Clinical and Experimental Pediatrics

The Korean Pediatric Society (대한소아청소년과학회)
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Apparent life-threatening event in infancy

  • Choi, Hee Joung (Department of Pediatrics, Keimyung University School of Medicine) ;
  • Kim, Yeo Hyang (Department of Pediatrics, Kyungpook National University School of Medicine)
  • Received : 2015.08.07
  • Accepted : 2015.10.07
  • Published : 2016.09.10
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Abstract

An apparent life-threatening event (ALTE) is defined as the combination of clinical presentations such as apnea, marked change in skin and muscle tone, gagging, or choking. It is a frightening event, and it predominantly occurs during infancy at a mean age of 1-3 months. The causes of ALTE are categorized into problems that are: gastrointestinal (50%), neurological (30%), respiratory (20%), cardiovascular (5%), metabolic and endocrine (2%-5%), or others such as child abuse. Up to 50% of ALTEs are idiopathic, where the cause cannot be diagnosed. Infants with an ALTE are often asymptomatic at hospital and there is no standard workup protocol for ALTE. Therefore, a detailed initial history and physical examination are important to determine the extent of the medical evaluation and treatment. Regardless of the cause of an ALTE, all infants with an ALTE should require hospitalization and continuous cardiorespiratory monitoring and evaluation for at least 24 hours. The natural course of ALTEs has seemed benign, and the outcome is generally associated with the affected infants' underlying disease. In conclusion, systemic diagnostic evaluation and adequate treatment increases the survival and quality of life for most affected infants.

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References

  1. American Academy of Pediatrics. Task Force on Prolonged Infantile Apnea. Prolonged infantile apnea: 1985. Pediatrics 1985;76: 129-31.
  2. National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring, Sept 29 to Oct 1, 1986. Pediatrics 1987;79:292-9.
  3. Willinger M, James LS, Catz C. Defining the sudden infant death syndrome (SIDS): deliberations of an expert panel convened by the National Institute of Child Health and Human Development. Pediatr Pathol 1991;11:677-84. https://doi.org/10.3109/15513819109065465
  4. Sahewalla R, Gupta D, Kamat D. Apparent Life-Threatening Events: An Overview. Clin Pediatr (Phila) 2016;55:5-9. https://doi.org/10.1177/0009922815591890
  5. Fu LY, Moon RY. Apparent life-threatening events: an update. Pediatr Rev 2012;33:361-8. https://doi.org/10.1542/pir.33-8-361
  6. Gray C, Davies F, Molyneux E. Apparent life-threatening events presenting to a pediatric emergency department. Pediatr Emerg Care 1999;15:195-9. https://doi.org/10.1097/00006565-199906000-00009
  7. Davies F, Gupta R. Apparent life threatening events in infants presenting to an emergency department. Emerg Med J 2002;19:11-6. https://doi.org/10.1136/emj.19.1.11
  8. Brooks JG. Apparent life-threatening events and apnea of infancy. Clin Perinatol 1992;19:809-38. https://doi.org/10.1016/S0095-5108(18)30432-9
  9. Kiechl-Kohlendorfer U, Hof D, Peglow UP, Traweger-Ravanelli B, Kiechl S. Epidemiology of apparent life threatening events. Arch Dis Child 2005;90:297-300. https://doi.org/10.1136/adc.2004.049452
  10. Kahn A; European Society for the Study and Prevention of Infant Death. Recommended clinical evaluation of infants with an apparent life-threatening event. Consensus document of the European Society for the Study and Prevention of Infant Death, 2003. Eur J Pediatr 2004;163:108-15. https://doi.org/10.1007/s00431-003-1365-x
  11. Hall KL, Zalman B. Evaluation and management of apparent life-threatening events in children. Am Fam Physician 2005;71:2301-8.
  12. Stratton SJ, Taves A, Lewis RJ, Clements H, Henderson D, McCollough M. Apparent life-threatening events in infants: high risk in the out-of-hospital environment. Ann Emerg Med 2004; 43:711-7. https://doi.org/10.1016/j.annemergmed.2003.10.038
  13. Tieder JS, Altman RL, Bonkowsky JL, Brand DA, Claudius I, Cunningham DJ, et al. Management of apparent life-threatening events in infants: a systematic review. J Pediatr 2013;163:94-9.e1-6. https://doi.org/10.1016/j.jpeds.2012.12.086
  14. Wijers MM, Semmekrot BA, de Beer HJ, Engelberts AC; Dutch Paediatric Association; Dutch Institute for Healthcare Improvement (CBO). Multidisciplinary guidelines for 'Apparent life threatening event' (ALTE). Ned Tijdschr Geneeskd 2009;153:A590.
  15. Shah S, Sharieff GQ. An update on the approach to apparent life-threatening events. Curr Opin Pediatr 2007;19:288-94. https://doi.org/10.1097/MOP.0b013e32815745a9
  16. Arad-Cohen N, Cohen A, Tirosh E. The relationship between gastroesophageal reflux and apnea in infants. J Pediatr 2000;137: 321-6. https://doi.org/10.1067/mpd.2000.107847
  17. Tieder JS, Cowan CA, Garrison MM, Christakis DA. Variation in inpatient resource utilization and management of apparent life-threatening events. J Pediatr 2008;152:629-35, 635.e1-2. https://doi.org/10.1016/j.jpeds.2007.11.024
  18. Vandenplas Y, Rudolph CD, Di Lorenzo C, Hassall E, Liptak G, Mazur L, et al. Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN). J Pediatr Gastroenterol Nutr 2009;49:498-547. https://doi.org/10.1097/01.mpg.0000361306.15727.54
  19. Bonkowsky JL, Guenther E, Filloux FM, Srivastava R. Death, child abuse, and adverse neurological outcome of infants after an apparent life-threatening event. Pediatrics 2008;122:125-31. https://doi.org/10.1542/peds.2007-3376
  20. Anjos AM, Nunes ML. Prevalence of epilepsy and seizure disorders as causes of apparent life- threatening event (ALTE) in children admitted to a tertiary hospital. Arq Neuropsiquiatr 2009;67(3A): 616-20. https://doi.org/10.1590/S0004-282X2009000400008
  21. Kahn A, Rebuffat E, Franco P, N'Duwimana M, Blum D. Apparent life-threatening events and apnea of infancy. In: Berckerman RC, Brouillette RT, Hunt CE, editors. Respiratory control disorders in infants and children. Baltimore: Williams and Wilkins, 1992;178-89.
  22. Ruggins NR, Milner AD. Site of upper airway obstruction in infants following an acute life-threatening event. Pediatrics 1993;91:595-601.
  23. Ricart S, Rovira N, Garcia-Garcia JJ, Pumarola T, Pons M, Munoz-Almagro C, et al. Frequency of apnea and respiratory viruses in infants with bronchiolitis. Pediatr Infect Dis J 2014;33:988-90. https://doi.org/10.1097/INF.0000000000000365
  24. Willwerth BM, Harper MB, Greenes DS. Identifying hospitalized infants who have bronchiolitis and are at high risk for apnea. Ann Emerg Med 2006;48:441-7. https://doi.org/10.1016/j.annemergmed.2006.03.021
  25. Woolf PK, Gewitz MH, Preminger T, Stewart J, Vexler D. Infants with apparent life threatening events. Cardiac rhythm and conduction. Clin Pediatr (Phila) 1989;28:517-20. https://doi.org/10.1177/000992288902801105
  26. Takahashi T, Yamada K, Kobayashi H, Hasegawa Y, Taketani T, Fukuda S, et al. Metabolic disease in 10 patients with sudden unexpected death in infancy or acute life-threatening events. Pediatr Int 2015;57:348-53. https://doi.org/10.1111/ped.12660
  27. Arens R, Gozal D, Williams JC, Ward SL, Keens TG. Recurrent apparent life-threatening events during infancy: a manifestation of inborn errors of metabolism. J Pediatr 1993;123:415-8. https://doi.org/10.1016/S0022-3476(05)81747-0
  28. Mittal MK, Shofer FS, Baren JM. Serious bacterial infections in infants who have experienced an apparent life-threatening event. Ann Emerg Med 2009;54:523-7. https://doi.org/10.1016/j.annemergmed.2008.12.037
  29. Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics 2005;115:885-93. https://doi.org/10.1542/peds.2004-0847
  30. Altman RL, Li KI, Brand DA. Infections and apparent life-threatening events. Clin Pediatr (Phila) 2008;47:372-8. https://doi.org/10.1177/0009922807310934
  31. Semmekrot BA, van Sleuwen BE, Engelberts AC, Joosten KF, Mulder JC, Liem KD, et al. Surveillance study of apparent life-threatening events (ALTE) in the Netherlands. Eur J Pediatr 2010; 169:229-36. https://doi.org/10.1007/s00431-009-1012-2
  32. Crowcroft NS, Zambon M, Harrison TG, Mok Q, Heath P, Miller E. Respiratory syncytial virus infection in infants admitted to paediatric intensive care units in London, and in their families. Eur J Pediatr 2008;167:395-9. https://doi.org/10.1007/s00431-007-0509-9
  33. De Piero AD, Teach SJ, Chamberlain JM. ED evaluation of infants after an apparent life-threatening event. Am J Emerg Med 2004; 22:83-6. https://doi.org/10.1016/j.ajem.2003.12.007
  34. Vellody K, Freeto JP, Gage SL, Collins N, Gershan WM. Clues that aid in the diagnosis of nonaccidental trauma presenting as an apparent life-threatening event. Clin Pediatr (Phila) 2008;47:912-8. https://doi.org/10.1177/0009922808320595
  35. Hall DE, Eubanks L, Meyyazhagan LS, Kenney RD, Johnson SC. Evaluation of covert video surveillance in the diagnosis of munchausen syndrome by proxy: lessons from 41 cases. Pediatrics 2000;105:1305-12. https://doi.org/10.1542/peds.105.6.1305
  36. Mittal MK, Sun G, Baren JM. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care 2012;28:599-605. https://doi.org/10.1097/PEC.0b013e31825cf576
  37. Al-Kindy HA, Gelinas JF, Hatzakis G, Cote A. Risk factors for extreme events in infants hospitalized for apparent life-threatening events. J Pediatr 2009;154:332-7, 337.e1-2. https://doi.org/10.1016/j.jpeds.2008.08.051
  38. Santiago-Burruchaga M, Sanchez-Etxaniz J, Benito-Fernandez J, Vazquez-Cordero C, Mintegi-Raso S, Labayru-Echeverria M, et al. Assessment and management of infants with apparent life-threatening events in the paediatric emergency department. Eur J Emerg Med 2008;15:203-8. https://doi.org/10.1097/MEJ.0b013e3282f4d13a
  39. Choi HJ, Kim YH. Relationship between the clinical characteristics and intervention scores of infants with apparent life-threatening events. J Korean Med Sci 2015;30:763-9. https://doi.org/10.3346/jkms.2015.30.6.763
  40. Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted? Pediatrics 2007;119:679-83. https://doi.org/10.1542/peds.2006-2549
  41. Kahn A, Bauche P, Groswasser J, Dramaix M, Scaillet S; Working Group, Groupe Belge de Pediatres Francophones. Maternal education and risk factors for sudden death in infants. Working Group of the Groupe Belge de Pediatres Francophones. Eur J Pediatr 2001;160:505-8. https://doi.org/10.1007/s004310100783
  42. Committee on Fetus and Newborn. American Academy of Pediatrics. Apnea, sudden infant death syndrome, and home monitoring. Pediatrics 2003;111(4 Pt 1):914-7. https://doi.org/10.1542/peds.111.4.914
  43. Samuels MP, Southall DP. Alarms during apparent life-threatening events. Am J Respir Crit Care Med 2003;167:A677
  44. Cote A. Home and hospital monitoring for ALTE. Paediatr Respir Rev 2006;7 Suppl 1:S199-201. https://doi.org/10.1016/j.prrv.2006.04.202
  45. Carroll JL. Apparent Life Threatening Event (ALTE) assessment. Pediatr Pulmonol Suppl 2004;26:108-9.
  46. Ramanathan R, Corwin MJ, Hunt CE, Lister G, Tinsley LR, Baird T, et al. Cardiorespiratory events recorded on home monitors: Comparison of healthy infants with those at increased risk for SIDS. JAMA 2001;285:2199-207. https://doi.org/10.1001/jama.285.17.2199
  47. Cote A, Hum C, Brouillette RT, Themens M. Frequency and timing of recurrent events in infants using home cardiorespiratory monitors. J Pediatr 1998;132:783-9. https://doi.org/10.1016/S0022-3476(98)70304-X
  48. Kant S, Fisher JD, Nelson DG, Khan S. Mortality after discharge in clinically stable infants admitted with a first-time apparent life-threatening event. Am J Emerg Med 2013;31:730-3. https://doi.org/10.1016/j.ajem.2013.01.002
  49. Nunes ML, Costa JC, Ferreira CP, Garcia CC, Marques FC, Spolidoro JV. Associated and prognosis in apparent life threatening events (ALTE). J Pediatr (Rio J) 1999;75:55-8. https://doi.org/10.2223/JPED.258
  50. Parker K, Pitetti R. Mortality and child abuse in children presenting with apparent life-threatening events. Pediatr Emerg Care 2011; 27:591-5. https://doi.org/10.1097/PEC.0b013e3182225563
  51. Oren J, Kelly D, Shannon DC. Identification of a high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea. Pediatrics 1986;77:495-9.
  52. Kahn A, Sottiaux M, Appelboom-Fondu J, Blum D, Rebuffat E, Levitt J. Long-term development of children monitored as infants for an apparent life-threatening event during sleep: a 10-year follow-up study. Pediatrics 1989;83:668-73.
  53. Milioti S, Einspieler C. The long-term outcome of infantile apparent life-threatening event (ALTE): a follow-up study until midpuberty. Neuropediatrics 2005;36:1-5. https://doi.org/10.1055/s-2004-830530
  54. Baroni MA. Apparent life-threatening events during infancy: a follow-up study of subsequent growth and development. J Dev Behav Pediatr 1991;12:154-61.

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