Brief resolved unexplained event

Background

• Peak incidence: 1wk - 2mo
• ALTE is a symptom, not a dx
• Only 10% have repeat events
• ALTE is not related to SIDS

Diagnosis

• Episode that is frightening to caregiver and involves combination of:
  • Apnea
  • Color change
  • Muscle tone change
  • Choking or gagging

History

• PMH
  • Prematurity, history of apnea, prior resp/feeding difficulties
  • Immunization status (pertussis)
• FH
  • History of SIDS, cardiac, seizure, metabolic disease
• Event
  • Duration, resus required
  • Temporal relationship with feeding, sleeping, crying, vomiting, choking
  • Central versus obstructive pattern of apnea
  • Episodic versus sustained change in mental status
• ROS
  • Respiratory symptoms
  • Medication use

Risk Factors

1. RSV infection
2. Prematurity
3. Recent anesthesia
4. GERD
5. Airway/maxillofacial anomalies

DDX

Common

1. Idiopathic (~50%)
2. GERD
3. Seizure
4. Respiratory tract infection
5. Misinterpretation of benign process (e.g. periodic breathing)
6. Vomiting/choking episode

Less Common

1. Pertussis
2. Inflicted injury
3. Poisoning
4. Serious bacterial infection
   1. Must consider in all febrile pts with ALTE
5. Electrolyte abnormality (incl glucose)

Uncommon

1. Arrhythmia
2. Anemia
3. Breath-holding spell (6mo - 4yrs)
4. Metabolic disease

Work-Up

(Individualize testing by history and exam)

1. CBC
2. Chem 10
3. UA
4. CXR
5. Pertussis nasal swab
6. RSV nasal swab
7. Consider:
   1. UCx/BC
   2. ECG
   3. LP
   4. LFTs
   5. MRI Brain

Management

1. Stable patients without a clear diagnosis
   1. No evidence-based guidelines for proper w/u dispo decision
2. Stable patients with a clear diagnosis
   1. Manage according to identified disease

Empiric Treatment for Unstable Patients without Clear Diagnosis

Medication/Intervention	Indication	Dose/Size (for neonate)
Glucose	Hypoglycemia	5–10 mL/kg of 10% dextrose in water IV
3% normal saline	Symptomatic hyponatremia	3–5 mL/kg bolus IV
Calcium	Hypocalcemia	50–100 milligrams/kg calcium gluconate or 20 milligrams/kg calcium chloride IV
Cefotaxime	Infection	50 milligrams/kg IV
Ampicillin	Infection	50 milligrams/kg IV
Packed red blood cells	Anemia	10 mL/kg IV
Normal saline	Hypotension, dehydration	20 mL/kg IV
10% dextrose in one fourth normal saline	Metabolic disease	1.5 maintenance (6 mL/kg/h for the first 10 kg)
Endotracheal intubation	Hypoventilation or frequent apnea	3mm for preemie; 3mm for term neonate, 4mm for older infant

Disposition

Admission in most cases

Especially for:

1. <48wk postconceptual age
2. Ill-appearing
3. Bronchiolitis or pertussis w/ apnea
4. >1 event in past 24hr or multiple ALTEs
5. Abnormalities in PMH
6. Prolonged central apnea >20s
7. ALTE requiring resus
8. Family history of SIDS

Source

Tintinalli