Apparent life-threatening event

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Chapter 5 APPARENT LIFE-THREATENING EVENT

Jonathan M. Wong

General Discussion

An apparent life-threatening event (ALTE) is defined as an episode that is frightening to the observer and is characterized by some combination of apnea, color change, change in muscle tone, choking, or gagging. These episodes may necessitate stimulation or resuscitation to arouse the child and reinitiate regular breathing.

The true incidence of ALTEs is unknown because epidemiologic data are derived from inpatient admissions and emergency rooms, and not all children who have an ALTE are brought in for evaluation. The reported incidence of ALTE is 0.05% to 6%. Most episodes occur in children younger than 1 year, and some studies have implied a peak incidence between 1 week and 2 months of age, with most occurring within the first 10 weeks of life.

The underlying cause of ALTE varies greatly and should be thought of as a manifestation of other conditions. In one half of patients, the cause is discovered either through careful history and physical examination, diagnostic evaluation (see below), or both so that intervention is possible, perhaps preventing future episodes. By default, a specific cause is not found in the remaining cases, placing them in the idiopathic category.

According to one major study of 243 patients, history and physical examination alone yielded a cause 21% of the time, whereas diagnostic tests alone (when history and physical were not elucidative), yielded a cause 14% of the time. This speaks to the importance of a careful history and physical examination while revealing that a shotgun approach to diagnostic testing is not helpful.

The challenge is to manage the immediate event, discern the underlying cause, educate parents and alleviate their concerns, and determine the need for future monitoring. The outcome depends on the subgroup into which the patient falls. For example, patients for whom the ALTE was a heralding event (seizure disorder or neurologic condition) have a higher mortality rate and less than optimal outcome. Mortality data reveal a rate between 0% and 4% between 1972 and 1989.

No clear association has been made between sudden infant death syndrome (SIDS) and ALTEs. The rate of ALTEs has not decreased with the “back-to-sleep” program; however, patients who have suffered from an ALTE are at greater risk for sudden death. Follow-up studies have shown no long-term neurodevelopmental, cognitive, or gross motor delays in children who have suffered an ALTE compared with controls.

Hospitalization for observation and work-up is recommended for most children with an ALTE. Criteria have been developed to help determine which children should be hospitalized. These criteria include the need for vigorous stimulation or cardiopulmonary resuscitation (CPR) to arouse the child, any abnormalities in the history or physical examination, or an unreliable home situation.

Causes of ALTE

Cardiac Causes (~5%)

• Cardiomyopathy

• Congenital heart disease such as double aortic arch

• Long QT syndrome

• Myocarditis

• Wolff-Parkinson-White syndrome

Child Abuse (<5%)

• Munchausen by proxy (suffocation, intentional salt poisoning, medication overdose, physical abuse, head injury)

• Smothering (intentional or accidental)

Gastrointestinal Causes (most common, up to 50% of diagnosed cases)

• Gastric volvulus

• Gastroesophageal reflux disease (GERD)

• Intussusception

• Swallowing abnormalities

Idiopathic, also known as central apnea (up to 50%)

Infectious Causes

• Urinary tract infection

Metabolic Abnormalities (<5%)

• Electrolyte disorders

• Endocrine disorders

• Inborn errors of metabolism

Neurologic Causes (~30%)

• Brainstem malformations

• Budd-Chiari malformation

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