Apparent Life-threatening Events Research Articles

Yield of Diagnostic Testing in Infants Who Have Had an Apparent Life-Threatening Event: In Reply

In Reply.—We welcome the systematic review by McGovern and Smith,1 which offers an important contribution to the apparent life-threatening event (ALTE) literature. We were not able to cite their work originally because it was published while our article2 was in press.Based on their review, McGovern and Smith proposed a list of diagnostic tests for patients with a history and physical examination that do not suggest a cause of the ALTE. They compiled their list based on the inventory of 728 final diagnoses reported in the 8 research studies they examined in detail (643 patients, 50 different diagnoses). The authors seem to be recommending that, unless a patient's history or examination points to a likely diagnosis, the physician should test for most or all of the 50 conditions.Investigating all of these possibilities requires many tests, which the authors enumerate. They call into question the adequacy of our much shorter list of tests, based evidently on the argument that our list would fail to detect many of the 50 conditions. The problem with that argument is that it neglects to consider which of those conditions might present as an occult cause of an ALTE, that is, without suggestive findings at the outset. One of the main goals of our study was to distinguish the occult causes so that it would be possible to obtain a limited subset of diagnostic tests in patients with nonsuggestive presentations, avoiding the need for an exhaustive testing protocol. We identified a minimum set of tests that would have detected all occult causes that occurred in our sample (N = 243), the largest consecutive series of ALTE patients of which we are aware.Our series did include ALTEs caused by metabolic disease or drug ingestion, but the history or physical examination provided reasons to test for these conditions. It seems that the 8 studies reviewed by McGovern and Smith provided insufficiently detailed data on patients' presentations to apply a similar analysis to the 643 cases. If future investigations identify other occult causes of an ALTE that occur with sufficient frequency to warrant routine testing for them, that would justify expanding our short list to include such testing.

Nonepileptic Disorders Imitating Generalized Idiopathic Epilepsies

Differential diagnosis between epileptic and nonepileptic paroxysmal disorders is fundamental not only to allow correct management of patients but also to avoid the burden of unnecessary antiepileptic medication. The focus of this chapter is limited to imitators of idiopathic generalized epilepsies (IGE) which are expressed through myoclonic, tonic-clonic, tonic, atonic, and absence seizures. Apparent losses of consciousness and drop attacks also have to be considered. Benign myoclonus of early infancy is the main nonepileptic disorder in the differential diagnosis of infantile spasms, but is not dealt with here because West syndrome is not an IGE. Hyperekplexia, metabolic disorders, hypnagogic myoclonus, and disturbed responsiveness caused by the use of drugs are listed in Table 1. Other conditions that may imitate more focal epileptic seizures are omitted. Benign neonatal sleep myoclonus, apnea and apparent life-threatening events in infants, cyanotic and pallid breath-holding spells, syncope, staring spells, psychogenic seizures, hyperventilation syndrome, and narcolepsy have been selected based on frequency or difficulties in differential diagnosis with the intention to cover the most conspicuous imitators of IGE in different ages.

Sleep Architecture in Term and Preterm Infants Beyond the Neonatal Period: The Influence of Gestational Age, Steroids, and Ventilatory Support

To examine (1) sleep architecture of infants at varied risk for sudden infant death syndrome, (2) delays or advances in preterm infants at term postmenstrual age, (3) whether ventilatory support and gestational age alter sleep, (4) whether steroids alter sleep, (5) confounding influences of sex, small for gestational age, and maternal smoking. Overnight polysomnography. Percentage of active sleep, quiet sleep, indeterminate, and awake time per total recording time; mean and longest duration of state epochs; number of episodes > or = 10 minutes; and sleep efficiency. Collaborative Home Infant Monitoring Evaluation (CHIME). Two hundred one preterm and 198 term infants between 33 and 58 weeks postmenstrual age during polysomnography. Fifty-one term infants with an apparent life-threatening event without known etiology (apnea of infancy), 59 subsequent siblings of babies who died of sudden infant death syndrome, and 88 healthy term infants. Tracings of infants with apnea of infancy and healthy term infants were similar. Subsequent siblings of babies who died of sudden infant death syndrome spent less time in quiet sleep. Preterm infants (< or = 37 weeks postmenstrual age) exhibited immature architecture compared with infants of term postmenstrual age. The latter exhibited similar sleep except that they had a lower percentage of quiet sleep and longer mean indeterminate and longest indeterminate episodes. Preterm infants with the youngest gestational age lagged behind older preterm infants. Neither sex nor use of steroids affected sleep. Assisted ventilation was associated with a delay in maturation, small-for-gestational age status with increased active sleep, and smoking with increased awake time. With few exceptions, asymptomatic premature infants do not exhibit significant delays in sleep architecture compared with term infants at comparable postmenstrual age. The preterm infant with an early gestational age and morbidity exhibited delayed sleep architecture.

Idiopathic Generalized Epilepsies: A Review and Modern Approach

Idiopathic Generalized Epilepsies: A Review and Modern Approach

Prevalence of Anemia in Children Presenting with Apparent Life-threatening Events

Anemia has been associated with apparent life-threatening events (ALTEs) in children. However, the nature of the association has not been well described. This study was conducted to determine how often anemia occurs in children presenting with ALTEs. Specifically, the authors sought to prospectively describe hemoglobin (Hb) levels and mean corpuscular volumes (MCVs) in children presenting with either a single ALTE or recurrent events, and to compare the values with those of an age-matched control population. Patients who had recurrent events were compared with those who had single events because it was hypothesized that patients who were anemic would be more likely to have recurrent events. This was a prospective cohort study set in an urban, tertiary care emergency department of a large children's hospital. Children presenting with ALTEs and an age-matched control population were included. The mean Hb level, mean MCV, mean value for the mean corpuscular hemoglobin (MCH), and proportion of patients found to be anemic were measured. Of 128 patients evaluated during the two-year study period, 108 were eligible for study and were age-matched to 108 control patients. Overall, the ALTE and control patients were similar with regard to age, gender, and race. However, the ALTE patients with recurrent events (37/108, 34.3%) were older (3.0 months vs. 1.6 and 2.1 months, p = 0.018) and had a lower mean Hb level (11.6 g/dL vs. 13.1 and 12.9 g/dL, p = 0.013), a lower MCH (30.3 fL vs. 33.1 and 32.4 fL, p < 0.001), and a lower MCV (88.4 pg vs. 96.6 and 93 pg, p < 0.01) than did the patients with a single event and the control patients, respectively. The rate of anemia in the ALTE patients with recurrent events was 21.6%, as compared with 16.9% of the patients with a single event (p = 0.13) and 9.3% of the control patients (p = 0.049). Anemia is common in pediatric patients with recurrent ALTEs. Patients with recurrent ALTEs are older and have lower Hb, MCH, and MCV values than patients with a single ALTE and age-matched control patients. Significantly lower MCH and MCV values in patients with recurrent ALTEs suggest that iron deficiency may be associated with the recurrence of events.

Prevalence of Anemia in Children Presenting with Apparent Life-threatening Events

Prevalence of Anemia in Children Presenting with Apparent Life-threatening Events

Catastrophic Presentation of Infant Botulism May Obscure or Delay Diagnosis

Three infants with infant botulism are presented to illustrate how atypical, early, and severe features may obscure or delay diagnosis. Two boys aged 6 weeks and 20 days, respectively, presented with rapid deterioration after brief periods of poor feeding, one with an apparent life-threatening event at home and the other with a full cardiopulmonary arrest. Initial abnormal laboratory findings of coagulopathy suggested sepsis in the first infant. In the second infant, severe acidosis and hypoglycemia suggested an underlying metabolic disorder. A third infant, aged 1 month, was hospitalized originally with an admitting diagnosis of "pharyngitis" resulting from his inability to take adequate feedings. He received intravenous fluids and antibiotics. One week later he suffered a respiratory arrest. Laboratory findings of severe hyponatremia and acidosis at the time of his arrest suggested a metabolic etiology. Even retrospectively, none of these infants had the typical initial complaint of constipation, and none were noted to have ptosis or facial weakness before catastrophic collapse. However, in each case, the parent had initially brought the child to the physician for "poor feeding" or "poor suck," which was not recognized by medical personnel as a result of bulbar weakness. Ultimately, all 3 infants were found to have infant botulism. All 3 had received antibiotics before catastrophic collapse, possibly contributing to the rapidity of the deterioration. Each recovered, although the delay in diagnosis made them ineligible for treatment with botulism immunoglobulin.

Testing the Association Between Gastroesophageal Reflux and Apnea in Infants

There is controversy regarding the association between gastroesophageal reflux and apnea. The controversy is further confused by the variety of ways reflux is detected, the varying methods of data analysis and the heterogeneity of subjects studied. To determine if apnea is associated with reflux and to determine whether the association differs with acid or non acid reflux. We prospectively evaluated infants with apparent life-threatening events or apnea by simultaneous pneumography, esophageal pH and multichannel intraluminal impedance monitoring. Apneic events and reflux frequency, duration, acidity and height were recorded. Apneic events were considered to be temporally linked to gastroesophageal reflux when they occurred during a gastroesophageal reflux episode or within 5 minutes after clearance of the refluxate. Data described with frequency tables, scatterplots and time series graphs were analyzed by regression analysis and chi testing. Twenty-five infants (10 males) aged 1 to 19 months were studied for up to 24 hours. Of 527 total apneic episodes, only 80 (15.2%) were temporally linked with gastroesophageal reflux: 37 (7.0%) with acid reflux and 43 (8.2%) with non-acid reflux. Scatterplots revealed no significant correlation between apnea and frequency or duration of reflux episodes. Individual chi analyses within subjects found limited associations between reflux and apnea. Regression analyses showed a significant association between apnea and reflux in 4 of 25 subjects. We found little evidence for an association between apnea and total reflux, acid reflux or non-acid reflux. There was no difference between acid gastroesophageal reflux and non-acid gastroesophageal reflux in the frequency association with apnea. Either a chi statistic for each subject or R value computed from a lagged regression model for each subject can be used as an index of association in patient evaluation.

Misconceptions Concerning Gastroesophageal Reflux in Children

To the Editor .— After reading the article “Yield of Diagnostic Testing in Infants Who Have Had an Apparent Life-Threatening Event” by Brand et al,1we were dismayed because of the perpetuation of a myth by well-meaning but misinformed pediatricians. The authors state that a subset of tests that led to the identification of all occult causes of an apparent life-threatening event would include screening for gastroesophageal reflux (GER). To this point we agree. However, their basis for this statement comes from the evaluation of 68 children who had upper gastrointestinal (UGI) series; 36 of the 37 children in whom findings contributed to the final diagnosis of an …

Misconceptions Concerning Gastroesophageal Reflux in Children: In Reply

In Reply .— Figure 1 of our article provides information about the relative yields of different diagnostic tests used in the evaluation of infants after an apparent life-threatening event (ALTE). In discussing the figure, we emphasize …

Accuracy of ECG Interpretation in the Pediatric Emergency Department

We assess accuracy of ECG interpretation and indications for obtaining ECGs and develop a clinical classification system of ECG abnormalities. Prospectively acquired ECG data on patients 0 to 21 years of age and presenting to our pediatric emergency department (ED) were obtained. Clinical indications were documented. The initial ECG interpretation (pediatric ED attending physician) was compared with the criterion standard (pediatric cardiologist). A blinded cardiology panel reviewed discrepancies, and a final concordance rate was determined. An ECG abnormality classification system was developed and used to categorize these abnormal ECGs. One thousand six hundred fifty-three ECGs from 1,501 patients, aged 2 days to 21 years (median 10.0 years), were obtained during 3.5 years. Fifty-one percent were male patients. ECG indications included chest pain (21%), seizure or syncope (18%), arrhythmias (17%), apparent life-threatening event or respiratory symptoms (16%), ingestions (10%), cardiac abnormality (10%), and miscellaneous (8%). From 1,631 ECGs, 1,160 (71%) were normal (class 0), 259 (16%) were minimally abnormal (class I), 174 (11%) were moderately abnormal (class II), and 38 (2%) were severely abnormal (class III). Kendall's tau-b test showed concordance of 0.73 (95% confidence interval 0.70 to 0.77) between pediatric ED and cardiology interpretation. The sensitivity of pediatric ED interpretation was 75%, and the specificity was 98.5%. The positive predictive value of pediatric ED interpretation was 88.3%, and the negative predictive value was 96.3%. We conclude that, overall, a high rate of concordance exists between the pediatric emergency physician's and the cardiologist's ECG interpretation. The majority of discordant ECGs are not clinically significant. However, among the clinically significant ECGs, there is a higher rate of discordance. These data suggest that review of pediatric ECGs by pediatric cardiologists may significantly reduce underdetection of clinically important ECG findings in children.

Malaises chez le nouveau-né de moins d'un mois

Apparent life threatening events (ALTE) frequency in newborn is unknown. Two populations have to be considered in neonate: ex-premature and full term newborn. In ex-premature babies beyond term gestation, persistent apnea and vagal overreactivity are involved but their existence and treatment are discussed. The third etiology is oesophageal reflux. The full term babies' ALTE are very like older infant in spite of some particularities suggested by personal data. At least, we have to keep in mind, link between sudden death and ALTE and manage a careful follow-up.

Yield of Diagnostic Testing in Infants Who Have Had an Apparent Life-Threatening Event

Many infants who have experienced an apparent life-threatening event (ALTE) seem normal by the time they reach the hospital. Nevertheless, they typically undergo an extensive evaluation to rule out serious underlying conditions. The purpose of the present investigation was to determine the yield of different diagnostic tests in helping to identify the cause of the ALTE. We reviewed test results from a consecutive series of infants who were younger than 12 months and admitted to a tertiary care academic medical center between November 1996 and June 1999 after having experienced a sudden breathing irregularity, color change, or alteration in mental status or muscle tone. For each patient, we noted whether a given test was performed, whether the result was positive, and, if so, whether the test contributed to the diagnosis, that is, suggested or helped establish the cause. We also noted whether the initial history and physical examination contributed information that eventually led to the final diagnosis. A total of 243 patients met the enrollment criteria. Of the 3776 tests ordered, 669 (17.7%) were positive and 224 (5.9%) contributed to the diagnosis. Prompted by findings from the initial clinical assessment, the following tests proved useful in patients who had a contributory history and physical examination: blood counts, chemistries, and cultures; cerebrospinal fluid analysis and cultures; metabolic screening; screening for respiratory pathogens; screening for gastroesophageal reflux; chest radiograph; brain neuroimaging; skeletal survey; electroencephalogram; echocardiogram; and pneumogram. In the remaining patients, who had a noncontributory history and physical examination, only the following tests proved useful: screening for gastroesophageal reflux, urine analysis and culture, brain neuroimaging, chest radiograph, pneumogram, and white blood cell count. Broad evaluations for systemic infections, metabolic diseases, and blood chemistry abnormalities were not productive in these patients. For many tests used in the evaluation of an ALTE, the likelihood of a positive result is low and the likelihood of a contributory result is even lower. Estimates of diagnostic yield derived from the present investigation can help clinicians maximize the productivity and efficiency of their evaluation.

Epidemiology of apparent life threatening events

Aims: To investigate the epidemiology and risk factors of apparent life threatening events (ALTE). Methods: A prospective study enrolled all live-born infants in the Tyrol (1993–2001). Information on pregnancy, sociodemographic...

The Long-Term Outcome of Infantile Apparent Life-Threatening Event (ALTE): A Follow-Up Study until Midpuberty

The neurological long-term sequelae of an idiopathic apparent life-threatening event (ALTE) were studied in 14 ALTE cases and 12 controls (of similar sex, age, and maturation of puberty). One ALTE case had developed motor and severe learning disabilities. Four other cases and one control were judged as MND (minor neurological deficits). Touwen's neurological profile was less optimal in children with an ALTE history than in controls (p < 0.05). A high amount of associated movements were found in combination with an inability of certain gross motor functions, such as standing or hopping on one leg for sufficiently long or walking on tip-toes or on heels. Fine and gross motor performance tested with the Bruininks-Oseretsky test and behaviour judged with Connors' Rating Scales--Revised, were not different between ALTE cases and controls. Our study provides evidence of neurological long-term sequelae of ALTE.

Cardiac Tamponade Presenting as an Apparent Life-Threatening Event

The initial emergency department (ED) evaluation of infants with an apparent life-threatening event (ALTE) often fails to identify a definitive cause for the event. Many children that present with an ALTE appear normal by the time they arrive to the ED. These factors can desensitize clinicians into prematurely discounting serious underlying causes of the ALTE or being less prompt in their evaluation of these patients. We present the case of a young infant who presented to an ED with an ALTE resulting from cardiac tamponade. Cardiac tamponade has not been reported as an underlying cause of infants presenting to the ED with an ALTE. Previously reported cases of cardiac tamponade in children have occurred as a complication of malignancies, cardiac surgery, trauma, infections, central venous catheter placement, rheumatologic, and autoimmune diseases. This case should serve as a reminder to clinicians to maintain a broad differential diagnosis and promptly evaluate all infants presenting with an ALTE.

Epidemiology of Apparent Life Threatening Events Differs from that of Sudden Infant Death Syndrome

Epidemiology of Apparent Life Threatening Events Differs from that of Sudden Infant Death Syndrome

Factors That Influence Use of a Home Cardiorespiratory Monitor for Infants

As part of the Collaborative Home Infant Monitoring Evaluation, a home monitor was developed to record breathing, heart rate, other physiologic variables, and the time the monitor was used. To determine the frequency of monitor use, factors that influence use, and validity of a model developed to predict use. We developed a model to predict monitor use using multiple linear regression analysis; we then tested the validity of this model to predict adherence for the first week of monitoring and for the subsequent 4-week period (weeks 2-5). Clinical research centers in Chicago, Ill; Cleveland, Ohio; Honolulu, Hawaii; Los Angeles, Calif; and Toledo, Ohio. Patients Preterm infants, infants younger than 1 month with a history of autopsy-confirmed sudden infant death syndrome in a sibling, and infants with an idiopathic apparent life-threatening event were divided into 2 cohorts based on enrollment date. Main Outcome Measure Mean hours of monitor use per week. In cohort 1, the variables available before monitoring were only weakly associated with total hours of monitor use in weeks 2 to 5 (total model r(2) = 0.08). However, when hours of monitor use in week 1 were included as a variable to predict monitor use in weeks 2 to 5, the r(2) increased to 0.64 for hours of monitor use per week. Our data show that monitor use in the first week was the most important variable for predicting subsequent monitor use. The study suggests that a major focus of home monitoring should be adherence in the first week, although it remains to be tested whether this adherence can be altered.

The web survey network of sudden infant death syndrome and apparent life-threatening events in the Emilia-Romagna region

To survey epidemiology and to study the etiology of sudden infant death syndrome (SIDS) and apparent life threatening events (ALTE) in Emilia-Romagna, a web network was constituted. A regional supervisor and a steering committee plan the action of district and local co-ordinators. They keep contact with the Regional Office of Health Services. District and local co-ordinators collect clinical and laboratory and, in case of SIDS, also autopsy data. Records are communicated to the Regional Supervising Center by on-line software. From these data, future planning of care and of mass information as well as auditing of their efficacy can be carried out. The characteristics of the network that has just started to collect data, as well its future developmental aspects, are discussed.

Causes of apparent life threatening events in infants: a systematic review

Aims: To determine the most likely diagnoses when infants first present with an apparent life threatening event (ALTE). Methods: Medline (1966–2002), Embase (1980–2002), and Cinahl (1982–2002) were searched. Primary authors...