Life-threatening Events In Infants Research Articles

Apparent life-threatening events in infants

Abstract Background The incidence of infant apparent life-threatening event (ALTE) was reported as 0.6-2.4 per 1000 live birth. The difficulty of the diagnosis lies in the delicate interpretation of the results of the clinical examination and the complementary examinations. The objectives of this study were to describe epidemiological, clinical and paraclinical characteristics of infants hospitalized for ALTE and to determine the most common diagnosis. Methods We conducted a case serie from January 2013 to April 2018 in the pediatric ward 2 at Abderrahim Harrouchi Children's Hospital, Casablanca of all infants aged less than 2 years hospitalized for malaise (newborn excluded). We obtained our data using a standardized form of service. We described our data by mean, frequency and percentages using SPSS 16. Results The mean age of onset of symptomatology is 4.8 months. Recurrence of discomfort was present in 30% of cases. The socio-economic conditions were unfavorable in more than half of the cases (63.3%). Clinical examination was abnormal in 6.6% of cases. Complementary examinations performed systematically in all patients were Blood cell count, blood ionogram, CRP, blood glucose and chest x-ray. Other examinations were performed according to the history and the clinic data. The most common diagnosis was gastroesophageal reflux (36.7%), cardiac problems (16.7%), lower respiratory tract infection (13.3%), and ‘'unknown'' (26.6%). Conclusions Few complementary examinations are systematically needed and their performance is increased if they are oriented by a careful history and physical examination which then allows to advance in the diagnostic procedure. Key messages Complementary examinations are largely inconclusive and only a history and complete clinical examination can make it possible to advance in the diagnostic procedure. Infants who demonstrate historical or physical examination elements suggestive of a specific etiology of their event, such as gastroesophageal reflux, should be evaluated and treated accordingly.

The Prevalence of Symptoms of Life-Threatening Events in Infants of the First Year of Life: a Cross-Sectional Population Study

Background.The prevalence of symptoms of life-threatening events in infants was previously studied using hospital data. However, not all parents in the event of such symptoms seek medical help in the hospital.Objective.Our aim was to identify the prevalence and risk factors of life-threatening events in infants in the first year of life.Methods.In the period from November 2017 to February 2018, we interviewed mothers who have children in their second year of life who are registered at children's outpatient clinics in Syktyvkar. Respondents noted episodes of absent, infrequent or irregular breathing, blanching or cyanosis of the skin, changes in muscle tone (hypo- or hypertonia), changes in the level of responses that occurred in infancy. The prevalence of symptoms of life-threatening events was estimated based on the total number of infants in the first year of life (n = 3088) who lived in Syktyvkar as of January 1, 2018.Results.At least one symptom of life-threatening events in infancy was reported by 43 (4.3%) of the 1001 mothers surveyed. The prevalence of symptoms was 429.5 [95% confidence interval (CI) 321–574] per 10,000 children of the corresponding age. Independent predictors of life-threatening events in children of the first year of life were sudden deaths of relatives under the age of 50 years [odds ratio (OR) 2.4; 95% CI 1.1–5.3], cases of pre-syncope or syncope in relatives (OR 4.4, 95% CI 2.1–9.0), artificial feeding of infants (OR 4.0, 95% CI 1.5–11.2). The sensitivity of the model, which took into account the presence of at least one of the three predictors, was 19% (8/43), specificity — 99% (2/958).Conclusion.The issue of the occurrence of life-threatening events in an infant can impact every 25th family. In every fifth infant, the occurrence of symptoms of life-threatening events can be predicted based on risk factors.

Apparent life-threatening events in infants: a single-center experience

Background Apparent life-threatening events (ALTEs) occur with diverse underlying medical conditions. Objective We aimed to assess the clinico-epidemiological characteristics of ALTEs in our locality in the Delta region located in Northern Egypt. Patients and methods A prospective cohort study included 53 patients younger than 1 year, who presented with ALTEs in emergency department of Mansoura University Children’s Hospital. All patients were subjected to full history taking, physical examination, and basic laboratory panel. Further investigations were individualized. All patients had 1-year follow-up for recurrence and outcome. Results The study included 53 patients, comprising 28 (52.8%) females, and the median age was 6 weeks (range, 2 days–11 months). Thirty-nine (73.6%) patients were defined as high-risk age group (below 2 months). Most of the patients had normal vital signs and stable medical condition at the time of their examination in the emergency department (40 cases, 75.5%). Recurrent ALTE was observed in 35 (66%) patients. Cardiac arrest occurred in 20.8% of patients, and eight of them died. Multivariate analysis revealed a significant effect of the cardiac arrest (odds ratio, 24; 95% confidence interval, 3.8–152.2; P=0.001) and abnormal physical examination (odds ratio, 15.5; 95% confidence interval, 1.74–138.2; P=0.014) on the number of deaths. Conclusion ALTE in our locality turned out not to be a rare condition. Its recognition and appreciation of the abnormal symptoms reported by the parents are important to promptly define any underlying etiology. Structured history and examination with tailored investigations have a high diagnostic yield.

Etiology and Outcome of Severe Apparent Life-Threatening Events in Infants.

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 of muscle tone, choking, or gagging." The aims of this study were to determine etiology and outcome of severe ALTE (requiring resuscitation measures) and to review diagnostic approaches in infants hospitalized after such an episode of ALTE. Retrospective analysis included patients hospitalized at the Intensive Care Unit, Institute of Child and Youth Healthcare of Vojvodina, after an episode of severe ALTE over a 4-year period. The study included 23 infants, 18 male (78.3%), and 5 female (21.7%). The average age at presentation was 78 days (1 day to 11 months). In 8 infants (34.7%), ALTE resulted in death. The most frequent conditions after diagnostic evaluation were lower respiratory tract infections (39.1%), intracranial and extracranial hemorrhages (13.0%), and central nervous system infections (8.6%). The cause remained unknown in 8.7% of cases. Initial investigations included complete blood cell count, C-reactive protein or procalcitonin, blood gasses, lactate, electrolytes, glucose, blood culture, urinalysis, and chest x-ray. Apparent life-threatening event represents a diverse disorder. Lower respiratory tract infections and neurological disorders were the most common established etiology. Prematurity and congenital heart diseases stood out as important risk factors. Diagnostic evaluation varied according to suspected cause and trigger factors.

Independent risk factors for recurrence of apparent life-threatening events in infants.

ALTE patients who had RTI symptoms at the ED visit for first ALTE should be admitted for close observation of potential recurrences. What is Known: • Approximately 10% of ALTE patients experienced recurrence of ALTE episodes. • The risk of recurrent ALTE is one of the major consideration for the management of ALTE patients at the ED because these patients have higher rates of serious underlying diseases which require interventions. What is New: • Respiratory infection symptoms at ED presentation can be independent risk factors for recurrent ALTE.

Sleep study as a diagnostic tool for unexplained respiratory failure in infants hospitalized in the PICU

PurposeThe aim of the study was to analyze the diagnostic and therapeutic value of a polygraphy (PG) in infants hospitalized for unexplained respiratory failure or life-threatening events in the PICU. Material and methodsThe PG of 13 infants (4 girls), mean age 6.8±7.7months, were analyzed. ResultsEight infants were admitted for unexplained respiratory failure and 5 for life-threatening events. PG showed features suggestive of respiratory muscle weakness in 5 infants whose final diagnoses were nemaline rod myopathy (n=2), congenital myasthenia (n=2), and diaphragmatic dysfunction (n=1). Four of these patients were successfully treated with noninvasive ventilation (NIV). PG was suggestive of brainstem dysfunction in 4 infants; 2 were treated successfully with NIV and another with caffeine. PG showed obstructive sleep apnea in 3 infants; 2 were treated successfully with NIV and one patient was lost during follow up. A typical pattern of congenital central hypoventilation syndrome was observed in the last patient who was treated successfully with invasive ventilation. One patient with diaphragmatic dysfunction and one with brain stem dysfunction died. ConclusionsPG may assist the diagnosis and guide the management of unexplained respiratory failure or life-threatening events in infants hospitalized in the PICU.

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.

Management of Apparent Life-Threatening Events in Infants: A Systematic Review

ObjectiveTo determine in patients who are well-appearing and without a clear etiology after an apparent life-threatening event (ALTE): (1) What historical and physical examination features suggest that a child is at risk for a future adverse event and/or serious underlying diagnosis and would, therefore, benefit from testing or hospitalization? and (2) What testing is indicated on presentation and during hospitalization? Study designSystematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE. ResultsThe final analysis was based on 37 studies; 18 prospective observational, 19 retrospective observational. None of the studies provided sufficient evidence to fully address the clinical questions. Risk factors identified from historical and physical examination features included a history of prematurity, multiple ALTEs, and suspected child maltreatment. Routine screening tests for gastroesophageal reflux, meningitis, bacteremia, and seizures are low yield in infants without historical risk factors or suggestive physical examination findings. ConclusionSome historical and physical examination features can be used to identify risk in infants who are well-appearing and without a clear etiology at presentation, and testing tailored to these risks may be of value. The true risk of a subsequent event or underlying disorder cannot be ascertained. A more precise definition of an ALTE is needed and further research is warranted. (J Pediatr 2013;163:94-9).

Management of Apparent Life-Threatening Events in Infants: A Systematic Review

To determine in patients who are well-appearing and without a clear etiology after an apparent life-threatening event (ALTE): (1) What historical and physical examination features suggest that a child is at risk for a future adverse event and/or serious underlying diagnosis and would, therefore, benefit from testing or hospitalization? and (2) What testing is indicated on presentation and during hospitalization? Systematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE. The final analysis was based on 37 studies; 18 prospective observational, 19 retrospective observational. None of the studies provided sufficient evidence to fully address the clinical questions. Risk factors identified from historical and physical examination features included a history of prematurity, multiple ALTEs, and suspected child maltreatment. Routine screening tests for gastroesophageal reflux, meningitis, bacteremia, and seizures are low yield in infants without historical risk factors or suggestive physical examination findings. Some historical and physical examination features can be used to identify risk in infants who are well-appearing and without a clear etiology at presentation, and testing tailored to these risks may be of value. The true risk of a subsequent event or underlying disorder cannot be ascertained. A more precise definition of an ALTE is needed and further research is warranted.

Pediatrics Digest

Pediatrics Digest| July 01 2012 Pediatrics Digest Pediatrics (2012) 130 (1): D1–D6. https://doi.org/10.1542/peds.digest1301 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Pediatrics Digest. Pediatrics July 2012; 130 (1): D1–D6. 10.1542/peds.digest1301 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP Grand RoundsAAP NewsAll AAP Sites Search Advanced Search Topics: attention-deficit/hyperactivity disorder, infant, premature, obesity, trend, apparent life-threatening events in infants, central line-associated bloodstream infection, necrotizing enterocolitis, celiac disease, central nervous system stimulants, fatigue Numerous studies report disparate use of dental services among poor children. National estimates vary based on the data source, and little is known about how age, race, and health plan affect use of dental services among Medicaid-enrolled children. Based on of Medicaid claims, dental services improved since 2002 but varied substantially by state, age, and type of insurance. Children entering school had the highest prevalence of care as did children in primary care case management and health maintenance organizations. Overall antibiotic prescribing rates for children declined throughout the 1990s and early 2000s. These declines were concurrent with changes in practice related to acute otitis media, the most common reason for antibiotic treatment in young children. The downward trend in antibiotic-dispensing rates to young children in 16 Massachusetts communities ended by 2004–2005 and remained stable thereafter. This trend was driven by a declining otitis media diagnosis rate. Antibiotic treatment of diagnosed... You do not currently have access to this content.

Apparent Life-Threatening Events in Infants: Deciphering Need for Admission

To identify factors that predict safe emergency department (ED) discharge of infants with apparent life-threatening events (ALTEs), investigators prospectively enrolled 832 patients (median age, 31 days) who presented to four EDs during a 28-month period with at least two ALTE criteria (breathing irregularity, color change, or marked change in muscle tone). Patients were …

Apparent life-threatening events in infants and homeopathy: An alternative explanation

A recent report showed increased frequency of apparent life-threatening events (ALTEs) in infants treated with the homeopathic medication GaliCol-Baby (GCB). The premise was that the ALTEs resulted from toxic effects of the drug's components. We examine an alternative explanation. The toxicological literature was searched for known reactions to the various GCB components, noting doses and reported symptoms. Dosage quantities and severity of reaction to the GCB were ranked independently by two groups of physicians, and a dose-response curve was generated. Reported toxic doses and symptoms were compared with those of the GCB series. The homeopathic literature was searched as well to determine the propensity of the GCB components to cause ALTE symptoms, when given in homeopathic doses to healthy volunteers (proving). Doses ingested in the GCB series were 10-13 orders of magnitude smaller than those reported to cause toxic reactions in humans. There was poor correlation between symptoms with GCB and toxic profiles of the components. A nonsignificant, inverse relationship between dose and severity of reaction was observed. Conversely, four GCB components (in homeopathic doses) had a high propensity to produce at least one of five symptoms which define ALTE, two of which had intermediate to high propensity to produce three symptoms. It is unlikely that the ALTE following ingestion of GCB was a toxic reaction to any of the drug's component. Homeopathic theory may explain this linkage, though further research is needed to understand the pathogenic effects of highly diluted homeopathic compounds.

Role of rhinovirus C in apparently life-threatening events in infants, Spain.

To assess whether infants hospitalized after an apparently life-threatening event had an associated respiratory virus infection, we analyzed nasopharyngeal aspirates from 16 patients. Nine of 11 infants with positive virus results were infected by rhinoviruses. We detected the new genogroup of rhinovirus C in 6 aspirates.

Role of Rhinovirus C in Apparently Life-Threatening Events in Infants, Spain

To assess whether infants hospitalized after an apparently life-threatening event had an associated respiratory virus infection, we analyzed nasopharyngeal aspirates from 16 patients. Nine of 11 infants with positive virus results were infected by rhinoviruses. We detected the new genogroup of rhinovirus C in 6 aspirates.

Apparent Life-Threatening Events: Neurological Correlates and the Mandatory Work-Up

The purpose of this study was to estimate the prevalence of neurological causes for apparent life-threatening events in infants and assess the neurological work-up mandatory to diagnose such diagnosis, hypothesizing that acute neurological disorders constitute the most common etiology for such an acute event. A retrospective chart review allocated 93 infants fulfilling the criteria of the National Institutes of Health presenting at 1 week to 8 months with apnea, color changes, gagging, unresponsiveness, and alterations of body tone. An underlying neurological etiology was detected in 18 (19%), whereby 15 had seizures and 3 had central apnea. Only one electroencephalography demonstrated epileptic discharges, and brain imaging was intact. Thus, it has been concluded that neurological impairment, mainly that of seizures inducing an apparent life-threatening event, are relatively uncommon. As such, recommendations are that history taking and repeat physical examination still remain the major diagnostic tools before resorting to extensive laboratory studies.

Accidental and Nonaccidental Poisonings as a Cause of Apparent Life-Threatening Events in Infants

Apparent life-threatening events are a relatively common event in children for which there may be a number of causes. Previous reports have suggested that poisonings, either accidental or intentional, may be causes of some events. However, this theory has not been systematically studied. We conducted a prospective, descriptive study of infants aged <2 years presenting to a pediatric emergency department of a large, urban tertiary care children's hospital with signs and symptoms of an apparent life-threatening event. All of the children presenting with an apparent life-threatening event were to undergo a standardized evaluation, which included obtaining a comprehensive urine toxicology screen. A positive toxicology screen result was defined as follows: a clinically insignificant screen result (identification of a medication that would not cause an apparent life-threatening event) or a clinically significant screen result (identification of a medication that could cause apnea or other event consistent with an apparent life-threatening event, even if it was a medication that the child was known to be taking). During the study period, 596 children presented to the emergency department with an apparent life-threatening event, and 274 (46.0%) had a toxicology screen performed. Of 274 toxicology screen results, 50 were considered truly positive (18.2%), and 23 positive screen results were considered clinically significant (23 of 274 [8.4%]). Thirteen toxicology screen results were positive for an over-the-counter cold preparation (13 of 274 [4.7%]). No parent admitted to having given his or her child an over-the-counter cold preparation. A substantial number of children presenting to the emergency department with an apparent life-threatening event had a positive toxicology screen result. In particular, a number of children were found to have been given an over-the-counter cold preparation. We would recommend that toxicology screens be included as part of the routine evaluation of children who present with an apparent life-threatening event.

Death, Child Abuse, and Adverse Neurological Outcome of Infants After an Apparent Life-Threatening Event

Apparent life-threatening events in infants constitute a significant challenge for health care providers. Apparent life-threatening event evaluation and management are poorly defined, and outcomes have not been clearly determined. Our objectives were to characterize short- and long-term risks for death, child abuse, and abnormal neurological outcomes of infants after an apparent life-threatening event and to identify clinical features that are predictive of these outcomes. We collected data from infants ages birth to 12 months of age who were hospitalized after an apparent life-threatening event during a 5-year time period. Patients were evaluated for subsequent death, child abuse, or adverse neurological outcome (chronic epilepsy or developmental delay). A total of 471 patients met inclusion criteria and were followed an average of 5.1 years. Two patients died after developing chronic epilepsy and severe developmental delay. Fifty-four (11%) patients were diagnosed as being a victim of child abuse, but only 2 were identified at initial presentation. There were 23 (4.9%) patients with adverse neurological outcomes, including 17 (3.6%) with chronic epilepsy and 14 (3.0%) with developmental delay. Of those who developed chronic epilepsy, 71% returned within 1 month of the initial apparent life-threatening event with a second event. Neurological evaluation at the time of the apparent life-threatening event had low yield for predicting those who would develop chronic epilepsy. Infants who suffer an apparent life-threatening event are at risk for subsequent child abuse and adverse neurological outcomes. Deaths were uncommon and only occurred in the setting of severe developmental delay and seizure disorders. Neurological evaluation during hospitalization for a first apparent life-threatening event is of low yield, but close follow-up is essential.

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.

Idiopathic Generalized Epilepsies: A Review and Modern Approach

Idiopathic Generalized Epilepsies: A Review and Modern Approach

Laryngeal Electromyographic, Cardiovascular, and Respiratory Effects of Neuropeptide Injections into the Nucleus Tractus Solitarius of Rats

Identifying central neurotransmitters that mediate laryngeal adductor activity may aid in managing pathological laryngeal adduction as occurs in laryngospasm or apparent life-threatening events in infants. We studied the effect on cricothyroid (CT) and thyroarytenoid (TA) electromyography (EMG) and on cardiovascular parameters of neurotransmitter injections into the rat nucleus tractus solitarius (NTS), the primary sensory relay center of the larynx. Twenty nanoliters of vasoactive intestinal peptide (VIP; 2.5 pmol), neurokinin B (NKB, 16 pmol), calcitonin gene-related peptide (3.0 pmol), neurokinin A (NKA; 35 pmol), or artificial cerebrospinal fluid (control solution) was stereotactically injected into the region of the NTS and the control nucleus gracilis in 119 studies performed in 24 mature, anesthetized Sprague-Dawley rats. Changes in diaphragm, CT, and TA EMG activity and blood pressure (BP) were compared. Injection sites were verified histologically. Injections of both VIP and NKB into the region of the NTS, but not the nucleus gracilis, induced life-threatening changes, including apnea, a marked decline in BP (p < .05), and increases in EMG activity of the CT and TA adductor muscles ranging from sustained contraction to mild phasic increases during inspiration. Calcitonin gene-related peptide injection also decreased BP (p < .05), but caused only mild increases in CT and TA EMG activity. NKA and control injections into the NTS did not alter respiration, BP, or CT or TA EMG activity. VIP and NKB may play important roles in modulating EMG activity of the CT and TA muscles. This information may prove useful in evaluating pharmacological targets of central reflex activity to manage life-threatening laryngeal adduction.