CASE PRESENTATION

• B/O Reshma Prakash D11 Mch from Honnali was admitted to our hospital on 28th,November

• C/C: H/O Hurried respiration H/O Bluish discoloration of lips• With above complaints local GP was consulted

who noticed 3 episodes of apnea in 30mins,Hence referred to our institute.

• Antenatal History:G4P3L2,Concieved spontaneously.Regular ANC with Iron and folic acid supplements.

• Birth History:FTND in Honnalli Govt Hospital,B wt-2.6kg,Cried immediately.Breast fed within 30mins.

• Postnatal:Uneventful upto D10 .

• There was no h/o cough,cold prior to onset of symptoms.

• No h/o cough,cold ,in family.• H/O sibling death at 45 days of age,with h/o

abdominal distension.

• On Examination:Baby Pink,Weak cry and poor activity.

HR-136/min. N volume and regular. RR-54cpm,Regular Spo2:96% with HBO2 Temp-97.6F• Head to Toe examn:AF at level,No facial

dysmorphisms.

• R/S:No retractions,B/L CREPS(+)

• CVS:S1,S2 heard ,short systolic murmur best heard in lower lt. parasternal area

• CNS:CRAT-poor,AF 2*2 ,AT level Moro Reflexe:Sluggish

TERM/AGA/M/LOS-?MENINGITIS WITH PNEUMONIA

Investigations:

• CBC:Hb:14.8%,WBC count:3790/cumm PMN:55%,ANC-2070/cumm Plt:1,72 Lac/cumm I:T=0.01• CRP:31.3mg/L• RFT,Electrolytes,LFT-Normal• ABG-Normal gas values with normal base defict.• CSF study:Normal

Course in Hospital

• D1-Baby continued to remain Obtunded,shallow respiration and multiple episodes of apnea in hospital requiring tactile stimulation.

• Neuroimaging was done to rule out IC Bleed-Normal study.

• 2D Echo-Normal.• On D4 of admission was intubated for prologed

apnea .• DAMA as attenders were not affordable.

TERM/AGA/M/LOS/PERSISTENT ENCEPHALOPATHY PRESENTING AS ALTE

APPARENT LIFE THREATENING EVENT(ALTE)

&BRIEFLY RESOLVED

UNEXPLAINED EVENT(BRUE)

Introduction:

• Many no. of infants present with acute events-unexpected change in breathing, color or behaviour.

• It is not a specific diagnosis, but rather a "chief complaint" that brings an infant to medical attention.

• Challenge is to identify the infants who may benefit from further testing and prolonged observation.

Epidemology:• Studies estimated that ALTEs occur in 3:10,000 to

41:10,000 infants.

• Lesser risk factors include premature birth or low birth weight and maternal smoking.

• Most common explanatory diagnosis were GERD,Seizures,RTI.

The main risk factors for acute events in infants described as ALTE are feeding difficulties,recent upper

respiratory symptoms, and age younger than two months, or a history of previous episodes

Definition: ALTE• This description was established by expert consensus in

1986.• Previously used terminology such as near-miss

sudden infant death syndrome (SIDS) or aborted crib death were abandoned.

An apparent life-threatening event (ALTE) is defined as an episode that is frightening to the observer and is characterized by some combination of1) apnea (central or obstructive),2) color change (cyanotic, pallid, erythematous or plethoric) 3)change in muscle tone (usually diminished). 4)choking or gagging.

‘Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent LifeThreatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016;137(5):e20160591

In 2016, the American Academy of Pediatrics (AAP) released a new clinical practice guideline that recommended the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE).’

Definition BRUE:

• In an infant younger than 1 year :-when the observer reports a sudden, brief(<1min), and

now resolved episode of ≥1 of the following:

• Only when the infant is asymptomatic on presentation.• when there is no explanation for the episode after a

focused history and physical examination.

(1) Cyanosis or Pallor(2) Absent, decreased, or irregular breathing.(3) Marked change in tone (hyper- or hypotonia) (4) Altered level of responsiveness

ALTE vs BRUE

ALTE• No age limit.

• May be due to specific cause.

• Care givers perception.

• Color change

• Redness and rubor present

BRUE• Age limit Upto 1 year.

• Only if no other explanation.

• Clinician characterization.

• Cyanosis or pallor

• Not included

ALTE

BRUE

ALTE vs BRUE ALTE• Apnea only.

• Change in muscle tone

• Includes choking & gagging

• Conciousness-not included

BRUE• Irregular,diminished,or

absent breathing.• Hypo or Hypertonia

• Not in defintion

• Altered level of conciousness.

Evaluation:History• Most important diagnostic tool –detail description of event.• The history should include information about any previous apneic events. recent illnesses or symptoms.the pregnancy and perinatal period.the infant's usual behavior-sleep and feeding habits. family history(including a history of siblings with similar

episodes, sudden deaths, early deaths, genetic, metabolic,cardiac, and neurologic problems).

a social history (including the presence of smoking, alcohol or substance use in the home, and a list of medications in the home)

Histoty pointers towards specific diagnosis:

Gastroesophageal reflux (GER) and/or laryngospasm:• Gross emesis or oral regurgitation that occurred at the

time of the event.• Acute events caused by laryngospasm typically occur

during feeding, or shortly after feeding, especially if the infant is in a supine position

• If symptoms are recurrent and/or the infant has underlying neurologic or developmental abnormalities, further evaluation for swallowing dysfunction may be warranted.

• A respiratory tract infection should be suspected based on symptoms (eg, history of nasal congestion,cough, and/or fever).

• Features suggestive of seizures include loss of muscle tone and unresponsiveness during the episode, and no history of choking or gagging.

• A history of previous episodes of severe events should particularly prompt consideration of child abuse,especially if the events occurred in the presence of a single caretaker and required CPR.

Examination:• Measurement of height, weight, and head

circumference and comparison of these values to standards for age and gender

• Measurement of vital signs, including pulse oximetry.• Examination for physical signs of trauma (bruising, sub

conjunctival or retinal hemorrhage, bulging anterior fontanel)

• Neurologic examination, including alertness and tone• Evaluation for respiratory distress or upper airway

obstruction, including assessment of facial dysmorphism • Developmental assessment, including assessment of

developmental reflexes

Risk Classification of BRUE:

(1) Lower-risk patients on the basis of history and physical examination, for whom evidence based guidelines for evaluation and management are offered.

(2) Higher-risk patients, whose history and physical examination suggest the need for further investigation, monitoring, and/or treatment, but for whom recommendations are not offered (because of insufficient evidence or the availability of guidance from other clinical practice guidelines specific to their presentation or diagnosis).

Management of Low risk BRUE:

Recommended steps:• Educate caregivers about BRUEs, and the low risk for

infants with these characteristics.• Offer resources for training in cardiopulmonary

resuscitation (CPR).• Engage in shared decision-making about further

evaluation and disposition.• Arrange for a follow-up check with a medical provider

within 24 hours to identify infants with evolving medical concerns that would require further evaluation and treatment.

Management of Low risk BRUE:

Optional steps:• A brief period of in-hospital observation (eg, one to four

hours) with continuous pulse oximetry and serial observations.

• 12-lead electrocardiogram with attention to QT interval. • Testing for pertussis (especially for infants with

suggestive symptoms).• Respiratory virus testing,such as for respiratory syncytial

virus, is reasonable if a rapid testing method is available.However, this testing is not required in these low-risk infants, who by definition have no respiratory symptoms and are >2 months of age

Evaluation of High risk BRUE:

• If there are clinical features that suggest a specific diagnosis (eg, upper respiratory tract infection or child abuse), the evaluation may be targeted toward that concern.

• If there are no clinical features suggesting a specific diagnosis, a general screening evaluation includes a complete blood count, urinalysis, plasma concentrations of glucose, electrolytes, calcium and magnesium, blood urea nitrogen, a chest radiograph, and an electrocardiogram.

D/D for High risk ALTE/BRUE

• GER/Laryngospasm• Neurolgical problems(seizures)• Repiratory tract infections• Child abuse• Cardiac disease• Upper airway obstruction• Bacterial infection• Metabolic disorders.• Toxin ingestion

Disposition:

• In-hospital observation with cardio respiratory monitoring is indicated for infants whose initial evaluation (whether by history, examination, or other diagnostic studies) suggests physiologic compromise.

• Includes infants with a history of more than one acute event within the previous 24 hours or any other warning signs prompting additional evaluation .

• Other reasons to consider hospitalization include: suspicion of trauma, neglect, poisoning or abuse; an other wiseunwell-appearing infant (such as failure to thrive of unknown etiology); social risk factors; or perceived need to monitor and observe feedings.

Warning Signs:

• The presence of the following warning signs increase the likelihood that the acute event is medically significant and may have a specific pathologic cause.

• Infants with these signs should be admitted to the hospital for observation with cardiorespiratory monitoring, with specific evaluation guided by the history

-Symptoms at the time of evaluation, including toxic appearance, lethargy, unexplained recurrent vomiting, or respiratory distress.

-Significant physiologic compromise during the event. Concerning symptoms include generalized sustained cyanosis or loss of consciousness, need for resuscitation by a trained CPR provider (more than just stimulation).

Warning Signs-contd• Bruising or any other evidence of trauma.• History of prior events in this patient, especially within the past

24 hours, or clusters of events.• History of clinically significant events or unexpected death in a

sibling.• History that raises suspicion for the possibility of child

maltreatment, such as an inconsistent description of the event, prior report for child maltreatment in the family, or a description that is inconsistent with the child's developmental stage.

• Dysmorphic features, congenital anomalies, and/or known syndrome

Home Monitoring:

• Studies of infants with a history of ALTE and who remain asymptomatic have failed to demonstrate a therapeutic benefit of home CR monitoring.

• Infants who may particularly benefit from home monitoring include premature infants with recurrent episodes of apnea and bradycardia, or infants with unstable airways or chronic lung disease.

Recurrence Risk:• The risk for recurrence of apparent life-threatening

events (ALTE) ranges from 10 to 25 percent in different reports.

• Substantially lower for infants meeting the narrower criteria for BRUE.

• Infants who present with multiple acute events preceding the hospital admission are more likely to have an underlying disease as compared with those with single events.

• Infants younger than two months of age require special attention because they are at increased risk for occult infection or undiagnosed congenital disorders

Death:

• The overall risk of subsequent death in infants who have experienced ALTE is estimated to be less than 1 percent and substantially lower for those meeting the narrower criteria for BRUE

• Infants with recurrent events requiring cardiopulmonary resuscitation (CPR) have a very high risk of subsequent death, ranging from 10 to 30 percent .

ALTE & SIDS

• Vast majority of SIDS victims do not experience acute events or apnea prior to death.

• Studies over the past two decades have failed to confirm a causal relationship between pre existing apnea and SIDS

• ALTE is unlikely to be a predictor of SIDS because ALTE refers to a heterogeneous group of problems with different causes and severities, ranging from benign to near-fatal.

• Over 80 percent of SIDS deaths occur between midnight and 6 AM whereas 82 percent of ALTE episodes occur between 8 AM and 8 PM.

• The peak incidence of ALTE is during the first two months of life, whereas the peak incidence of SIDS is between two and four months of age .

• Interventions to prevent SIDS (eg, supine sleeping) have not resulted in a decreased incidence of ALTE .

• The risk factors for SIDS and ALTE differ . Prone sleeping, lack of breastfeeding, and maternal smoking were risks for SIDS, whereas behavioral characteristics (eg, previous episodes of apnea, pallor, cyanosis, or feeding difficulties) were risk factors for ALTE .

• Prematurity and low birthweight are much stronger risk factors for SIDS than for ALTE

References:• National Institutes of Health Consensus Development Conference on

Infantile Apnea and Home Monitoring, Sept 29 to Oct 1, 1986. Pediatrics 1987; 79:292.

• Tieder JS, Bonkowsky JL, Etzel RA. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: Executive summary. Pediatrics 2016;137:e2 0160591.3.

• Kiechl-Kohlendorfer U, Hof D, Peglow UP, et al. Epidemiology of apparent life threatening events.Arch Dis Child 2005; 90:297.

• Michael J Corwin, MD. Acute events in infancy including brief resolved unexplained event (BRUE),UpTodate :Oct 11, 2016

• Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics 2005; 115:885.

• Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted.Pediatrics 2007; 119:679.

• Brooks JG. Apparent life-threatening events and apnea of infancy. Clin Perinatol 47. 1992; 19:809.

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