wrongwrong, there is nothing wrong--except except there is nothing wrongthere is nothing wrong.”.”

•• Harold G. Moore, LTG, USAHarold G. Moore, LTG, USA--retret

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First First Things FirstThings First……

Apparent lifeApparent life--threatening event (ALTE):threatening event (ALTE):sudden event, frightening to the observer, sudden event, frightening to the observer, , g g ,, g g ,in which the infant exhibits a combination in which the infant exhibits a combination of symptoms, including apnea, change in of symptoms, including apnea, change in color, change in muscle tone, choking, color, change in muscle tone, choking, gagging or coughinggagging or coughing

Apnea:Apnea: cessation cessation of airflow for any reasonof airflow for any reason•• May be central, obstructive or mixedMay be central, obstructive or mixed

Pathologic apnea:Pathologic apnea: lasts lasts >20 seconds and >20 seconds and accompanied by accompanied by bradycardiabradycardia, cyanosis, , cyanosis, hypotoniahypotonia or other signs of compromiseor other signs of compromise

More More DefinitionsDefinitions

Periodic breathing:Periodic breathing: 3 3 or more or more pauses >3 seconds but < 20 pauses >3 seconds but < 20 pauses, >3 seconds, but < 20 pauses, >3 seconds, but < 20 seconds and normal respiration in seconds and normal respiration in betweenbetween

Sudden Infant Death Syndrome:Sudden Infant Death Syndrome:sudden sudden death of a child without death of a child without historical physical historical physical laboratory laboratory or or historical, physical, historical, physical, laboratory laboratory or or postpost--mortem findings that explain mortem findings that explain the cause of deaththe cause of death

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Apnea of InfancyApnea of Infancyvs.vs.

Apnea of PrematurityApnea of Prematurity AoIAoI

•• TERM INFANT!TERM INFANT! AoPAoP

•• Preterm infantPreterm infant•• TERM INFANT!TERM INFANT!•• Unexplained pauses Unexplained pauses

lasting >20 secondslasting >20 seconds•• <20 second pauses <20 second pauses

with systemic with systemic compromisecompromise Bradycardia, color Bradycardia, color

•• Preterm infantPreterm infant•• Same Same

characteristics as characteristics as AoIAoI with relation to with relation to times and systemic times and systemic signssigns

•• Usually resolves by Usually resolves by change, hypotonia change, hypotonia

•• Reserved for ALTE Reserved for ALTE without identifiable without identifiable causecause

37 weeks 37 weeks gestation gestation but may persist up but may persist up to 43 weeks GAto 43 weeks GA

EpidemiologyEpidemiology ~1% of ER visits and ~2.5% of admissions~1% of ER visits and ~2.5% of admissions Average LOS 4.4 days (Average LOS 4.4 days (++5.6 days)5.6 days) Mean adjusted Mean adjusted chargecharge

•• $15,567$15,567++$28,510$28,510

2.5% readmission rate2.5% readmission rate Inpatient mortality ~0.6%Inpatient mortality ~0.6%

•• ~75% were <2 months old~75% were <2 months old•• ~75% were <2 months old~75% were <2 months old

Variable resources utilization between Variable resources utilization between hospitals and within hospital groups as wellhospitals and within hospital groups as well

•• From From TiederTieder, , et alet al, J , J PediatrPediatr 20082008

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Also of Also of NoteNote……

CHIME Study GroupCHIME Study Group•• 43% of healthy term infants have 43% of healthy term infants have at at

leastleast one 20 sec apnea event in first 3 one 20 sec apnea event in first 3 months of lifemonths of life Irony is only about 5% of these events get Irony is only about 5% of these events get

reported or observed by parentsreported or observed by parents

•• PremiesPremies up to 76% had at least one up to 76% had at least one •• PremiesPremies--up to 76% had at least one up to 76% had at least one severe apnea eventsevere apnea event Risk normalized by 43 weeks PCARisk normalized by 43 weeks PCA

EpidemiologyEpidemiology

KiechlKiechl--KohlendorferKohlendorfer in 2004in 2004•• 2.46/1,000 2.46/1,000 live birthslive births•• ALTE risk factors not identical to SIDSALTE risk factors not identical to SIDS

Smoking was the only common risk factorSmoking was the only common risk factor•• Thank goodness no one in Kentucky smokes…Thank goodness no one in Kentucky smokes…

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So So WhatWhat??

SIDS and ALTE are differentSIDS and ALTE are different•• No ALTE kids went on to have SIDSNo ALTE kids went on to have SIDS•• Mean age of ALTE was 8 wksMean age of ALTE was 8 wks•• Mean age of SIDS was 18 wks with Mean age of SIDS was 18 wks with

peaks at 12 and 36 wkspeaks at 12 and 36 wks•• Back to Back to sleep sleep works for works for SIDS SIDS not ALTEnot ALTEpp

Take Home MessageTake Home Message

SIDS and ALTE are differentSIDS and ALTE are differentS d S d SIDS SIDS b t t b t t Some programs reduce Some programs reduce SIDS SIDS but not but not ALTEALTE

Smoking cessation may reduce BOTHSmoking cessation may reduce BOTH Relatively low incidenceRelatively low incidence

•• Despite the fact I seem to have 2Despite the fact I seem to have 2--3 on 3 on ppservice at any given time!service at any given time!

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PathophysiologyPathophysiology Central ApneaCentral Apnea

•• Disruption of brainstem respiratory output and Disruption of brainstem respiratory output and neuromuscular responseneuromuscular response Trauma, tumor, prematurity, congenital central Trauma, tumor, prematurity, congenital central

hypoventilation syndromehypoventilation syndrome

Obstructive ApneaObstructive Apnea•• Breathing through an occluded airwayBreathing through an occluded airway

PierrePierre--Robin sequence, Robin sequence, adenotonsillaradenotonsillar hypertrophy, foreign hypertrophy, foreign bodies, functional or dynamic obstructions, vocal cord bodies, functional or dynamic obstructions, vocal cord paralysisparalysis

Mixed ApneaMixed ApneaC f b h b i d l C f b h b i d l •• Components of both obstructive and central apneaComponents of both obstructive and central apnea AdenotonsillarAdenotonsillar hypertrophy and sedationhypertrophy and sedation GERDGERD--Choking, Choking, bronchospasmbronchospasm and laryngeal and laryngeal

chemoreceptor reflex central apneachemoreceptor reflex central apnea RSVRSV--reflex central apnea due to altered laryngeal reflex central apnea due to altered laryngeal

chemoreceptor sensitivity with airway inflammationchemoreceptor sensitivity with airway inflammation

Differential DiagnosisDifferential Diagnosis

ALTE and shock simileALTE and shock simile•• Both are descriptions or clinical Both are descriptions or clinical

conditionsconditions•• Have to consider a vast array of Have to consider a vast array of

possible causespossible causes•• Percentages of disease frequency are Percentages of disease frequency are

confusingconfusing•• Will list in order of most common to less Will list in order of most common to less

commoncommon

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Differential DiagnosisDifferential Diagnosis

GastrointestinalGastrointestinalIdi thiIdi thi

Metabolic/EndocrineMetabolic/EndocrineC di lC di l IdiopathicIdiopathic

NeurologicNeurologic RespiratoryRespiratory Abuse/NeglectAbuse/Neglect

CardiovascularCardiovascular Miscellaneous infectionsMiscellaneous infections Miscellaneous eventsMiscellaneous events

Differential DiagnosisDifferential Diagnosis

Gastrointestinal (33)Gastrointestinal (33)•• GERD, gastroenteritis, esophageal dysfunction, GERD, gastroenteritis, esophageal dysfunction, GERD, gastroenteritis, esophageal dysfunction, GERD, gastroenteritis, esophageal dysfunction,

colic, surgical abdomencolic, surgical abdomen Idiopathic (23)Idiopathic (23)

•• About 20% of the time, the idiot (that’s me) About 20% of the time, the idiot (that’s me) can’t figure out the pathologycan’t figure out the pathology

Neurologic (15)Neurologic (15)•• Seizure, head injury, central Seizure, head injury, central

/h til ti CNS i f ti /h til ti CNS i f ti apnea/hypoventilation, CNS infection, apnea/hypoventilation, CNS infection, hydrocephalus, mass, neuromuscular hydrocephalus, mass, neuromuscular disorders, vasovagal reactions, congenital disorders, vasovagal reactions, congenital anomaliesanomalies

(occurrence % listed in parentheses)(occurrence % listed in parentheses)

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Differential DiagnosisDifferential Diagnosis

Respiratory (15)Respiratory (15)Infections aspiration reactive airway disease Infections aspiration reactive airway disease •• Infections, aspiration, reactive airway disease, Infections, aspiration, reactive airway disease, dynamic/functional obstructions, foreign bodydynamic/functional obstructions, foreign body

Abuse/Neglect (11)Abuse/Neglect (11)•• Shaken Baby, MunchausenShaken Baby, Munchausen--byby--proxy, proxy,

suffocationsuffocation

Metabolic/Endocrine (1)Metabolic/Endocrine (1) Metabolic/Endocrine (1)Metabolic/Endocrine (1)•• Electrolyte disorders, hypoglycemia, inborn Electrolyte disorders, hypoglycemia, inborn

errors of metabolismerrors of metabolism

Differential DiagnosisDifferential Diagnosis

Cardiovascular (1)Cardiovascular (1)Congenital heart disease cardiomyopathy Congenital heart disease cardiomyopathy •• Congenital heart disease, cardiomyopathy, Congenital heart disease, cardiomyopathy, myocarditis, arrhythmiasmyocarditis, arrhythmias

Miscellaneous infectionsMiscellaneous infections•• Sepsis, UTISepsis, UTI

Miscellaneous eventsMiscellaneous events•• Anemia drug reactions physiologic events Anemia drug reactions physiologic events •• Anemia, drug reactions, physiologic events, Anemia, drug reactions, physiologic events,

breath holding, choking, hypothermiabreath holding, choking, hypothermia

So, in other words, think of everything!So, in other words, think of everything!

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History is ParamountHistory is Paramount Chief ComplaintChief Complaint Who, What, When, Where, Why, HowWho, What, When, Where, Why, How Who, What, When, Where, Why, HowWho, What, When, Where, Why, How HistoryHistory

•• Birth, Medical, Allergies, Medications, Birth, Medical, Allergies, Medications, Family history, Maternal medications, Family history, Maternal medications, Past Past ALTEsALTEs, Monitor use, Monitor use

Abuse Red FlagsAbuse Red Flags Abuse Red FlagsAbuse Red Flags•• Recurrent ALTE, previous infant death in Recurrent ALTE, previous infant death in

the care of the same person especially if the care of the same person especially if caregiver is unrelated, discovery of caregiver is unrelated, discovery of blood in mouth or noseblood in mouth or nose

Physical Exam is Just as ImportantPhysical Exam is Just as ImportantUncle Billy says soUncle Billy says so

“Get the patient in good “Get the patient in good li h li h U U fi fi light. light. Use Use your five senses. your five senses. We We miss more by not miss more by not seeing than we do by not seeing than we do by not knowing. knowing. Always Always examine examine the back. the back. ObserveObserve, record, , record, tabulate communicate ”tabulate communicate ”tabulate, communicate.tabulate, communicate.

Sir William OslerSir William Osler

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Clinical CluesClinical Clues

CaregiverCaregiver--child interactionschild interactions Stigmata of abuseStigmata of abuse Growth curve evaluation including Growth curve evaluation including

head circumferencehead circumference Dysmorphic featuresDysmorphic features

Diagnostic EvaluationDiagnostic Evaluation

Get ready, because my karma might Get ready, because my karma might d ! d !run over your dogma!run over your dogma!

There is no peer reviewed, trial There is no peer reviewed, trial proven, standardized evaluation proven, standardized evaluation for apparent lifefor apparent life--threatening threatening for apparent lifefor apparent life--threatening threatening eventsevents

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Society for the Study of Prevention of Infant DeathSociety for the Study of Prevention of Infant Death

Children’s National Medical CenterChildren’s National Medical Center

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Still Still Don’t Like ThatDon’t Like That??

What’s a What’s a Bloke Bloke to to DoDo??

THINK!THINK!C idC id b i l b t b i l b t ConsiderConsider basic laboratory basic laboratory investigationsinvestigations•• CBC, CMP, UA/Urine cultureCBC, CMP, UA/Urine culture•• ?lactate, ?EKG, ?CXR, ?EEG?lactate, ?EKG, ?CXR, ?EEG

Observe a feed, if event associated Observe a feed, if event associated around a feedaround a feed

Sepsis evaluation with appropriate Sepsis evaluation with appropriate culturescultures

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How How Beneficial Beneficial is is TestingTesting??

The more tests you do, probability The more tests you do, probability t t th h h f t t th h h f states the more chance you have of states the more chance you have of

getting a spurious resultgetting a spurious result Diagnostic tests are more beneficial Diagnostic tests are more beneficial

if performed based on contributing if performed based on contributing information from history and physicalinformation from history and physicalinformation from history and physicalinformation from history and physical

How How Beneficial Beneficial is is TestingTesting??

Brand in 2005 showed that Brand in 2005 showed that di ti t t iti l di ti t t iti l diagnostic tests are positive only diagnostic tests are positive only about 34% of the timeabout 34% of the time•• They contribute to a diagnosis only 6% They contribute to a diagnosis only 6%

of the time, most commonly UTIof the time, most commonly UTI•• Diagnostic tests may be better to rule Diagnostic tests may be better to rule

out than rule in problemsout than rule in problems

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How How Beneficial Beneficial is is TestingTesting??

Altman Altman et alet al in 2007 addressed the in 2007 addressed the common concern of dogmatically common concern of dogmatically common concern of dogmatically common concern of dogmatically performing a sepsis evaluation in a performing a sepsis evaluation in a well appearing childwell appearing child•• Retrospective study using Brand’s dataRetrospective study using Brand’s data•• 90 infants with sepsis evaluations90 infants with sepsis evaluations•• 30 had serious bacterial illness30 had serious bacterial illness•• 30 had serious bacterial illness30 had serious bacterial illness

25 had signs or symptoms25 had signs or symptoms 5 who did not5 who did not

•• 1 pneumonia, 4 UTI’s1 pneumonia, 4 UTI’s

•• All All ALTEs ALTEs should have UA/should have UA/UcxUcx and CXR?and CXR?

Take Home Message…Take Home Message…

The most important test is the The most important test is the LAPLAPt tt ttesttest

••LLook ook AAt t PPatientatient

Keep the initial evaluation simpleKeep the initial evaluation simple In a day and age of In a day and age of CPGs CPGs and and

l ith th l ti f l ith th l ti f ALTE ALTE algorithms, the evaluation of algorithms, the evaluation of ALTEs ALTEs requires thought and individual requires thought and individual evaluationevaluation

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Take Home Message…Take Home Message…

Diagnostic testing that was ordered Diagnostic testing that was ordered b d i f ti b d i f ti f f th th based on information based on information from from the the history and physical is beneficialhistory and physical is beneficial

Dogmatic testing is very low yield Dogmatic testing is very low yield and expensiveand expensive

Low threshold for UTI screeningLow threshold for UTI screening Low threshold for UTI screeningLow threshold for UTI screening

Discharge PlanningDischarge Planning

Start this from time of admissionStart this from time of admission Treatment aimed at the specific Treatment aimed at the specific

pathology or if none found, the chief pathology or if none found, the chief complaintcomplaint

Basic resuscitation trainingBasic resuscitation trainingEducation on SIDSEducation on SIDS Education on SIDSEducation on SIDS

Consideration for an apnea monitorConsideration for an apnea monitor

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A Few Final IssuesA Few Final Issues

ALTE and SIDSALTE and SIDSA itA it Apnea monitorsApnea monitors

ALTE and anemiaALTE and anemia Admitting Admitting all all ALTEsALTEs Is a CPG possible?Is a CPG possible?

Apnea MonitorsApnea Monitors

AAP in 2003 recommended monitors for the AAP in 2003 recommended monitors for the following situationsfollowing situationsfollowing situationsfollowing situations•• Known unstable airway, abnormal respiratory Known unstable airway, abnormal respiratory

control, technology dependent chronic lung control, technology dependent chronic lung diseasedisease

CHIME studyCHIME study Obstructive apneas often missedObstructive apneas often missed Obstructive apneas often missedObstructive apneas often missed Based on emotional stress, are they Based on emotional stress, are they

beneficial?beneficial?•• Abendroth, 1999, J Pediatr Health CareAbendroth, 1999, J Pediatr Health Care

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ALTEs ALTEs and Anemiaand Anemia

When compared to controls, children When compared to controls, children ith ith ALTE ALTE d t h i ifi tl d t h i ifi tl with with ALTEs ALTEs do not have significantly do not have significantly

different patient profilesdifferent patient profiles When kids with single events vs. When kids with single events vs.

recurrent events were comparedrecurrent events were compared•• Controls = 9.3Controls = 9.3% anemic for age% anemic for ageControls 9.3Controls 9.3% anemic for age% anemic for age•• Single Single ALTE = 16.9ALTE = 16.9% anemic for age% anemic for age•• Multiple Multiple ALTE = 21.6ALTE = 21.6% anemic for age% anemic for age

Do Do All ALTEsAll ALTEsNeed Need to be to be AdmittedAdmitted??

Claudius and Keens, 2007, PediatricsClaudius and Keens, 2007, Pediatrics•• Pilot study, small sample size, weakly Pilot study, small sample size, weakly y, p , yy, p , y

poweredpowered•• Showed that children with ALTE who Showed that children with ALTE who

were >1 month old and had only a were >1 month old and had only a single event could be dischargedsingle event could be discharged

Multicenter trial needed and being Multicenter trial needed and being l dl dplannedplanned

Could reduce ALTE admissions up to Could reduce ALTE admissions up to 40%40%

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Do Do All ALTEsAll ALTEsNeed Need to be to be AdmittedAdmitted??

My answer is noMy answer is no It really does depend on your It really does depend on your

patient’s presentation and evaluationpatient’s presentation and evaluation Dr. Dr. Maul’s Maul’s 3Cs3Cs

•• CCar, ar, CCommunication, ommunication, CCluelue Keep the evaluation simple and Keep the evaluation simple and Keep the evaluation simple and Keep the evaluation simple and

expand it as neededexpand it as needed

Is a CPG Is a CPG PossiblePossible??

Probably, and it is needed to help Probably, and it is needed to help t d di ALTE ti idt d di ALTE ti idstandardize ALTE care nationwidestandardize ALTE care nationwide

Currently in development between Currently in development between AAP Section of Hospital Medicine and AAP Section of Hospital Medicine and Society of Hospital MedicineSociety of Hospital Medicine•• Target release date is 2009Target release date is 2009--20102010Target release date is 2009Target release date is 2009 20102010

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DenouementDenouement

Case 1Case 1H&P fo nd finge ma ks on poste io H&P fo nd finge ma ks on poste io •• H&P found finger marks on posterior H&P found finger marks on posterior ribcage, retinal hemorrhages, admitted ribcage, retinal hemorrhages, admitted for suspected and eventually confirmed for suspected and eventually confirmed abuseabuse

Case 2Case 2•• Simple choking event; “normal feedSimple choking event; “normal feed”= 8 ”= 8 •• Simple choking event; normal feedSimple choking event; normal feed = 8 = 8

ozoz, observed overnight without event, , observed overnight without event, counseled on CPR, parents vehemently counseled on CPR, parents vehemently wanted monitor, didn’t get onewanted monitor, didn’t get one

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KiechlKiechl--KohlendorferKohlendorfer, U., D. Hof, et al. (2005). "Epidemiology of apparent life , U., D. Hof, et al. (2005). "Epidemiology of apparent life threatening events." threatening events." Arch Arch DisDis ChildChild 9090(3): 297(3): 297--300.300.

McGovern, M. C. and M. B. Smith (2004). "Causes of apparent life threatening McGovern, M. C. and M. B. Smith (2004). "Causes of apparent life threatening events in infants: a systematic review." events in infants: a systematic review." Arch Arch DisDis ChildChild 8989(11): 1043(11): 1043--8.8.McGovern M C and M B Smith (2005) "Yield of diagnostic testing in infants McGovern M C and M B Smith (2005) "Yield of diagnostic testing in infants

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