UMEM Educational Pearls

Title: ALTE Overview

Keywords: ALTE, life threatening, child abuse, GERD (PubMed Search)

Posted: 8/2/2013 by Joey Scollan, DO
Click here to contact Joey Scollan, DO

Definition: An episode that is characterized by some combination of apnea, color change, change in muscle tone, choking, gagging, or a fear in the observer that the infant has died.

DDx: VAST!

- GERD is by far the most common underlying etiology

- Do NOT forget about child abuse

Workup: Dependent on your Hx/PE (Take into account the child’s age (<30 days or h/o prematurity), existence of prior ALTE episodes, general appearance, etc.)

One study showed the concordance of initial working to discharge diagnosis of GERD was 96%, and non-concordant diagnoses evolved within 24 hours

Dispo: The easy part! ADMIT!

Even well-appearing children with a “benign” diagnosis like GERD have been shown to benefit from admission. And there is a high likelihood that ALTE’s from a serious cause are likely to recur within 24hours.

A recent study looked at 176 infants who presented to the ED with an ALTE over a 5 year period. Essentially all were admitted.

Blood cultures were obtained in 63% and CSF cultures were obtained in 37% and no pathogens were identified in either
CXRs were obtained in 115 (65%) patients and 12 had infiltrates
RSV nasal washing were obtained in 32% and positive in 9 patients
At the time of follow up, 2 patients had died, both after hospital discharge and within 2 weeks of ED visit and both of pneumonia. Both had a negative diagnostic evaluation in the ED.

Conclusion: The risk of subsequent mortality in infants presenting ALTE is substantial, and we should consider routine admission for all of these patients.

References

Doshi A, Bernard-Stover L, Kuelbs C, Castillo E, Stucky E. Apparent life-threatening event admissions and gastroesophageal reflux disease: The value of hospitalization. Pediatr Emerg Care, January 2012. 28(1): p. 17-21.

Shruti Kant, Jay D. Fisher, David G. Nelson, Shehma Khan. Mortality after discharge in clinically stable infants admitted with a first-time apparent life-threatening event. AJEM, April 2013. 31(4): p 17-21. 730-733 (DOI: 10.1016/j.ajem.2013.01.002)

Zuckerbraun NS, Zomorrodi A, Pitetti RD. Occurrence of serious bacterial infection in infants aged 60 days or younger with an apparent life-threatening event. Pediatr Emerg Care, January 2009. 25(1): p. 19-25.