Apparent Life Threatening Event

(ALTE)Dr Mohamed I. AbunadaDr Mohamed I. Abunada

Pediatric NeurologyPediatric NeurologyDr Alrantisi spezialised Dr Alrantisi spezialised

ped Hospitalped Hospital

Case2 mo old female infant presents

to ED via ambulance after her mother witnessed an episode of turning blue and having stopped breathing. Mother tried stimulating baby and after 1-2 minutes baby opened eyes. Mother called 110 immediately.

Case Definition ALTE was defined in 1986 at the NIH

Consensus Development Conference on Infantile Apnea and Home Monitoring as:

– “an episode that is frightening to the observer and is characterized by some combination of apnea, color change, marked change in muscle tone, choking or gagging.”

IntroductionALTE is a poorly defined termALTE infants represent an extremely

heterogeneous group of patients of varying ages with diverse pathophysiology

Important to recognize that ALTE is NOT a specific diagnosis; rather it describes a symptom/chief complaint that brings the infant to medical attention

Diagnostic Evaluation

HAVING A GOOD DIFFERENTIAL DIAGNOSIS WILL BE THE KEY!

Differential diagnosis of ALTE…

Differential Diagnosis

Respiratory Laryngomalacia/ tracheomalacia Breath holding spells Aspiration Central apnea Isolated prolonged

apnea Vocal cord

dysfunction Vascular ring Upper airway

obstruction

Infectious Sepsis Bronchiolitis Pertussis Meningitis Pneumonia

Differential Diagnosis (cont)

Neurologic Seizure Encephalopathy Structural

abnormality Intracranial

hemorrhage Increased ICP

Gastrointestinal GERD Suck-swallow

incoordination

Differential Diagnosis (cont)

Cardiac Congenital heart

disease Dysrhythmia Cardiomyopathy

Trauma Forced aspiration Suffocation Shaken baby Munchausen’s by

Proxy

Differential Diagnosis (cont)

Metabolic Inborn error Electrolyte

abnormality

Unknown As many as 50%

will ultimately fall into this category

History Taking – the event

State – asleep, awake, crying, relationship to feeding or emesis? Respiratory effort – none, shallow, increased, struggling, or choking? Color – cyanotic, pale, gray, red ? Color change – entire body, extremities, face, peri-oral, lips? Tone – limp, rigid, tonic/clonic ? Eyes – open, closed, dazed, staring, rolled, bulging? Noise – none, cough, choking, stridor ? Fluid – none, mucus, milk, vomit, blood ? Duration – seconds, minutes?

History Taking - interventions

None Gentle stimulation? Vigorous stimulation? Mouth to mouth resuscitation? CPR Duration?

History taking How was the baby behaving during the day

prior to the event? How did the baby act after the event? How long before the baby was acting at

baseline, and what was different until then?

PH- focusing on detailed birth history, feeding history, developmental history, h/o tiring/cyanosis/sweating with feeds

FH- focusing on cardiac hx, seizures, neuro disease, genetic disease, SIDS, other ALTEs

Physical Exam

General- Ill-appearing? Toxic? Arousable ? Tone?

Fontanelle? Fundi ? Hemotympanum? Bleeding? Dysmorphic? Chest- Wheezing/crackles/cough?

Tachypnea? Noisy breathing/stridor? CV- Murmur? Pulses? Abd- Hepatomegaly? Ext- Bruising? Well-perfused? Neuro- Tone? Focal findings?

Initial Evaluation

Admit orders include- – Monitored bed– CR monitor and continuous pulse ox– Event log

Remainder of management is based on likely category of etiology as determined by initial H&P

Evaluation by Clinical Category

Respiratory CXR ENT or Pulm eval for direct airway

visualization May overlap with infectious and metabolic

Infectious Respiratory viral

screen Pertussis PCR CBC Blood/Urine Cx LP CXR

Evaluation by Clinical Category

Gastrointestinal Reflux precautions Thickened feeds If severe apnea,

consider:GI ConsultProton Pump

Inhibitor or H2 blocker

Neurologic Seizure precautions Basic electrolytes,

glucose, calcium, Mg

EEG Neuro consult Head imaging LP

Evaluation by Clinical Category

Cardiac EKG CXR Echo Cardiology consult ABG/VBG

Trauma. Child Protective Team Dilated retinal exam Head CT Skeletal survey

Metabolic Electrolytes LFT Lactate, pyruvate Thyroid tests

Before Discharge

Specific treatment will be dictated by the results of the evaluation

All parents receive CPR training SIDS prevention education

Home Apnea Monitors

AAP Policy Statement. Pediatrics. 2003: 111: 914-917

AAP Policy Statement. Pediatrics. 2005: 116:1245-1255

SIDS Sudden Infant Death Syndrome

S – SuddenI – InfantD – DeathS – Syndrome

Definition of SIDS

Sudden Infant Death Syndrome (SIDS) is the sudden death of an infant under one year of age, which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history.

Source: Willinger M et al. Pediatr Pathol, 1991

Characteristics of SIDS

Peak incidence at 2 to 4 months of age Slight male predominance More prevalent in cold, winter months Not considered genetic or hereditary Not due to suffocation, aspiration, abuse or

neglect

Source: CDC Facts About SIDS

Common Myths To Dispel About SIDS

SIDS is not caused by vaccines or immunizations SIDS is not contagious SIDS is not hereditary SIDS is not a result of child abuse or neglect SIDS, or “crib death”, is not caused by cribs Apnea monitors will not prevent SIDS

Source: NICHD Back To Sleep Campaign: Resource Kit for Reducing the Risk of SIDS in African American Communities

What Causes SIDS?

SIDSExogenous Stressors

Vulnerable Infant

Critical Development

Period

Researchers believe there is probably more than one cause of SIDS, and that babies who die of SIDS are born with abnormalities which make them susceptible to sudden death at critical developmental periods. The vulnerable infant is met with an environmental challenge at a critical developmental period and cannot respond adequately, resulting in immediate death.

Source: Filiano JJ, Kinney HC. Biology of the Neonate, 1994

Triple-Risk Model

Five Steps in the Terminal Respiratory Pathway Associated with the Sudden Infant Death Syndrome.Death results from one or more failures in protective mechanisms against a life

threatening event during sleep in the vulnerable infant during a critical period .

Risk Factors for SIDS

Prone sleep position for infants (stomach sleeping) Large, soft bulky blankets Large objects in sleeping

area Soft mattress

Lack of (or late) prenatal care

Maternal age below 20 (adolescent mothers)

Maternal substance use during pregnancy

Low birth weight, premature and multiple-birth infants

Exposure to cigarette smoke (prenatal and postnatal)

Low socioeconomic status

Sources: NICHD, Sudden Infant Death Syndrome, April 1997. Sullivan FM, Barlow SM, Paediatr Perinat Epidemiol, 2001

Key Points to Communicate to Parents and Caregivers

Always place baby on his/her back to sleep, even for naps.

• Since 1994, it has been recommended that babies always be put to sleep on their back.*

• This is the best way you can help reduce your baby’s risk for SIDS. Even though the cause is unknown, it is known that infants put to sleep on their back are less likely to die of SIDS.

• Even if bedsharing, make sure baby is sleeping face up.

*Source: AAP Task Force on Infant Sleep Position and SIDS, Pediatrics 2000 X

X

Remove soft and fluffy bedding from sleep area.

• This includes pillows, quilts, toys, and stuffed animals.

Don’t allow the baby to sleep on soft surfaces.

• This includes the couch, sofa, adult bed, waterbed or other soft surfaces.

• Use a firm, tight-fitting mattress for the crib.

• Make sure baby can’t get trapped between the sofa cushions, mattress or framework of the bed or crib.

Key Points to Communicate Key Points to Communicate to Parents and Caregiversto Parents and Caregivers

Key Points to Communicate to Parents and Caregivers

Make sure baby’s head and face remain uncovered during sleep.Keep baby’s mouth and nose clear of any blankets or

coverings.

Don’t let baby get too warm while sleeping. Babies should not be tightly bundled or “swaddled” in a

blanket, even in hospital settings.Remember that a baby’s environment should be the same

temperature that is comfortable for an adult, about 70° F.

Create a smoke-free environment for your baby.

• Don’t smoke during pregnancy or after the birth of your baby.

• Make sure that no one smokes around your baby.

Key Points to Communicate Key Points to Communicate to Parents and Caregiversto Parents and Caregivers

Common Barriers To “Back-To-Sleep”

Grandparents and other caregivers recommend putting baby to sleep on their stomach

– This includes older caregivers as well as mothers who gave birth to their last child more than 10 years ago.

– Ask them why they choose to use the prone position and address how to overcome these concerns.

– Discuss how practices have changed over the years, re-educate caregivers. “Did you know that we are supposed to put babies to sleep on their backs?”

Source: NICHD Back To Sleep Campaign: Resource Kit for Reducing the Risk of SIDS in African American Communities

Common Barriers To “Back-To-Sleep”

A belief that baby will develop a permanent flat spot or bald spot on his head– Remind parents/caregivers that this is a

passing condition that goes away after baby starts learning to sit up.

– This can be avoided with “tummy time” – placing the baby on his stomach when he is awake and is being observed.

A common belief that baby can choke in the back-sleep position– Some caregivers may need more intense education

to dispel this misconception, since this is often one of their main reasons against using the supine position.*

– Inform parents/caregivers that infants automatically swallow or cough up fluid. The number of babies dying on their backs has not increased since the initiation of the Back-to-Sleep campaign in 1994.

Common Barriers To “Back-To-Sleep”

Source: NICHD Back To Sleep Campaign: Resource Kit for Reducing the Risk of SIDS in African American Communities, * NYC DOHMH, Report on SIDS Focus Groups, 2004, unpublished data.

Common Barriers To “Back-To-SleepCommon Barriers To “Back-To-Sleep””

A belief that babies sleep better on their stomachs Most babies get used to the back position quickly. The

earlier you put baby on his/her back to sleep, the more quickly baby gets used to it.

Babies sleeping on their stomachs may not wake up as quickly if something is wrong.

Parents can comfort baby by putting her to sleep on their chest, and then laying sleeping baby on her back in the crib.

They put the baby to sleep on his side or stomach in the hospitalStudies have found that back-sleeping is the

safest position for infants, even safer than side sleeping.

Side sleeping increases babies’ risk of rolling to the prone position.

Common Barriers To “Back-To-Sleep”Common Barriers To “Back-To-Sleep”

Source: NICHD Back To Sleep Campaign: Resource Kit for Reducing the Risk of SIDS in African American Communities

Breastfeeding and SIDS

• Although several retrospective studies have demonstrated a protective effect of breastfeeding on SIDS, other analyses and prospective cohort studies failed to find such an effect after adjustment for confounding variables.*

• However, breastfeeding is known to provide many other health benefits and should be practiced exclusively for at least the first 6 months.

*Source: AAP Task Force on Infant Sleep Position and SIDS, Pediatrics 2000

“According to AAP, evidence is insufficient to recommend breastfeeding as a strategy to reduce SIDS.”

– AAP Task Force on Infant Sleep Position and SIDS, Pediatrics 2000*

Bedsharing: A Controversial IssueThere are insufficient data to conclude that bedsharing under carefully

controlled conditions is clearly hazardous or clearly safe. – AAP Task Force on Infant Sleep Position and SIDS, Pediatrics 2000

Risks1-3

Research has shown that bedsharing may increase risk for SIDS in certain situations. This includes bedsharing with a parent who is:• A smoker• Under the influence of alcohol,

drugs, or medications that may impair arousal

• Extremely tired or ill• Obese

Benefits4-6

Some believe bedsharing may have certain benefits, such as:

• Increased breastfeeding• Enhanced closeness between parent

and baby• Increased awareness of parent to

infant’s needs and arousals• More infant arousals and less deep

sleep for infant

* Note: No epidemiologic studies have shown that bedsharing has a protective effect from SIDS.1

Sources: 1) AAP Task Force on Infant Sleep Position and SIDS, Pediatrics 2000 2) NICHD, Sudden Infant Death Syndrome, April 1997 3) Association of SIDS and Infant Mortality Programs, 2001 4) 2001 UNICEF UK Baby Friendly Initiative/FSID, July 2003 5) Willinger M et al, Arch Pediatr Adolesc Med, 2003 6) Brenner RA et al, Arch Pediatr Adolesc Med, 2003.

“Safer” Bedsharing If Bedsharing, take care to observe the standard

recommendations for “safer” Bedsharing:

Nonprone sleeping

Avoidance of soft sleeping surfaces, loose adult bedding (i.e. pillows, quilts, comforters), overheating or overbundling.

As an alternative to Bedsharing, parents may place baby’s crib near their bed for more convenient breastfeeding and parent contact.

Source: AAP Task Force on Infant Sleep Position and SIDS, Pediatrics 2000

Communicating with Patients About Bedsharing Keep in mind that Bedsharing is a common practice in many

cultures and households.* If parents decide to share a bed with the baby, make sure to

discuss “safer” Bedsharing practices. Parents and caregivers should not bedshare if the adult is a

smoker, is very tired or ill, or is under the influence of substances (such as alcohol, drugs, or prescription medications) that may impair arousal.

* Sources: Willinger M et al. Arch Pediatr Adolesc Med, 2003; Brenner RA et al. Arch Pediatr Adolesc Med, 2003.

Scene Size Up

DOCUMENT ALL DETAILS CAREFULLY AND ACURATELY:– Clothing, position of child, crib or bed, bedding, objects in

bed, any unusual odors, room temperature, medications (OTC or other)

– DOCUMENTATION OF EVERY DETAIL IS VERY IMPORTANT; ALL DEATHS ARE CONSIDERED CRIME SCENES UNTIL PROVEN OTHERWISE.

Event History

Retrieval of a good history:– What happened– Infant location (who found infant)– Interventions (CPR or other) by

parents/caregivers– When was the infant last seen alive– Recent illnesses and past medical history– Any meds (OTC or others) the infant has received

Patient Assessment

External Appearance with SIDS:– Cold skin– Frothy or blood tinged fluid in mouth and/or nose– Normal hydration and nutrition– Lividity and rigor mortis– Vomitis is occasionally present– ENSURE ALL FINDINGS AND

OBSERVATIONS ARE DOCUMENTED

SIDS prevention

Sleep Sacks

To eliminate the possibility of loose blankets covering the infant's face and to reduce the likelihood of overheating, the AAP recommends using sleep clothing with no other covering or using infant sleep sacks. Properly designed sleep sacks keep the infant warm without the chance that the garment might cover the head. In our NICU, infants were initially placed in sleep sacks hand-sewn by a local church group that volunteered its services. The sleep sacks were sized appropriately, had openings for monitor wires, and were placed on all infants when they were moved to an open crib. Parents could observe their infant in the supine position wearing a safe sleep garment, which reinforces SIDS prevention strategies.

Halo Sleep Sack wearable blanket

A 10-year-old boy is brought to the emergency department after being struck by a car while riding his bicycle. Physical examination immediately upon arrival reveals that he is responsive to painful stimuli only by moaning. His pupils are equal, small, and reactive.

Of the following, the sign MOST LIKELY to be associated with increasing intracranial pressure in this patient is

A. hyperventilationB. hypotensionC. hypothermiaD. nystagmusE. tachycardia

A

You are seeing a 2-month-old male infant who has trisomy 21 for a health supervision visit. Theboy's mother expresses concern that the infant has been having "noisy breathing" during thepast 2 to 3 weeks. The infant has been exclusively formula-fed and has had no choking ordifficulty feeding. According to the mother, the noise, which occurs on inspiration, is louder when the infant is supine and when crying. She has not noticed any rhinorrhea, cough, or other upper respiratory viral illness symptoms. The infant was born via an uneventful vaginal delivery that did not require forceps. Apgar scores were 8 and 9 at 1 and 5 minutes, respectively. On physical examination, the infant, whose physical appearance is consistent with trisomy 21, is resting comfortably. His vital signs are appropriate for age, but you hear an audible noise during inspiration.Of the following, the MOST likely explanation for the infant's respiratory symptoms isA. laryngomalaciaB. subglottic tracheal web C. tracheomalacia D. vascular ring E. vocal cord paralysis 

When evaluating an infant who presents with “noisy breathing,” it is important to obtain athorough birth history and current medical history, observe breathing patterns in differentpositions, and auscultate the airway. Secondary evaluation tools include radiography,spirometry, and direct airway visualization. In general, breathing noises can be classified as inspiratory, expiratory, or biphasic.Disorders at the level of and superior to the vocal cords result in a harsh, inspiratory noisecalled stridor (Item C111A). Lesions inferior to the vocal cords typically result in wheezing, ahigh-pitched expiratory noise. Laryngomalacia is the most common congenital laryngeal abnormality resulting in stridor.Symptoms may begin shortly after birth, although they typically occur between 1 and 2 monthsafter birth. As with the child described in the vignette, infants are happy, thriving, and not havingdifficulty during feedings, but stridor usually worsens during supine positioning, increased cryingor agitation, or a viral illness. Direct visualization of an omega-shaped epiglottis that prolapses(Item C111B) during inspiration is a hallmark of the condition. Severe cases may require surgicalcorrection, although laryngomalacia usually improves spontaneously by 2 years of age.A laryngeal web results from failure of the embryonic airway to recanalize. Most laryngealwebs occur at the level of the vocal cords and present at birth with stridor. The delayed onset ofstridor in the infant in the vignette makes a laryngeal web unlikely. Tracheomalacia (Item C111C) results from defective cartilaginous rings causing flaccidity ofthe tracheal wall. Both tracheomalacia and laryngomalacia present at similar ages and areexacerbated by crying, viral respiratory infections, and supine positioning. However, infants whohave tracheomalacia present with wheezing instead of stridor.Extrinsic compression of the trachea by vascular anomalies such as a vascular ring (ItemC111D) can result in recurrent wheezing that is worsened with crying, feeding, or neck flexion.The right-sided aortic arch with left ligamentum arteriosum and the double aortic arch accountfor most cases. Unilateral or bilateral vocal cord paralysis (Item C111E) can be associated with inspiratorystridor, but often results in a weak cry, coughing, and choking. When vocal cord paralysis issuspected, a thorough search for underlying causes (eg, congenital central lesions, atrialenlargement, birth trauma, traumatic forceps delivery, prior surgical procedures) should be

A 3-year-old boy presents to the emergency department following the abrupt onset of Coughing and wheezing. You order a chest radiograph for evaluation of a suspected foreign body aspiration. Of the following, the MOST appropriate statement regarding foreign body aspiration i

s thatA. most foreign body aspirations present within 24 hours B. nonfood items (eg, coins, pins, pencaps) are the most

 common items aspirated by infants and toddlersC. the classic triad of cough, wheeze, and decreased breath sounds

 is present in most casesD. the majority of aspirated foreign bodies are located in the larynx 

or tracheaE. toy balloons are a common cause of foreign body aspirations

The presentation of a foreign body aspiration depends on whether the event was witnessed, theage of the child, the type of object aspirated, the elapsed time since the event, and the location 

ofthe object. Most foreign body aspirations (50% to 75%) present and are diagnosed within 24hours. Although an acute choking or coughing episode accompanied by wheezing is highlysuspicious for a foreign body aspiration, some infants and children present with few or nosymptoms. The classic triad of coughing, wheezing, and decreased breath sounds is present inless than 50% of cases.Food is the most common item aspirated by infants and toddlers (eg, sunflower seeds, nuts,beans, carrots, corn); nonfood items (eg, coins, paper clips, pins, pen caps) more commonlyare aspirated by older children. Although a rare cause of foreign body aspiration, toy balloonaspiration can be fatal. Most aspirated foreign bodies lodge in the right lung rather than the larynx or trachea (). Long-

term complications of undiagnosed or retained foreign bodies include recurrentpneumonia, atelectasis, and bronchiectasis. 

A

All of the following statements concerning acute epiglottitis are correct, EXCEPT:

A) it progresses slowlyB) fever and excitement are observedC) dyspnea, cyanosis and retroflection of the head

are observedD) suffocation might develop

A

Which of the following statements about subglottic laryngitis is correct?

A) it is most commonly manifested between the ages of 8-10y

B) it is always associated with a high feverC) the speech is clearD) an expiratory type dyspnea developsE) a "barking" cough is detected

E

Which of the following procedures is reliable in the diagnosis

or exclusion of a foreign body in the airways?A) a physical examinationB) a thorough history takingC) bronchoscopyD) chest transillumination (Holzknecht's sign)E) chest x-ray

C