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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.