From the April 2014 issue of Pediatric Emergency Medicine Practice, “Apparent Life-Threatening Events In Children: Practical Evaluation And Management.” Reprinted with permission. To access your EMRA member benefit of free online access to all EM Practice, Pediatric EM Practice, and EM Practice Guidelines Update issues, go to www.ebmedicine.net/emra, call 800-249-5770, or email ebm@ebmedicine.net.
- “The mother's history of the event is unclear. She isn't even sure her baby stopped breathing or changed color. The patient appears well with a normal physical examination, so I am going to discharge them home to follow up with their pediatrician.”
The observer's description of the episode is often skewed due to the frightening nature of ALTEs. If the history is unclear, emergency clinicians should be calming and reassuring, and take the event seriously. Emergency clinicians will need to spend more time with the observer to obtain as much detail as possible about the event. A thorough physical examination is essential in evaluating the infant. Infants may also need to be observed in the ED to provide reassurance to the caregiver if it is felt that this was likely not an ALTE. - “The patient has been having upper respiratory infection symptoms for the past several days, so this episode is most likely part of the upper respiratory infection, and he can be discharged.”
Recent data conflict with regard to the risk of upper respiratory infection in patients with ALTEs. Some studies have reported that upper respiratory infection symptoms may put a patient at increased risk for extreme apnea or bradycardia. However, a recent clinical decision rule showed that the absence of upper respiratory infection was associated with an increased risk of an infant with an ALTE requiring an intervention. The presence of upper respiratory infection remains an unclarified risk factor and should not influence the evaluation of an infant with an ALTE. - “This 4-month-old patient had an ALTE, but she has a normal history and physical examination in the ED. She has no risk factors for an underlying condition. I ordered a screening basal metabolic panel and blood culture, just to be sure.”
Recent studies have shown that screening tests without a history and physical examination that is contributory to a diagnosis are of low yield, and do not always add to the evaluation of an ALTE. - “The patient has a small bruise on his arm, and his mother said he must have rolled against the bar in his crib. The injury is minor, so I am not really worried about nonaccidental trauma.”
It is important for the emergency clinician to decide whether the injury is consistent with the mechanism reported. Nonaccidental trauma can be a cause for an ALTE, and the clinician needs to have a high index of suspicion in these cases. When nonaccidental trauma is suspected, cranial imaging and skeletal survey may need to be obtained. - “This patient was reported as having 3 episodes of color change today, but she is completely well-appearing now. We observed her in the ED and decided to discharge her.”
Patients who experience recurrent ALTEs within 24 hours prior to presentation are at increased risk for having serious underlying pathology. Patients presenting with multiple episodes should be admitted to the hospital for observation and possible diagnostic testing. - “This patient had an episode of limpness and facial cyanosis, but he is 6 months old, so this cannot be an ALTE.”
The definition of an ALTE does not include an age range. ALTEs have been found predominantly in infants aged < 3 months, but there is no set upper limit. ALTEs should be considered in any patient aged < 1 year. - “The infant seems to be having reflux, so I am sending her home with reflux precautions.”
Although GERD may be a cause of an ALTE, there are reports of notable underlying etiologies even in the presence of GERD. Infants with ALTEs and GERD-like symptoms should still be considered for further diagnostic evaluation and monitoring. - “I decided to admit the patient for an ALTE, but suggested to the hospitalist that the infant should be discharged with a home monitor for safety.”
Home monitoring has been recommended for only a select group of patients, and discussions regarding whether or not a patient needs home monitoring should be initiated by the inpatient team and the clinicians providing follow-up. - “The patient has a cough, but appears to be stable, so I planned for discharge.”
RSV and pertussis infection can present with minimal symptoms, especially in young infants. Testing for these pathogens should be performed when seasonally appropriate. - “The patient looked very well after the event, witnessed at home by the mother. The physical examination was normal, so I discharged her with a plan for follow-up with her pediatrician.”
Patients often appear well after an ALTE; however, a normal examination does not rule out all serious pathology. Infants with ALTEs should be considered for admission to the hospital for further monitoring and targeted diagnostic evaluation.