Apparent Life-threatening Events Research Articles

Incidence of apparent life-threatening events and post-neonatal risk factors.

Even though a standard clinical definition for an apparent life-threatening event (ALTE) was established more than two decades ago, the specific International Classification of Disease (ICD) code was firstly included only in 2012. This study estimated the incidence of ALTEs in Northern Italy, together with features and risk factors. We used the Lombardy Region Hospital Discharge Records (HDR) database to estimate the cumulative incidence for ALTE during 2002-2006 and drew up a risk profile by comparing cases with and without ALTE who were followed in infancy. There were 246 infants registered in the HDR with ALTE putative diagnostic codes, suggesting a cumulative incidence of 4.1 per 1000 live births in the study area. Of the 148 cases with clinical co-morbidities, 31% had gastroesophageal reflux and 7% had acute respiratory infections. We analysed follow-up data from 15 ALTE cases and 1619 healthy infants and found that the significant risk factors were gastroesophageal reflux and a family history of sudden death. We established the regional incidence of ALTE and found risk factors in infants considered healthy in the first week of life and without pathological perinatal conditions. The systematic use of the specific ALTE ICD code (R68.13, ICD-10-CM) and common knowledge about ALTE diagnostic guidelines are clearly needed.

P-06: Novel Technique for The Correction of Severe Tracheobronchomalacia

Tracheobronchomalacia (TBM) may result in severe, apparent life-threatening events and debilitating respiratory compromise requiring surgery in children. Our aim was to describe a series of patients who underwent isolated posterior tracheopexies to treat severe TBM. All patients treated at our hospital for TBM from January 2011 to June 2014 were retrospectively reviewed. A previously described classification system was utilized to describe the specific location of malacia. Estimated gestational age, gender, comorbid conditions, endoscopic evaluations, surgical technique, and complications were collected. A novel endoscopic score evaluated severity between preoperative and postoperative exam. Nineteen underwent posterior tracheopexies (Figure 1). Primary indication was respiratory distress. Thirty-two percent were female. Fifty-three percent were premature. Median gestational age was 37 weeks (range: 31–40 weeks). Seventy-four percent had one-comorbid condition; either cardiac or VACTERL. Eleven-percent had a previously performed operation. Median number of bronchoscopies was 3 bronchoscopies (range 1–10). Median age at operation was 10 months (range: 2–168 months). Median weight was 6.4 kg (range: 3.8–38.8 kg). Operative approach was determined by the surgeon and not randomized; 11% by median sternotomy, 84% by thoracotomy, and 5% utilizing both. No short-term recurrences or complications have occurred. Median decrease in TBM endoscopic severity score was 7 (range: 1–16) in 10 patients. In this series of patients, an evolution in the manner in which TBM was surgically treated occurred. Given the heterogeneity of this patient population, larger studies are needed to ascertain longer-term outcomes and the validity of the TBM endoscopic score.

Malaise et mort inattendue du nourrisson : deux entités différentes

Most infant apparent life-threatening events (ALTEs) are minor with spontaneously favorable prognosis. Frequent etiologies are gastroesophageal reflux, obstructive apneas, respiratory infections, and breath-holding spells. Some rare but potentially serious causes must be discussed. Diagnosis is usually guided by careful questioning of the parents and repeated clinical examinations. A few complementary examinations are systematically needed and their performance is increased if they are oriented by clinical aspects. Hospitalization is usual for monitoring, further etiological investigation, and management of parental anxiety. ALTE and sudden unexpected death in infancy (SUDI) etiologies are often different. SUDI is called sudden unexplained death in infancy if it remains unexplained after investigation including autopsy. The annual incidence in France fell sharply after prevention campaigns in the 1990s, and now is about 400 SUDI, including 250 unexplained SUDI. The main guidelines of prevention are back sleeping, cessation of smoking during and after pregnancy, securing the bed and bedding, prevention of hyperthermia, and avoidance of dangerous factors of bed sharing. In the future, infants with particular vulnerabilities may be identified. The Haute Autorité de santé (French National Authority for Health) has published guidelines to support SUDI, standardize procedures, and improve our understanding of the causes of death.

A Case of Apparent Life-Threatening Event: Comorbid Gastric Volvulus Associated Gastroesophageal Reflux Disease and Epilepsy in a 4-Month-Old Boy.

Most isolated episodes of apparent life-threatening events (ALTEs) do not lead to the diagnosis of serious conditions, and their prognoses are generally benign. However, recurrent ALTEs are often associated with a risk of future serious adverse events and should be evaluated for appropriate management. Here we present ALTE case in which gastric volvulus associated gastroesophageal reflux disease was detected as an etiology initially, followed by the detection of epilepsy as another etiology. Clinicians should consider possibility of two or more etiologies in a single recurrent ALTE case.

ALTE and Feeding Intolerance as a Presentation of Double Aortic Arch.

Many children who are admitted to pediatric hospitals with the chief complaint of apparent life-threatening event (ALTE) are, in fact, well appearing by the time the inpatient medical team evaluates the patient. This presents a diagnostic and therapeutic challenge. We describe a case of a six-month-old full-term female presenting with an ALTE and found to have a double aortic arch, a congenital anomaly that usually presents with a more progressive onset of symptoms such as chronic cough, positional stridor, and feeding difficulties. This case highlights the importance of maintaining a broad differential in a patient presenting with findings of tracheoesophageal pathology on clinical exam.

Crib Bumpers Continue to Cause Infant Deaths: A Need for a New Preventive Approach

To assess whether clutter (comforters, blankets, pillows, toys) caused bumper deaths and provide an analysis of bumper-related incidents/injuries and their causal mechanisms. Bumper-related deaths (January 1, 1985, to October 31, 2012) and incidents/injuries (January 1, 1990, to October 31, 2012) were identified from the US Consumer Product Safety Commission (CPSC) databases and classified by mechanism. Statistical analyses include mean age, 95% CIs, χ(2) test for trend, and ANOVA with a paired-comparisons information-criterion post hoc test for age differences among injury mechanisms. There were 3 times more bumper deaths reported in the last 7 years than the 3 previous time periods (χ(2)(3) = 13.5, P ≤ .01). This could be attributable to increased reporting by the states, diagnostic shift, or both, or possibly a true increase in deaths. Bumpers caused 48 suffocations, 67% by a bumper alone, not clutter, and 33% by wedgings between a bumper and another object. The number of CPSC-reported deaths was compared with those from the National Center for the Review and Prevention of Child Deaths, 2008-2011; the latter reported substantially more deaths than CPSC, increasing the total to 77 deaths. Injury mechanisms showed significant differences by age (F4,120 = 3.2, P < .001) and were caused by design, construction, and quality control problems. Eleven injuries were apparent life-threatening events. The effectiveness of public health recommendations, industry voluntary standard requirements, and the benefits of crib bumper use were not supported by the data. Study limitations include an undercount of CPSC-reported deaths, lack of denominator information, and voluntary incident reports.

Possible role of trace elements in epilepsy and febrile seizures: a meta-analysis.

Seizures are among the most common causes of apparent life-threatening events. There are discrepancies among the published reports on the correlation between epilepsy/febrile seizures and deficiency or overload of trace elements. The objective of this review and meta-analysis was to examine the present knowledge on the concentrations of the most investigated trace metals, including zinc, copper, selenium, and magnesium, in patients with epilepsy and febrile seizures. The PubMed and Scopus databases were searched to identify case-control studies that compared the concentration of zinc, copper, magnesium, and selenium in serum, hair, or cerebrospinal fluid between patients with epilepsy/febrile seizures and controls. A total of 60 articles were included in the present study (40 pertaining to epilepsy and 25 pertaining to febrile seizures). The serum concentration of zinc in nontreated patients with epilepsy was significantly higher than in controls (P = 0.034). There were significantly reduced serum concentrations of zinc (P = 0.018) and selenium (P = 0.012) in patients with febrile seizures compared with controls. The concentrations of copper, magnesium, and zinc were all significantly altered in patients with epilepsy who received antiepileptic drugs compared with untreated patients with epilepsy. Designing treatments to selectively restore zinc levels may be a strategy for treating patients with epilepsy. It is still unclear whether these ions are causal to, or a cofactor in, the development of epilepsy. Knowledge of the effects of various antiepileptic drugs on trace element homeostasis could potentially be used to effectively guide appropriate therapeutic strategies in the future.

The role of complementary examinations and home monitoring in patients at risk from apparent life threatening event, apneas and sudden infant death syndrome

Abstract Introduction Home apnea monitors detect abnormalities in cardiac and respiratory frequency, but their use in the diagnosis of respiratory-related sleep disturbances in children has not been demonstrated, as was originally thought. Objective To describe the type of patients being monitored, for how long and their outcome. Material and methods A retrospective descriptive study was conducted on patients with controlled home cardiorespiratory monitoring from October 2008 to September 2012 in the Outpatient department of a Maternity tertiary hospital. Results During the study period 88 patients were included, 58% of them were male, with a median age of 15.5 days, and followed up for a period of 4.7 months. The reason for monitoring was due to a history of sudden death without finding underlying pathology in 20.5%, 25% due to apnea of prematurity, 20.5% due to apparent life-threatening event, and 14.8% due to choking. Other causes accounted for 19.3% (apnea/hypopnea, desaturation and periodic breathing). Of these last three groups, pathological events were observed in 50% of them: reflux disease (9), apnea of prematurity (2), neurological causes (3), and apnea of unknown cause (10). Conclusions Suspected infant apnea is a cause for consultation that creates a great deal of concern to the family and the paediatrician. Home monitoring is useful in detecting changes in cardiac and respiratory frequency, but is necessary to limit its indications and ensure proper monitoring of these patients, avoiding the abuse of other tests or treatments.

Malaise et mort inattendue du nourrisson : deux entités différentes

Most infant apparent life-threatening events (ALTEs) are minor with spontaneously favorable prognosis. Frequent etiologies are gastroesophageal reflux, obstructive apneas, respiratory infections, and breath-holding spells. Some rare but potentially serious causes must be discussed. Diagnosis is usually guided by careful questioning of the parents and repeated clinical examinations. A few complementary examinations are systematically needed and their performance is increased if they are oriented by clinical aspects. Hospitalization is usual for monitoring, further etiological investigation, and management of parental anxiety. ALTE and sudden unexpected death in infancy (SUDI) etiologies are often different. SUDI is called sudden unexplained death in infancy if it remains unexplained after investigation including autopsy. The annual incidence in France fell sharply after prevention campaigns in the 1990s, and now is about 400 SUDI, including 250 unexplained SUDI. The main guidelines of prevention are back sleeping, cessation of smoking during and after pregnancy, securing the bed and bedding, prevention of hyperthermia, and avoidance of dangerous factors of bed sharing. In the future, infants with particular vulnerabilities may be identified. The Haute Autorité de santé (French National Authority for Health) has published guidelines to support SUDI, standardize procedures, and improve our understanding of the causes of death.

Discovering apparent life-threatening events in the first 24 hours of birth: A case study

The benefits of early skin-to-skin contact and its role in the promotion of successful breastfeeding are widely known and well recognized. One rare but potentially devastating consequence is an apparent life-threatening event, or ALTE. A review of current literature reveals that an exact definition for an ALTE is vague, however several common themes emerge including a decrease in the level of consciousness of the neonate, loss of muscle tone, apnea and pallor/cyanosis. ALTEs are thought to occur most commonly in first time mothers and when the mother was not under direct observation by a healthcare provider. This paper examines the prevalence of ALTE's in the first 24 h of life and includes a case study of an ALTE that occurred at 50 min of life in a full-term neonate born to a primaparous mother who was holding her baby skin to skin.

A 3-Month-Old Infant With Recurrent Apparent Life-Threatening Events in a Car Seat

A 3-month-old infant was brought to clinic for evaluation of recurrent apparent life-threatening events (ALTEs). Two ALTE episodes occurred while the infant was sleeping in a safety car seat. The first one occurred when he was 4 weeks old. His mother noticed that he was not breathing; he appeared limp with full body cyanosis. His mother picked him up from the car seat, and he started breathing spontaneously and without any sign of distress. His skin color returned to normal. He was evaluated at the ED where the physical examination was normal. He was hospitalized 1 day for observation. During this time, workup, including ECG and chest radiograph, was normal. The parents were instructed on cardiorespiratory resuscitation and recommended to change car seats. The infant was discharged with an apnea monitor. He wore the apnea monitor while in the car seat. A second similar episode occurred at 10 weeks of age for which he was seen at the ED and referred to our clinic for further evaluation. Neither episode was related to feeding.

Papel de las exploraciones complementarias y de la monitorización domiciliaria en los pacientes de riesgo de episodio aparentemente letal, apneas y síndrome de muerte súbita del lactante

IntroductionHome apnea monitors detect abnormalities in cardiac and respiratory frequency, but their use in the diagnosis of respiratory -related sleep disturbances in children has not been demonstrated, as was originally thought. ObjectiveTo describe the type of patients being monitored, for how long and their outcome. Material and methodsA retrospective descriptive study was conducted on patients with controlled home cardiorespiratory monitoring from October 2008 to September 2012 in the Outpatient department of a Maternity tertiary hospital. ResultsDuring the study period 88 patients were included, 58% of them were male, with a median age of 15.5 days, and followed up for a period of 4.7 months. The reason for monitoring was due to a history of sudden death without finding underlying pathology in 20.5%, 25% due to apnea of prematurity, 20.5% due to apparent life-threatening event, and 14.8% due to choking. Other causes accounted for 19.3% (apnea/hypopnea, desaturation and periodic breathing). Of these last three groups, pathological events were observed in 50% of them: reflux disease (9), apnea of prematurity (2), neurological causes (3), and apnea of unknown cause (10). ConclusionsSuspected infant apnea is a cause for consultation that creates a great deal of concern to the family and the pediatrician. Home monitoring is useful in detecting changes in cardiac and respiratory frequency, but is necessary to limit its indications and ensure proper monitoring of these patients, avoiding the abuse of other tests or treatments.

Direct tracheobronchopexy to correct airway collapse due to severe tracheobronchomalacia: Short-term outcomes in a series of 20 patients

PurposeTracheobronchomalacia (TBM) is associated with esophageal atresia, tracheoesophageal fistulas, and congenital heart disease. TBM results in chronic cough, poor mucous clearance, and recurrent pneumonias. Apparent life-threatening events or recurrent pneumonias may require surgery. TBM is commonly treated with an aortopexy, which indirectly elevates trachea’s anterior wall. However, malformed tracheal cartilage and posterior tracheal membrane intrusion may limit its effectiveness. This study describes patient outcomes undergoing direct tracheobronchopexy for TBM. MethodsThe records of patients that underwent direct tracheobronchopexy at our institution from January 2011 to April 2014 were retrospectively reviewed. Primary outcomes included TBM recurrence and resolution of the primary symptoms. Data were analyzed by McNemar’s test for matched binary pairs and logistic regression modeling to account for the endoscopic presence of luminal narrowing over multiple time points per patient. ResultsTwenty patients were identified. Preoperative evaluation guided the type of tracheobronchopexy. 30% had isolated anterior and 50% isolated posterior tracheobronchopexies, while 20% had both. Follow-up was 5months (range, 0.5–38). No patients had postoperative ALTEs, and pneumonias were significantly decreased (p=0.0005). Fewer patients had tracheobronchial collapse at postoperative endoscopic exam in these anatomical regions: middle trachea (p=0.01), lower trachea (p<0.001), and right bronchus (p=0.04). ConclusionThe use of direct tracheobronchopexy resulted in ALTE resolution and reduction of recurrent pneumonias in our patients. TBM was also reduced in the middle and lower trachea and right mainstem bronchus. Given the heterogeneity of our population, further studies are needed to ascertain longer-term outcomes and a grading scale for TBM severity.

Mortality of babies enrolled in a community-based support programme: CONI PLUS (Care of Next Infant Plus)

ObjectiveTo report mortality in babies enrolled on a community-based programme, Care of Next Infant Plus (CONI PLUS), which primarily supports parents anxious because of previous sudden unexpected death in infancy...

Relationship between the Clinical Characteristics and Intervention Scores of Infants with Apparent Life-threatening Events.

We investigated the clinical presentations, diagnostic and therapeutic modalities, and prognosis from follow-up of infants with apparent life-threatening events (ALTE). In addition, the relationship between the clinical characteristics of patients and significant intervention scores was analyzed. We enrolled patients younger than 12 months who were diagnosed with ALTE from January 2005 to December 2012. There were 29 ALTE infants with a peak incidence of age younger than 1 month (48.3%). The most common symptoms for ALTE diagnosis were apnea (69.0%) and color change (58.6%). Eleven patients appeared normal upon arrival at hospital but 2 patients required cardiopulmonary resuscitation during the initial ALTE. The most common ALTE cause was respiratory disease, including respiratory infection and upper airway anomalies (44.8%). There were 20 cases of repeat ALTE and 2 cases of death during hospitalization. Four patients (15.4%) experienced recurrence of ALTE after discharge and 4 patients (15.4%) showed developmental abnormalities during the follow-up period. The patients with ALTE during sleep had lower significant intervention scores (P=0.015) compared to patients with ALTE during wakefulness and patients with previous respiratory symptoms had higher significant intervention scores (P=0.013) than those without previous respiratory symptoms. Although not statistically significant, there was a weak positive correlation between the patient's total ALTE criteria and total significant intervention score (Fig. 2, r=0.330, P=0.080). We recommend that all ALTE infants undergo inpatient observation and evaluations with at least 24 hr of cardiorespiratory monitoring, and should follow up at least within a month after discharge.

Infantile Apparent Life-Threatening Events, an Educational Review.

Many physicians have received a frantic call from anxious parents stating that their child had stopped breathing, become limp, or turned blue but then had recovered quickly. An apparent life-threatening event (ALTE) is defined as "an episode that is frightening to the observer, and is characterized by some combination of apnea, color change, marked change in muscle tone, choking, gagging, or coughing". The incidence of ALTE is reported to be 0.05% to 6%. The knowledge about the most common causes and factors associated with higher risk of ALTE could be resulted in a more purposeful approach, improving the decision making process, and benefiting both children and parents. The aim of this review article was to report the epidemiology, etiology, evaluation, management, and disposition of ALTE. Infants with an ALTE might present no signs of acute illness and are commonly managed in the emergency settings that often require significant medical attention; hence, the emergency medicine personnel should be aware of the its clinical importance. There is no specific treatment for ALTE; therefore, the clinical evaluations should be focused on the detection of the underlying causes, which will define the outcomes and prognosis. ALTE is a confusing entity, representing a constellation of descriptive symptoms and signs; in other words, it is not a diagnosis. There are multiple possible etiologies and difficulties in evaluating and managing infants with these events, which are challenges to primary care physicians, emergency medicine specialists, and subspecialty pediatricians. The evaluation of these events in infants includes a detailed history, appropriate physical examination, diagnostic tests guided by obtained clues from the history and physical examination, and observation in the emergency department.

Control of breathing

Late preterm infants have been called “great imposters” [1] because they often appear to be and are therefore treated as term infants, however their brainstem development and neural control of respiration are less mature than in full-term infants. During late gestation there are dramatic developmental changes in the brainstem and forebrain: at 34 gestational weeks the total brain weight is 65% of that at term [2]. The control of lung volume, laryngeal reflexes, upper airways, chemoreceptor activity, coordination of sucking, swallowing, breathing, the incidence of apnea and periodic breathing and the control of heart rate are still developing during late gestation and the degree of maturity of these mechanisms appears to lie on a continuum that extends from more immature infants to after term. Also, these reflexes are influenced by sleep-wake states whose neurobiological development is still evolving. The brainstem is not completely mature even at term, as confirmed by the fact that its myelination, the marker of completed neuronal/axonal maturation, is still incomplete at that time. This protracted maturation is not surprising, considering that the neurodevelopment of the respiratory control and sleep-wake cycle continues into infancy. The few data on control of breathing in late preterm infants indicate that ventilatory responses to CO2 and hypoxia as well as autonomic control of heart rate are not yet mature at 36 weeks PMA. Clinically, late preterm infants have more apnea and periodic breathing than term infants and immature coordination of sucking, swallowing and breathing often delay their ability to feed without episodes of bradycardia, desaturation and even apnea [3]. The incidence of apparent life-threatening events is more common in preterm infants (8-10%) than full-term infants (1% or less). In the Collaborative Home Infant Monitoring Evaluation studies the frequency of conventional and extreme (clinically relevant) events in near term infants is intermediate between preterm infants <34 weeks at birth and full-term infants [4]. Clinical data indicate that late preterm are also predisposed to wheezing in infancy and early childhood although not exposed to excessive supplemental oxygen or ventilator support [5]. Exposure to 21% oxygen could represent premature exposure to hyperoxic environment compared to that in utero, with long-term effects on the still immature conducting airways. Recent data demonstrate that immature human airway smooth muscle are highly sensitive to even short durations of hyperoxia, with increased proliferation at moderate levels of oxygen (< 60%) but apoptosis at higher levels [6].

Pertinence de la prescription au service d’accueil des urgences d’un électroencéphalogramme après un malaise du nourrisson

Neurological causes are common diagnoses for apparent life-threatening events in infants. The objective of this study was to evaluate the relevancy of electroencephalography performed after an apparent life-threatening event. A retrospective study was conducted in a children's hospital over a 1-year period. The charts of infants under 2 years of age who were admitted following an apparent life-threatening event were reviewed. Clinical and biological data were collected and electroencephalograms - divided into normal and abnormal - were reviewed. To evaluate the follow-up state of the patients, parents were invited to complete an evaluation form an average 13 months after the event. The yield for electroencephalography was established according to the ratio of positive results contributing to the diagnosis of the cause of the apparent life-threatening event. A total of 47 patients met the inclusion criteria. Fifteen had had an EEG, 32 had not. The rate of abnormal neurological signs described by parents during the apparent life-threatening event was higher in the EEG group compared to the group without EEG (53% vs. 22%, P=0.05). In the follow-up, 35% of the children presented a second event, which was described as being similar or less impressive and occurred in the 1st month after the event (91%). Of the eight abnormal electroencephalograms, six had no specific abnormalities and two contributed to the diagnosis of epileptic seizure. Therefore, the diagnostic yield of electroencephalography in this study was 13% (2/8). The yield of electroencephalography performed after an apparent life-threatening event is low. Neurological history and repeated physical examinations still remain the major diagnostic tools before resorting to electroencephalography.

Eventos que aparentan amenazar la vida (ALTE): abordaje diagnóstico

Apparent Life-Threatening Events (ALTE) are a form of clinical presentation of various problems or diseases in children under one year of age. A frequency of 0.6/1000 newborns is estimated. In Mexico, there is no known incidence, systematic approach or guidelines for hospital discharge, so we performed a literature review. Its etiology may be gastrointestinal, neurological, cardiovascular, metabolic, endocrine or-idiopathic. The detailed history and physical examination provide an outline to select the laboratory and imaging studies to perform.

Pediatric emergency medicine asynchronous e-learning: a multicenter randomized controlled Solomon four-group study.

Asynchronous e-learning allows for targeted teaching, particularly advantageous when bedside and didactic education is insufficient. An asynchronous e-learning curriculum has not been studied across multiple centers in the context of a clinical rotation. We hypothesize that an asynchronous e-learning curriculum during the pediatric emergency medicine (EM) rotation improves medical knowledge among residents and students across multiple participating centers. Trainees on pediatric EM rotations at four large pediatric centers from 2012 to 2013 were randomized in a Solomon four-group design. The experimental arms received an asynchronous e-learning curriculum consisting of nine Web-based, interactive, peer-reviewed Flash/HTML5 modules. Postrotation testing and in-training examination (ITE) scores quantified improvements in knowledge. A 2 × 2 analysis of covariance (ANCOVA) tested interaction and main effects, and Pearson's correlation tested associations between module usage, scores, and ITE scores. A total of 256 of 458 participants completed all study elements; 104 had access to asynchronous e-learning modules, and 152 were controls who used the current education standards. No pretest sensitization was found (p = 0.75). Use of asynchronous e-learning modules was associated with an improvement in posttest scores (p < 0.001), from a mean score of 18.45 (95% confidence interval [CI] = 17.92 to 18.98) to 21.30 (95% CI = 20.69 to 21.91), a large effect (partial η(2) = 0.19). Posttest scores correlated with ITE scores (r(2) = 0.14, p < 0.001) among pediatric residents. Asynchronous e-learning is an effective educational tool to improve knowledge in a clinical rotation. Web-based asynchronous e-learning is a promising modality to standardize education among multiple institutions with common curricula, particularly in clinical rotations where scheduling difficulties, seasonality, and variable experiences limit in-hospital learning.