Objecti tives and Goals Understand the contemporary definition of - - PDF document

Beyond SIDS: ALTE 5/17/13 Advances & Controversies in Clinical Pediatrics 2006 1

Objecti tives 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
• 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

Beyond SIDS: ALTE 5/17/13 Advances & Controversies in Clinical Pediatrics 2006 2

• 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”

• 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
• 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

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?

Beyond SIDS: ALTE 5/17/13 Advances & Controversies in Clinical Pediatrics 2006 3

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 form 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 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 form 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

• 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

• 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 whi while asl sleep and nd who who requi uire 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.

Beyond SIDS: ALTE 5/17/13 Advances & Controversies in Clinical Pediatrics 2006 4

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

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

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
• 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%)

Beyond SIDS: ALTE 5/17/13 Advances & Controversies in Clinical Pediatrics 2006 5

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, otherwise normal
• exam. Cause of ALTE provided by:

• A. Cardiac event monitor
• B. CT scan of head
• C. EEG
• D. pH probe
• E. Metabolic screening

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, otherwise normal
• exam. Cause of ALTE provided by:

• A. Cardiac event monitor
• B. CT scan of head
• C. EEG
• D. pH probe
• E. Metabolic screening
• 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.
• 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

Beyond SIDS: ALTE 5/17/13 Advances & Controversies in Clinical Pediatrics 2006 6

• 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

• 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

• 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…

• 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

Beyond SIDS: ALTE 5/17/13 Advances & Controversies in Clinical Pediatrics 2006 7

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

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
• 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.

• 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 5/17/13 Advances & Controversies in Clinical Pediatrics 2006 8

• 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

• A definitive cause of the ALTE is often not

found, contributing to caretaker and physician anxiety. GERD, LRI, SZ top 3 Dx

• 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

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