ALTE: ALTE: Apparently a Lot of pparently a Lot of Disclosures - - PDF document

Beyond SIDS: ALTE 4/18/2013 Advances & Controversies in Clinical Pediatrics 2006 1

ALTE: ALTE: Apparently a Lot of pparently a Lot of Terro Terror for Everyb for Everybody!

A P Perennial nnial Conundr undrum –

Apparent Life Threatening Events

46 46th

th Annual A

al Advances & & Controve versie rsies i s in Clin inical ical Pediat atrics rics San F n Francis ancisco, C co, Californ fornia ia May 17, May 17, 201 2013 Pre Presen ente ted by: Tim by: Tim Ke Kelly, y, MD MD Clin Clinical Prof Profes essor of Pe

• f Pedi

diatrics Direct ctor,

• r, Advan

vanced C Clerkships kships a and I Intern rn Sele lect ction ion Pediatri ric H c Hospitalist italist De Depa partment of

• f Pe

Pediatri rics Univ iversit sity o

• f Californ

fornia, S ia, San F Fran ancisco sco

Discl Disclosures sures

For purpo For purposes of es of this this talk, talk, I I have have nothing to nothing to dis disclose: lose:

Objec Objectives and Goals es and Goals

• Understand the contemporary definition of

“ALTE”

• Explore the relationship between SIDS, ALTE

and other historical terms

• Become more adept at creating a case-

specific differential diagnosis and evaluation strategy

• Incorporate appropriate management
• ptions into practice
• Obtain comprehensive literature references

and resources

• Improve knowledge of SIDS counseling

Outline Outline

• Speaker perspective and experience
• Background/History
• Studying ALTE
• Epidemiology
• Differential Diagnosis
• Evaluation—focused, specific and economical
• Management options (hospitalization,

monitors, caffeine, CPR classes)

• SIDS counseling
• References

Speake Speaker perspect r perspective ive and experience and experience

• Critical care background (attending in PICU

for 12 years) and Pediatric Hospitalist since 1987

• Direct involvement in workup and

management of 8-12 cases of ALTE per year

• Regular comprehensive review of the

literature

• Presenting as “experienced” rather than

“expert”

Backgr Background/H nd/Hist istory

• ALTE are always concerning AND

consterning, to varying degrees!

• Standardized definition of ALTE offered by

the NIH Consensus Development Conference 1987

• Frightening to the observer, some

combination of:

• Apnea (central or obstructive)
• Color change

(cyanotic>pallor>red>plethoric)

• Muscle tone change (limp)
• Choking or gagging

Beyond SIDS: ALTE 4/18/2013 Advances & Controversies in Clinical Pediatrics 2006 2

Studying ALTE Studying ALTE

• Definition too broad?—some exclude
• bvious choking or include only “major”

episodes

• Definition too narrow?--some include

altered Mental Status

• Descriptions often quite subjective by

frightened, inexperienced caregiver-- “objective” and “measurable” criteria elusive

• No ICD-9 code—ALTE is NOT a

diagnosis, rather a symptom complex, “chief complaint” or presenting problem— hard to track or include in studies

Studying ALTE Studying ALTE (cont.)

Study design is complex:

• Retrospectively, selection bias based on

variable inclusion/exclusion criteria as noted above make Multi-Center study problematic— dyspnea, apnea vs. cyanosis, choking/gagging. Discharge diagnoses are often determined by “coders” which may further complicate the selection of appropriate patients. Are causes of ALTE then excluded?

• Prospectively how to capture patients—general
• vs. specialty services within an institution
• # needed to draw meaningful conclusions?

ARS ARS

1 mo boy, brief choking and gagging episode. ED evaluation is well, normal exam. Observe for a while—no spells. Discharge him directly to home from the ED if his ONLY risk factor for having another spell is that:

• A. Nasal swab RSV +
• B. Frequent spit ups
• C. Delivered at 32 weeks post conception
• D. One previous similar episode
• E. Mother smoked cigarettes throughout the

pregnancy

Epidemiology Epidemiology

• Almost half of monitored healthy children had

at least one apnea > 20 seconds

• Estimates are that 1-2% of infants in the

general population will have an ALTE and 0.2- 0.8% will have an apneic event leading to admission

• Maternal smoking and single parent

households seem to be risk factors

• Median age 8 weeks, male=female
• Post conception age < 44 weeks of age at

higher risk (immature respiratory center); preemies; prior ALTE also higher risk

Epidemi Epidemiolo logy gy (con

(cont.)

• SIDS ≠ ALTE—no causal relationship has ever

been found, despite the obvious “frightening” nature of the event.

• SIDS ≠ALTE—only ~5% of SIDS victims had a

prior ALTE (consider recall bias).

• SIDS ≠ ALTE—risk of subsequent death among

all infants with ALTE is estimated at most 1-2%, but is increased in the (rare) subgroup of infants who have ALTE while as ile asleep leep an and w who requir ire e CPR CPR when discovered (“severe”) ALTE.

• SIDS ≠ ALTE—recurrent, severe ALTE is the

highest risk group and therefore get the most extensive workups and monitoring.

ARS ARS

Previously healthy 1 mo runny nose, cough x 2days. 3rd day—brief apnea, pale motionless—gentle stimulation and he is back to normal. Likely cause?:

• A. Seizure
• B. Organic acid disorder
• C. RSV
• D. Cardiac dysrhythmia
• E. Intentional poisoning

Beyond SIDS: ALTE 4/18/2013 Advances & Controversies in Clinical Pediatrics 2006 3 DDx/Causes DDx/Causes

Based on first presentation (ESTIMATES)

• GI (up to 33%)—GERD (beware of the

extraordinarily high prevalence even in normal children and be wary of assigning “cause” of ALTE), AGE, esophageal dysfunction

• Neurological (15%)—seizure, central

apnea, head injury, infections

• Respiratory (11%)—RSV, pertussis, FB
• Airway (4%)—malacias, stenoses, OSA

DDx/Causes (cont.) DDx/Causes (cont.)

• Cardiovascular (1%)—arrhythmia
• Metabolic/Endocrine—

electrolyte/glucose alterations, IEM (rare)

• Infections (5-30% with seasonal

variability)

• Other—SBS, abuse, Munchausen, breath-

holding, choking, temperature, “exaggerated laryngeal chemoreceptor reflex apnea” associated with reflux? OR

• Idiopathic (20-60%)

ARS ARS

6 week old to the ED after 3 bouts of choking/gagging previous evening—turned dusky. Kind of a spitty baby, but no episodes like this

• before. 3 caregivers at home, each with some

variation on the story. Appears a little sleepy,

• therwise normal exam. Cause of ALTE provided by:
• A. Cardiac event monitor
• B. CT scan of head
• C. EEG
• D. pH probe
• E. Metabolic screening

Evaluation/Investigation Evaluation/Investigation

• History—most important component.

Caregiver witness issues: presence, overlook

• r distort due to distressing event. History is

particularly focused on ALTE causes, and include specifics like lighting, proximity and clothes/blankets covering. Details of apnea, choking and feeding also critical.

• Physical examination—extremely detailed,

thorough and particularly focused on ALTE causes, caretaker interaction, feeding

• bservation, e.g.

Eval/Investigation ( nvestigation (cont.)

• nt.)
• Evaluation: determine frequency,

severity, nature of the events as well as underlying cause.

• No standard investigative protocol has

been tested, only suggested—recent Dutch recommendations

• Challenging number and array of tests

available—cost, risk, convenience, pain, sensitivity and specificity play a role

Eval/Investigation (cont.) Eval/Investigation (cont.)

• Hospitalization for cardiorespiratory

monitoring and evaluation is extremely common, although readily identifiable (and preventable) causes may be excepted. ALTE can cluster or repeat and may be “captured” in hospital occasionally. LOS = 23-72 hrs.

• Workups should be thoughtful, directed and

case-specific, logical

• Screening tests may be indicated (“no clue”):

CBC, chemistry panel, venous blood gas, EKG

Beyond SIDS: ALTE 4/18/2013 Advances & Controversies in Clinical Pediatrics 2006 4

Eval/Investigation ( nvestigation (cont.)

• nt.)
• Polysomnography with or without EEG;

echocardiogram; airway or brain imaging; pH probe each may occasionally be indicated but rarely if ever are ALL such tests performed initially.

• Study published concluded “for many tests

used in the evaluation of ALTE, the likelihood

• f a positive result is low and the likelihood
• f a contributory result is even lower”.
• Recurrent and/or severe apnea=high

priority

Manageme Management nt

• Strong consideration for hospitalization for

monitoring, evaluation and counseling

• Specifically treat any identified cause

(anticonvulsants, GERD, infections, caffeine, etc.)

• “Back to Sleep” reinforcement
• Modify other risk factors such as smoking,

unsafe sleep practices

• Strongly consider infant CPR certification

course (American Red Cross, e.g.): greatly enhances parental confidence in preparedness in “what to do” IF…

Manageme Management (cont.) nt (cont.)

• Home monitoring is generally unwarranted
• Obstructive apnea is not identified until the

terminal event (decreased HR)

• No proven efficacy to prevent SIDS
• Adverse effects: false alarms, increased

anxiety, depression and hostility, developmental implications

• IF monitoring, strongly consider event

recorders that can download data for analysis

ARS ARS

Previously healthy 3 week old has an event of floppiness and cyanosis. Occasionally a spitter. In the ED, lethargic and pale. ABG = mixed acidosis. Your Dx is ‘extreme ALTE’, but no other findings on exam. Admitted to hospital and recovers fully. All other tests including CT scan are normal. Which (statistically) elevates her subsequent risk of SIDS?:

• A. Delivered at 44 weeks
• B. Her mother is Asian
• C. Her mother just turned 30
• D. Her mother smoked throughout the pregnancy
• E. The baby sleeps on her side

The Unthinkable: SIDS The Unthinkable: SIDS

• There are 2 very different roles that

pediatricians play (advocate for or delegate): the investigation into the death AND that of counselor and informant for the bereaved family.

• The sense of loss and other emotions

associated with SIDS affects BOTH the family AND the pediatrician.

• “Did I miss something?” and fear of

blame may overwhelm and frighten.

The Unthinkable: SIDS The Unthinkable: SIDS (cont.) (cont.)

• A thorough post-mortem examination

MUST include a “scene investigation” as well as an autopsy that is carefully geared toward the uniqueness of SIDS: look for metabolic errors on liver samples, thorough evaluation for trauma, etc.

• The greatest contribution of the

pediatrician is “non-abandonment”— parents fear the loss of the relationship with their regular care provider the most in the grieving process

Beyond SIDS: ALTE 4/18/2013 Advances & Controversies in Clinical Pediatrics 2006 5

The Unthinkable: SIDS The Unthinkable: SIDS (cont.) (cont.)

• Enlist professional counseling support for

direct therapy, but STA STAY I INVOL VOLVED ED and talk about the “hard issues” as needed. Basic grief counseling is listening empathetically while the family does their grieving, perhaps guided by another.

• Families may not be able to talk to friends and

family in the same way, and the pediatrician can validate the family’s response in a powerful way.

• Review autopsy with family to help translate

and interpret findings

• Screen for “pathological grief”

Summar Summary

• ALTE are not infrequent, nonspecific and

generally benign presenting problems, NOT a diagnosis unto itself

• Studying ALTE is challenged by variations in

definitions, observer-dependence and methodological flaws

• No true relationship between ALTE and SIDS
• Broad differential diagnosis mandates

extraordinarily careful H & P to direct thoughtful, limited workup

Summar Summary (cont. (cont.)

• A definitive cause of the ALTE is often not

found, contributing to caretaker and physician anxiety

• CBC w/diff, CRP, chem panel including NH3,

lactate and pyruvate; VBG; U/A; tox screen EKG; RSV & pertussis (in season) are potentially useful; admit for 23-72 hrs

• Consider infant CPR training certification
• Home monitoring is generally unwarranted

and may inadvertently contribute to morbidity in the household

ALTE ALTE Refere Referenc nces es

• Hoki R, Bonkowsky JL, Minich LL, Srivastava R, Pinto NM.

Cardiac testing and outcomes in infants after an apparent life-threatening event. Arch Dis Child. Dec 2012; 97(12):1034-8.

• Fu LY, Moon RY. Apparent life-threatening events: an
• update. Pediatr Rev. Aug 2012; 33(8):361-8; quiz 368-9.
• Parker K, Pitetti R. Mortality and child abuse in children

presenting with apparent life-threatening events. Pediatr Emerg Care. Jul 2011; 27(7):591-5.):1-5.

• [Multidisciplinary guidelines for 'Apparent life

threatening event' (ALTE)]. Wijers MM, Semmekrot BA, de Beer HJ, Engelberts AC; Ned Tijdschr Geneeskd. 2009;153:A590. Dutch.

ALTE ALTE Refere Referenc nces (cont.) es (cont.)

• Altman RL, Li KI, Brand DA. Infections and apparent life-

threatening events. Clin Pediatr (Phila). May 2008;47(4):372-8.

• Dewolfe CC. Apparent life-threatening event: a review.

Pediatr Clin North Am. 2005 Aug;52(4):1127-46, ix. Review.

• Puntis JW, Booth IW. ALTE and gastro-oesophageal reflux.

Arch Dis Child. 2005 Jun;90(6):653; author reply 653.

• Brand DA, Altman RL, Purtill K, Edwards KS. Yield of

diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. 2005 Apr;115(4):885-

• 93. Erratum in: Pediatrics. 2005 Sep;116(3):802-803.
• Milioti S, Einspieler C. The long-term outcome of infantile

apparent life-threatening event (ALTE): a follow-up study until midpuberty. Neuropediatrics. 2005 Feb;36(1):1-5.

ALTE Refere ALTE Referenc nces es (cont.) (cont.)

• Kiechl-Kohlendorfer U, Hof D, Peglow UP, Traweger-

Ravanelli B, Kiechl S. Epidemiology of apparent life threatening events. Arch Dis Child. 2005 Mar;90(3):297- 300.

• McGovern MC, Smith MB. Causes of apparent life

threatening events in infants: a systematic review. Arch Dis Child. 2004 Nov;89(11):1043-8. Review.

• Altman RL, Brand DA, Forman S, Kutscher ML, Lowenthal

DB, Franke KA, Mercado VV. Abusive head injury as a cause of apparent life-threatening events in infancy. Arch Pediatr Adolesc Med. 2003 Oct;157(10):1011-5.

• Davies F, Gupta R. Apparent life threatening events in

infants presenting to an emergency department. Emerg Med J. 2002 Jan;19(1):11-6.

Beyond SIDS: ALTE 4/18/2013 Advances & Controversies in Clinical Pediatrics 2006 6

ALTE Refere ALTE Referenc nces es (cont.) (cont.)

• Farrell PA, Weiner GM, Lemons JA.

SIDS, ALTE, apnea, and the use of home monitors. Pediatr Rev. 2002 Jan;23(1):3-9. Review.

• Carbone T, Ostfeld BM, Gutter D, Hegyi T. Parental

compliance with home cardiorespiratory monitoring. Arch Dis

• Child. 2001 Mar;84(3):270-2.
• Gray C, Davies F, Molyneux E. Apparent life-threatening

events presenting to a pediatric emergency department. Pediatr Emerg Care. 1999 Jun;15(3):195-9.

• American Red Cross for Infant CPR courses:

http://www.redcross.org/services/hss/courses/infchild.html

• Esani N, Hodgman J, Ehsani N, Hoppenbrousers T. Apparent

Life-Threatening Events and Sudden Infant Death Syndrome: A Comparison of Risk Factors. Journal of Pediatrics. March 2008; 152: 365-70.

SIDS SIDS Referenc References

• Moore A, Debelle G, Symonds L, Green A. Investigation of

sudden unexpected deaths in infancy. Arch Dis Child. 2000 Sep;83(3):276.

• Limerick, Downham MA. Support for families bereaved by

cot death: joint voluntary and professional view. Br Med J. 1978 Jun 10;1(6126):1527-9

• Cook P, White DK, Ross-Russell RI. Bereavement support

following sudden and unexpected death: guidelines for

• care. Arch Dis Child. 2002 Jul;87(1):36-8.
• Fleming PJ, Blair PS, Sidebotham PD, Hayler T.

Investigating sudden unexpected deaths in infancy and childhood and caring for bereaved families: an integrated multiagency approach. BMJ. 2004 Feb 7;328(7435):331-4.

• Goldberg J. The counseling of SIDS parents. Clin
• Perinatol. 1992 Dec;19(4):927-38.