Idiopathic apparent life-threatening event in Northern Israel

Apparent life-threatening events: assessment, risks, reality

Apparent life-threatening events (ALTEs), because of their prevalence as well as their potential to hide serious diseases and consume significant medical resources, remain a challenge for physicians caring for infants. In this review, we focused on the assessment of the well-appearing infant for the most serious diagnoses, namely serious bacterial infections, seizure disorders, child abuse, metabolic disorders and severe apnoea with hypoxemia. Our extensive review of the literature has highlighted the difficulties physicians are facing in this evaluation, especially for the youngest infants (aged less than 2 months). Large-scale prospective studies are needed to identify risk factors and to guide physicians as to who should be investigated and the minimal investigation needed to avoid missing such conditions as serious bacterial infection, abusive head injury or repeated severe cardiorespiratory events. While infants with severe forms of metabolic disorders typically present with evident signs and symptoms, less severe forms of metabolic disorders, seizure disorders, and some forms of child abuse will often be diagnosed only when recurrent events are investigated.

[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.

Assessment and management of infants with apparent life-threatening events in the paediatric emergency department

OBJECTIVE

To report our experience with a guideline approach for the assessment of apparent life-threatening events (ALTE) at our paediatric emergency department (PED).

METHODS

Prospective observational case series study of a guideline approach for infants under the age of 12 months who suffered an ALTE between 1 April 2005 and 31 June 2006.

RESULTS

A total of 66 infants with ALTE were included. Fourteen had perinatal risk factors and 16 previous ALTE. Only 14 presented significant abnormalities at examination at the PED. Eight had recurrent ALTE at the PED. Laboratory investigations were abnormal in 35 infants. A total of 45 infants were admitted. Associated conditions (secondary ALTE) were reported in 24 infants (36%), mostly respiratory infections and gastroesophageal reflux. Laboratory investigations contributed to a related diagnosis in nine cases. Compared with idiopathic group, the secondary ALTE sufferers had more perinatal risk factors, more abnormal examination findings, higher risk of recurrence and more frequent need for intervention in the PED.

CONCLUSION

Most infants with a first episode of ALTE have normal physical examination. The absence of data suggesting underlying disease, after detailed history and examination, identifies a pool of infants who may be handled conservatively. This group may be monitored as outpatients after keeping them under watch for a short time at the emergency unit, thus avoiding unnecessary admissions. The low yield of laboratory tests in this group suggests that they could be safely omitted in most ALTE and restricted to cases with risk factors and/or whose progress at the observation unit is not satisfactory.