Increased incidence of apparently life-threatening events due to supine position

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

AIM

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Role of pneumography and esophageal pH monitoring in the evaluation of infants with apparent life-threatening event: a prospective observational study

OBJECTIVE

To determine if a positive result on pneumography, diagnosis of gastroesophageal reflux disease (GERD), or nontreatment of those diagnosed with GERD with antireflux medications predicts an increased recurrence risk of apparent life-threatening event (ALTE) over the first 4 weeks of follow-up.

METHODS

Secondary analysis of a prospective, observational study of 300 infants diagnosed with ALTE.

RESULTS

The relative risk of recurrent ALTE was 1.26 (95% confidence interval = 0.47-3.38) among infants with an abnormal versus normal result on pneumography, 1.98 (1.02-3.86) among those diagnosed with GERD versus those not, and 0.46 (0.20-1.03) among those with GERD and started on antireflux medications versus those not started on such medications.

CONCLUSIONS

Positive pneumography for apnea or reflux does not predict an increase in recurrence rate of an ALTE. Infants diagnosed with GERD are more likely to have recurrent ALTE; treatment with antireflux medications may reduce this risk.

Consequences of the "back to sleep" program in infants

Sudden infant death syndrome (SIDS) is the third leading cause of infant mortality in the United States and the leading cause of death among infants 28-364 days of age. The "Back to Sleep" program was implemented in 1992 to promote supine sleeping in efforts to prevent SIDS. Along with this implementation came several consequences that are avoidable in infants. The purposes of this article are to describe the Back to Sleep program and its intended purpose, to identify the adverse consequences, and to develop a teaching program for nurse practitioners to use with parents that will both promote safe sleeping and reduce the untoward consequences of the back to sleep program while maintaining the integrity of the SIDS prevention advice.

[Epidemiological characteristics and risk factors for apparent life-threatening events]

INTRODUCTION

To report our experience with a guideline approach for the assessment of apparent life-threatening events (ALTE) in our pediatric emergency departments (PED), to know their incidence, epidemiological characteristics and the yield of laboratory investigations (LI).

PATIENTS AND METHODS

Prospective, case-control study of a guideline approach for infants under age 12 months who suffered an ALTE between 01/06/06 and 31/05/07 and were attended at our PEDs. We ordered LI as a function of the clinical history. All the cases were admitted for a minimum of 12h. We conducted a telephone interview at 12 months.

RESULTS

Fifty ALTE were included, corresponding to an incidence of 5 per thousand live births. The median age was 8.46+/-8.7 weeks. Compared to controls they had significantly more primogenits and previous behavioral abnormalities. Only 13 presented significant abnormalities at examination, and 6 had recurrent ALTE at the PED. LI were abnormal in 41 (82%), but only in 8 cases did they contribute to a secondary diagnosis. There were 29 idiopathic ALTE (58%). Twenty one (42%) had associated conditions, who had smoked significantly more during pregnancy, age older than 12 weeks and abnormalities at examination. Four had recurrence of the episodes: one suffered a sudden infant death syndrome (SIDS). At 12 months the cases had a significantly higher incidence of recurrent vomiting, breath holding spells and weight-psychomotor retardation.

CONCLUSIONS

The ALTE incidence was 5 per thousand live births. Primogenits and/or behavioral abnormalities were most frequent during the first weeks after birth and/or thereafter at 12 months of age. A total of 42% had a related diagnosis: associated with age older than 12 weeks, maternal smoking habits and abnormalities at examination. There was one case of SIDS. Laboratory investigations had a low yield.

Perfil epidemiológico de crianças com Apparent Life Threatening Event (ALTE) e avaliação prospectiva da etiologia determinante do episódio

OBJETIVO: determinar a causa de ALTE (apparent life threatening events - eventos com aparente risco de vida) em crianças encaminhadas à emergência de hospital terciário e sua associação com características clínicas, recorrência e morbidade. MÉTODOS: estudo transversal com coleta prospectiva de dados através de anamnese, exame físico e aplicação de protocolo específico para identificação etiológica de ALTE. Após inclusão no estudo os pacientes foram seguidos ambulatorialmente para verificação de morte súbita inexplicada. As variáveis com significância estatística foram incluídas em modelo de regressão linear. RESULTADOS: trinta crianças foram incluídas entre setembro de 2004 e março de 2006, constituindo 4,2% das internações pediátricas no mesmo período. Houve predomínio no sexo masculino (73%) e nascidos a termo (70%). Em 80% dos pacientes o primeiro episódio foi observado até os três meses de idade, predominantemente em vigília (83%). Dos casos estudados, 50% foram considerados ALTE idiopático, 20% causados pelo refluxo gastroesofágico (RGE) e 10%, por epilepsia. O seguimento evidenciou um caso de recorrência e óbito. CONCLUSÕES: a prevalência, etiologia e frequência de casos de ALTE encontradas assemelham-se aos da literatura. As variáveis estudadas não foram preditivas quanto à recorrência do episódio, mas o tratamento específico foi determinante no seu controle.

Sudden infant death syndrome: another year of new hope but no cure

PURPOSE OF REVIEW

Sudden infant death syndrome has inspired increasingly sophisticated studies at a time when rates are declining because of the Back-to-Sleep campaign, but ethnic disparities are widening. This review evaluates and discusses original, recent research in this area.

RECENT FINDINGS

The epidemiology of sudden infant death syndrome was evaluated, corroborating known risk factors and identifying new risk factors such as socioeconomic depression and air pollution. Deficits in our understanding of risk factors for this syndrome persist, suggesting a need for ethnicity-specific education, especially among the underserved. Both autopsy and genetic testing were found to improve diagnostic accuracy or identify other causes of death (e.g. long Q-T syndrome). Debate persists over counseling regarding pacifiers and co-sleeping within the context of breastfeeding. Support was found for a relationship between sudden infant death syndrome and autonomic dysregulation via the serotonergic pathway, but more research is needed.

SUMMARY

The cause of sudden infant death syndrome remains elusive. Recent studies, however, suggest that improved culturally sensitive educational programs, increased diagnostic specificity, and further clarification of the link between genetics and developmental stage might further decrease the number of infants lost to this devastating disease and elucidate the mechanism(s) responsible for this syndrome.