Brief resolved unexplained event

Background

• 3% of infants experience ALTEs
• Mean age of ALTE: 8-16 wks
  • <6mo-1yr

Maternal Risk Factors

1. Smoking in pregnancy
2. Parity greater than 2
3. Mom's age < 20yrs
4. Decreased number of prenatal visits
5. Crowding in home
6. Mom not finish High School
7. Illicit drugs in pregnancy
8. Unmarried
9. Anemia in Pregnancy
10. < 20lbs wt gain in pregnancy
11. UTI in pregnancy

Diagnosis

Definition - episode, frightening to observer with witnessed apnea, color change, or change in tone, choking or gagging

History

1. Central question: did heart/respirations stop?
2. position, activity before, during event, asleep vs. awake
3. previous hx of apnea
4. relation to eating
5. change in color
6. change in tone
7. any intervention done? Duration, CPR? rescue breathes?
8. social history/screen for abuse

Work-Up

ED

1. CBC, U/A, Lytes
2. CXR, EKG, EEG,

Inpt

1. pH probe, barium swallow
2. CVR monitoring
3. Pneumogram
4. Metabolic studies (Lac/pyruv/NH4, urine AA and OAs)
5. Imaging

DDX

1. idiopathic (50%)... Apnea of infancy
2. infectious... PNA, RSV, Sepsis, Meningitis, encephalitis, botulism, UTI
3. CNS... Sz, ICH
4. Cardiac... CHD, dysrhythmias, CHF
5. GI... GERD, TE Fistula
6. Metabolic... hypoglycemia, hyponatremia, anemia
7. Child abuse
8. Toxic ingestions/fb
9. Breath Holding Spell
   1. usu 6mo to 3-4yr!!
   2. in awake pt, begins w/ crying, stops breathing in end expiration, w/resultant cyanosis & LOC
   3. resumes breathing spontaneously
10. Cyanotic Heart Dz
    1. difficulty feeding w/ diaphoresis & poor wt. gain
11. Apnea
    1. central vs obstructive or mixed
    2. short (< 15 s) can be normal
    3. is pathologic if > 20 sec, or w/ cyanosis, bradycardia, pallor or hypotonia
12. Periodic Breathing
    1. 3 or more resp pauses of > 3 sec
13. Apnea of Prematurity

Obstructive Apnea

1. Stridor - vascular ring, FB, croup, epiglottitis
2. Prematurity - position, laryngomalacia, web, tracheomalacia etc.
3. Airway anatomy abnormalities

Mixed Apnea

1. shock, dysrhythmias, cong heart dz, prolonged QT
2. sepsis, pertussis, RSV, meningitis, PNA, infant botulism
3. Trauma, anemia, poisoning, NM d/o, metabolic d/o

Specified Etiology (50%)

1. Neuro: Seizure, breath-holding spell
2. GE reflux (Sandifer's sign: arching back to get comfortable), TEF
3. Infection: sepsis, meningitis, PNA, bronchiolits, Apnea of prematurity
4. 15% are CNS: sz, ventricular hemorrhage, hydrocephalus
5. Cardiac: Duct-dependent lesion, long QT, arrhythmias
6. Metabolic, electrolytes, abuse

Disposition

at least 48 hrs for r/o sepsis

Prognosis

generally excellent--only 10% have repeat events

Source

Adapted from Pani