1
|
Vigne MH, Moreau M, Gascoin G, Darviot E. Descriptive analysis of infant population younger than 1 year admitted for BRUE. Arch Pediatr 2023:S0929-693X(23)00026-X. [PMID: 37069022 DOI: 10.1016/j.arcped.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 11/20/2022] [Accepted: 02/12/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION In 2016, the American Academy of Pediatrics defined the brief resolved unexplained event (BRUE) of high and low risk to characterize fainting in infants under 1 year of age. In the case of low-risk BRUE, it is recommended to perform no further systematic examination, but to monitor the child with a saturometer in the emergency room for 1-4 h. OBJECTIVE The objective of this study was to identify events corresponding to high- and low-risk BRUE criteria for infants admitted to the Angers University Hospital Center, and to analyze their medical care. METHOD We conducted an observational, retrospective, descriptive and single-center study of the population of infants younger than 1 year admitted for an unexplained event to the Pediatric Emergency Department of Angers University Hospital Center between 1 January 2017 and 31 December 2019. Two patient databases were crossed to identify patients. RESULTS Among the 203 patients presenting for fainting, 54 patients met the criteria for BRUE, including 40 high-risk BRUE and 14 low-risk BRUE cases. All complementary examinations performed on low-risk BRUE children were normal. Two of these patients had a recurrence of non-severe fainting several months after the first episode. CONCLUSION Identification of infants according to the BRUE criteria helps to harmonize practices and to limit the number of complementary examinations or hospitalizations for low-risk BRUE.
Collapse
Affiliation(s)
- M H Vigne
- Centre Hospitalier Universitaire d'Angers, 49100 Angers, France.
| | - M Moreau
- Centre Hospitalier Universitaire d'Angers, 49100 Angers, France
| | - G Gascoin
- Centre Hospitalier Universitaire d'Angers, 49100 Angers, France
| | - E Darviot
- Centre Hospitalier Universitaire d'Angers, 49100 Angers, France
| |
Collapse
|
2
|
Doswell A, Anderst J, Tieder JS, Herman BE, Hall M, Wilkins V, Knochel ML, Kaplan R, Cohen A, DeLaroche AM, Harper B, Mittal MK, Shastri N, Prusakowski M, Puls HT. Diagnostic testing for and detection of physical abuse in infants with brief resolved unexplained events. CHILD ABUSE & NEGLECT 2023; 135:105952. [PMID: 36423537 DOI: 10.1016/j.chiabu.2022.105952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 11/03/2022] [Accepted: 11/08/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND A Brief Resolved Unexplained Event (BRUE) can be a sign of occult physical abuse. OBJECTIVES To identify rates of diagnostic testing able to detect physical abuse (head imaging, skeletal survey, and liver transaminases) at BRUE presentation. The secondary objective was to estimate the rate of physical abuse diagnosed at initial BRUE presentation through 1 year of age. PARTICIPANTS AND SETTING Infants who presented with a BRUE at one of 15 academic or community hospitals were followed from initial BRUE presentation until 1 year of age for BRUE recurrence or revisits. METHODS This study was part of the BRUE Research and Quality Improvement Network, a multicenter retrospective cohort examining infants with BRUE. Generalized estimating equations assessed associations with performance of diagnostic testing (adjusted odds ratio (aOR)). RESULTS Of the 2036 infants presenting with a BRUE, 6.2 % underwent head imaging, 7.0 % skeletal survey, and 12.1 % liver transaminases. Infants were more likely to undergo skeletal survey if there were physical examination findings concerning for trauma (aOR 8.23, 95 % CI [1.92, 35.24], p < 0.005) or concerning social history (aOR 1.89, 95 % CI [1.13, 3.16], p = 0.015). There were 7 (0.3 %) infants diagnosed with physical abuse: one at BRUE presentation, one <3 days after BRUE presentation, and five >30 days after BRUE presentation. CONCLUSION There were low rates of diagnostic testing and physical abuse identified in infants presenting with BRUE. Further study including standardized testing protocols is warranted to identify physical abuse in infants presenting with a BRUE.
Collapse
Affiliation(s)
- Angela Doswell
- Division of Child Abuse and Neglect, Department of Pediatrics, Connecticut Children's Medical Center and University of Connecticut School of Medicine, 282 Washington Street, Hartford, CT 06106, United States of America.
| | - James Anderst
- Division of Child Adversity and Resilience, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri and University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
| | - Joel S Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital and School of Medicine, University of Washington, 4800 Sand Point Way NE, Seattle, WA 98105, United States of America
| | - Bruce E Herman
- Division of Pediatric Emergency Medicine, Primary Children's Hospital and University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States of America
| | - Matt Hall
- Children's Hospital Association, 16011 College Boulevard, Lenexa, KS 66219, United States of America
| | - Victoria Wilkins
- Division of Pediatric Hospital Medicine, Primary Children's Hospital and University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States of America
| | - Miguel L Knochel
- Division of Pediatric Hospital Medicine, Primary Children's Hospital and University of Utah, 100 North Mario Capecchi Drive, Salt Lake City, UT 84113, United States of America
| | - Ron Kaplan
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, United States of America
| | - Adam Cohen
- Division of Hospital Medicine, Department of Pediatrics and Department of Education, Innovation and Technology, Baylor College of Medicine and Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, United States of America
| | - Amy M DeLaroche
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48201, United States of America
| | - Beth Harper
- Division of Hospital Medicine, Department of Pediatrics, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, United States of America
| | - Manoj K Mittal
- Division of Emergency Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, 3401 Civic Center Boulevard, Philadelphia, PA 19104, United States of America
| | - Nirav Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri and University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
| | - Melanie Prusakowski
- Department of Emergency Medicine, Carilion Children's Hospital, 1906 Belleview Avenue SE, Roanoke, VA 24014, United States of America
| | - Henry T Puls
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri and University of Missouri-Kansas City, 2401 Gillham Road, Kansas City, MO 64108, United States of America
| |
Collapse
|
3
|
Bochner R, Tieder JS, Sullivan E, Hall M, Stephans A, Mittal MK, Singh N, Delaney A, Harper B, Shastri N, Hochreiter D, Neuman MI. Explanatory Diagnoses Following Hospitalization for a Brief Resolved Unexplained Event. Pediatrics 2021; 148:peds.2021-052673. [PMID: 34607936 DOI: 10.1542/peds.2021-052673] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Most young infants presenting to the emergency department (ED) with a brief resolved unexplained event (BRUE) are hospitalized. We sought to determine the rate of explanatory diagnosis after hospitalization for a BRUE. METHODS This was a multicenter retrospective cohort study of infants hospitalized with a BRUE after an ED visit between October 1, 2015, and September 30, 2018. We included infants without an explanatory diagnosis at admission. We determined the proportion of patients with an explanatory diagnosis at the time of hospital discharge and whether diagnostic testing, consultation, or observed events occurring during hospitalization were associated with identification of an explanatory diagnosis. RESULTS Among 980 infants hospitalized after an ED visit for a BRUE without an explanatory diagnosis at admission, 363 (37.0%) had an explanatory diagnosis identified during hospitalization. In 805 (82.1%) infants, diagnostic testing, specialty consultations, and observed events did not contribute to an explanatory diagnosis, and, in 175 (17.9%) infants, they contributed to the explanatory diagnosis (7.0%, 10.0%, and 7.0%, respectively). A total of 15 infants had a serious diagnosis (4.1% of explanatory diagnoses; 1.5% of all infants hospitalized with a BRUE), the most common being seizure and infantile spasms, occurring in 4 patients. CONCLUSIONS Most infants hospitalized with a BRUE did not receive an explanation during the hospitalization, and a majority of diagnoses were benign or self-limited conditions. More research is needed to identify which infants with a BRUE are most likely to benefit from hospitalization for determining the etiology of the event.
Collapse
Affiliation(s)
- Risa Bochner
- State University of New York Downstate Health Sciences University and Department of Pediatrics, New York City Health and Hospitals Kings County, Brooklyn, New York
| | - Joel S Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's and School of Medicine, University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Allayne Stephans
- Division of Pediatric Hospital Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Manoj K Mittal
- Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nidhi Singh
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Atima Delaney
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Beth Harper
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Nirav Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | - Daniela Hochreiter
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | | |
Collapse
|
4
|
Brand DA, Mock A, Cohn E, Krilov LR. Implementing the 2016 American Academy of Pediatrics Guideline on Brief Resolved Unexplained Events: The Parent's Perspective. Pediatr Emerg Care 2021; 37:e243-e248. [PMID: 30399064 DOI: 10.1097/pec.0000000000001659] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A "brief resolved unexplained event" refers to sudden alterations in an infant's breathing, color, tone, or responsiveness that prompt the parent or caregiver to seek emergency medical care. A recently published clinical practice guideline encourages discharging many of these infants home from the emergency department if they have a benign presentation. The goal is to avoid aggressive inpatient investigations of uncertain benefit. The present research explored parents' reactions to the prospect of returning home with their infant following such an event. METHODS The study used qualitative research methods to analyze semistructured, audio-recorded interviews of parents who had witnessed a brief resolved unexplained event between 2011 and 2015 and taken their infant to the emergency department of an academic teaching hospital. RESULTS A total of 22 parent interviews were conducted. The infants included 8 boys and 14 girls aged 3.6 ± 3.5 months (mean ± SD). Qualitative analysis of interview transcripts revealed a near-universal apprehension about the child's well-being, ambivalence about the best course of action after the evaluation in the emergency department, and need for reassurance about the unlikelihood of a recurrence. Parents did not, however, answer the main research question with a single voice: attitudes toward the return-home scenario ranged from unthinkable to extreme relief. Two-thirds of parents expressed at least some reservations about the idea of returning home. CONCLUSIONS Successful implementation of the 2016 guideline will require close attention to the parent's point of view. Otherwise, parental resistance is likely to compromise clinicians' best efforts.
Collapse
Affiliation(s)
| | - Ann Mock
- Department of Pediatrics, Children's Medical Center, NYU Winthrop Hospital, Mineola
| | - Elizabeth Cohn
- Center for Health Innovation, Adelphi University, Garden City, NY
| | | |
Collapse
|
5
|
Chaiyachati BH, Wood JN. Brief resolved unexplained events vs. child maltreatment: a review of clinical overlap and evaluation. Pediatr Radiol 2021; 51:866-871. [PMID: 33999231 DOI: 10.1007/s00247-020-04793-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/01/2020] [Accepted: 08/04/2020] [Indexed: 10/21/2022]
Abstract
Within their first year, a number of infants present for medical evaluation because of unexplained changes in color, tone, breathing, or level of responsiveness. This broad collection of symptoms has an accordingly large differential diagnosis that includes both brief resolved unexplained event (BRUE) and child maltreatment. The overlap between clinical presentation for BRUE and maltreatment can present a diagnostic challenge - especially given the significant consequences for infants and families for diagnostic error at that juncture. In this review, we provide overviews of the presenting features and findings in cases of BRUE and child maltreatment with a focus on areas of overlap and differentiation.
Collapse
Affiliation(s)
- Barbara H Chaiyachati
- Division of General Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.,Safe Place: The Center for Child Protection and Health, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Joanne N Wood
- Division of General Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA. .,Safe Place: The Center for Child Protection and Health, Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. .,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,PolicyLab, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| |
Collapse
|
6
|
Prezioso G, Perrone S, Biasucci G, Pisi G, Fainardi V, Strisciuglio C, Marzano FN, Moretti S, Pisani F, Tchana B, Argentiero A, Neglia C, Caffarelli C, Bertolini P, Bersini MT, Canali A, Voccia E, Squarcia A, Ghi T, Verrotti C, Frusca T, Cecchi R, Giordano G, Colasanti F, Roccia I, Palanza P, Esposito S. Management of Infants with Brief Resolved Unexplained Events (BRUE) and Apparent Life-Threatening Events (ALTE): A RAND/UCLA Appropriateness Approach. Life (Basel) 2021; 11:171. [PMID: 33671771 PMCID: PMC7926945 DOI: 10.3390/life11020171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/15/2022] Open
Abstract
Unexpected events of breath, tone, and skin color change in infants are a cause of considerable distress to the caregiver and there is still debate on their appropriate management. The aim of this study is to survey the trend in prevention, decision-making, and management of brief resolved unexplained events (BRUE)/apparent life-threatening events (ALTE) and to develop a shared protocol among hospitals and primary care pediatricians regarding hospital admission criteria, work-up and post-discharge monitoring of patients with BRUE/ALTE. For the study purpose, a panel of 54 experts was selected to achieve consensus using the RAND/UCLA appropriateness method. Twelve scenarios were developed: one addressed to primary prevention of ALTE and BRUE, and 11 focused on hospital management of BRUE and ALTE. For each scenario, participants were asked to rank each option from '1' (extremely inappropriate) to '9' (extremely appropriate). Results derived from panel meeting and discussion showed several points of agreement but also disagreement with different opinion emerged and the need of focused education on some areas. However, by combining previous recommendations with expert opinion, the application of the RAND/UCLA appropriateness permitted us to drive pediatricians to reasoned and informed decisions in term of evaluation, treatment and follow-up of infants with BRUE/ALTE, reducing inappropriate exams and hospitalisation and highlighting priorities for educational interventions.
Collapse
Affiliation(s)
- Giovanni Prezioso
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | - Serafina Perrone
- Unit of Neonatology, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.P.); (S.M.); (F.C.); (I.R.)
| | - Giacomo Biasucci
- Pediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29122 Piacenza, Italy;
| | - Giovanna Pisi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | - Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Francesco Nonnis Marzano
- Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, 43126 Parma, Italy;
| | - Sabrina Moretti
- Unit of Neonatology, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.P.); (S.M.); (F.C.); (I.R.)
| | - Francesco Pisani
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | | | - Alberto Argentiero
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | - Cosimo Neglia
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | - Carlo Caffarelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | | | - Maria Teresa Bersini
- Primary Care Pediatrics, AUSL of Parma, 43126 Parma, Italy; (M.T.B.); (A.C.); (E.V.)
| | - Andrea Canali
- Primary Care Pediatrics, AUSL of Parma, 43126 Parma, Italy; (M.T.B.); (A.C.); (E.V.)
| | - Emanuele Voccia
- Primary Care Pediatrics, AUSL of Parma, 43126 Parma, Italy; (M.T.B.); (A.C.); (E.V.)
| | - Antonella Squarcia
- Unit of Neuropsychiatry of Children and Adolescents, AUSL Parma, 43126 Parma, Italy;
| | - Tullio Ghi
- Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (T.G.); (T.F.)
| | | | - Tiziana Frusca
- Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (T.G.); (T.F.)
| | - Rossana Cecchi
- Legal Medicine Section, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Giovanna Giordano
- Pathology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Filomena Colasanti
- Unit of Neonatology, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.P.); (S.M.); (F.C.); (I.R.)
| | - Ilenia Roccia
- Unit of Neonatology, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.P.); (S.M.); (F.C.); (I.R.)
| | - Paola Palanza
- Unit of Neuroscience, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| |
Collapse
|
7
|
Carbayo Jiménez T, Romero PC, Sánchez IG. Replacing “Apparent Life Threatening Event” (ALTE) with “Brief Resolved Unexplained Event” (BRUE). A retrospective review of the ALTEs that meet the criteria of a BRUE. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2020; 93:261-262. [DOI: 10.1016/j.anpede.2019.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 12/17/2019] [Indexed: 10/23/2022] Open
|
8
|
Sustitución de ALTE por BRUE: revisión retrospectiva de los ALTE que cumplen criterios de BRUE. An Pediatr (Barc) 2020; 93:261-262. [DOI: 10.1016/j.anpedi.2019.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 12/15/2019] [Accepted: 12/17/2019] [Indexed: 11/22/2022] Open
|
9
|
Alhaboob AA. Clinical Characteristics and Outcomes of Patients Admitted with Brief Resolved Unexplained Events to a Tertiary Care Pediatric Intensive Care Unit. Cureus 2020; 12:e8664. [PMID: 32699664 PMCID: PMC7370642 DOI: 10.7759/cureus.8664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to determine outcomes of patients admitted to a tertiary care pediatric intensive care unit (PICU) with brief, resolved, unexplained event (BRUE), and to review the diagnostic and treatment options utilized for such patients. A retrospective data analysis was conducted for infants and children who were admitted to the PICU at a tertiary hospital with a diagnosis of BRUE over a period of three years (2015-2017). The study included 30 infants, 15 males, and 15 females. All patients survived to hospital discharge. The most frequent presenting symptoms and signs were apnea (73.3%), cyanosis (60.0%), and cough (20.0%). The most frequent reported affected systems were respiratory (33.3%), gastrointestinal (20%), and infection-related illness (20.0%). We conclude that the careful history taking, complete physical examination, and the appropriate workup for patients with BRUE play an integral role in optimum health service and utilization of critical care beds. Survival to hospital discharge with no serious in-hospital events warrants the adaptation of evidence-based medicine guidelines to stratify such patients based on the risk of recurrence or a serious underlying condition. Prospective multicenter studies are recommended to explore the effectiveness of such guidelines implementation on outcomes and diagnostic testing in such patients to optimize the utilization of the limited critical care beds.
Collapse
|
10
|
Dugue R, Cay-Martínez KC, Thakur KT, Garcia JA, Chauhan LV, Williams SH, Briese T, Jain K, Foca M, McBrian DK, Bain JM, Lipkin WI, Mishra N. Neurologic manifestations in an infant with COVID-19. Neurology 2020; 94:1100-1102. [PMID: 32327489 PMCID: PMC7455334 DOI: 10.1212/wnl.0000000000009653] [Citation(s) in RCA: 99] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 04/17/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
- Rachelle Dugue
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY.
| | - Karla C Cay-Martínez
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - Kiran T Thakur
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - Joel A Garcia
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - Lokendra V Chauhan
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - Simon H Williams
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - Thomas Briese
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - Komal Jain
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - Marc Foca
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - Danielle K McBrian
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - Jennifer M Bain
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - W Ian Lipkin
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| | - Nischay Mishra
- From the Department of Neurology (R.D., K.C.C.-M., K.T.T., D.K.M., J.M.B.), Columbia University Irving Medical Center; Center for Infection and Immunity (J.A.G., L.V.C., S.H.W., T.B., K.J., W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Epidemiology (W.I.L., N.M.), Mailman School of Public Health, Columbia University; Department of Pediatric Infectious Disease (M.F.), Columbia University Irving Medical Center; and New York Presbyterian Hospital (R.D., K.C.C.-M., K.T.T., M.F., D.K.M., J.M.B.), Columbia University Medical Center, New York, NY
| |
Collapse
|
11
|
Ginsburg D, Maken K, Deming D, Welch M, Fargo R, Kaur P, Terry M, Tinsley L, Ischander M. Etiologies of apnea of infancy. Pediatr Pulmonol 2020; 55:1495-1502. [PMID: 32289209 DOI: 10.1002/ppul.24770] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND To date there are limited data in the literature to guide the initial evaluation for etiologies of apnea in full-term infants born at greater than or equal to 37 weeks conceptional age (apnea of infancy [AOI]). Pediatricians and pediatric pulmonologists are left to pursue a broad, rather than targeted and a stepwise approach to begin diagnostic evaluation. METHODS We performed a retrospective chart review of 101 symptomatic full-term infants (age under 12 months) diagnosed with apnea with an inpatient multichannel pneumogram (six channels) or a fully attended overnight pediatric polysomnogram in our outpatient sleep center accredited by American Academy of Sleep Medicine (AASM), scored using the standards set forth by the AASM. The infant was diagnosed as having AOI if the apnea hypopnea index (AHI) was greater than 1 (AHI is defined as the number of apnea and hypopnea events per hour of sleep). The final diagnosis/etiology was determined based on physician clinical assessment and work up. We then determined the frequency for each diagnosis. RESULTS We found that the three most common etiologies were gastroesophageal reflux disease (GERD) (48/101), upper airway abnormalities/obstruction (37/101), and neurological diseases (19/101). There were significant numbers of infants with multiple etiologies for AOI. CONCLUSION Based on the frequencies obtained, pediatric practitioners caring for full-term infants with apnea of unknown etiology are advised to begin with evaluation of more likely causes such as GERD and upper airway abnormalities/obstruction before evaluating for less common causes.
Collapse
Affiliation(s)
- Daniella Ginsburg
- Department of Pediatrics, Division of Pediatric Pulmonology, Children's Hospital Los Angeles, Los Angeles, California
| | - Kanwaljeet Maken
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Loma Linda University Medical Center, Loma Linda, California
| | - Douglas Deming
- Department of Pediatrics, Division of Neonatology, Loma Linda University Children's Hospital, Loma Linda, California
| | - Mark Welch
- Department of Medicine and Psychiatry, Loma Linda University Medical Center, Loma Linda, California
| | - Ramiz Fargo
- Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Loma Linda University Medical Center, Loma Linda, California
| | | | - Michael Terry
- Pulmonary Physiology Laboratories, Loma Linda University, Loma Linda, California
| | - Larry Tinsley
- Department of Pediatrics, Division of Neonatology, Loma Linda University Children's Hospital, Loma Linda, California
| | - Mariam Ischander
- Department of Pediatrics and Adolescents, Homer Stryker MD School of Medicine, Western Michigan University, Kalamazoo, Michigan
| |
Collapse
|
12
|
Merritt JL, Quinonez RA, Bonkowsky JL, Franklin WH, Gremse DA, Herman BE, Jenny C, Katz ES, Krilov LR, Norlin C, Sapién RE, Tieder JS. A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event. Pediatrics 2019; 144:peds.2018-4101. [PMID: 31350360 DOI: 10.1542/peds.2018-4101] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/24/2019] [Indexed: 11/24/2022] Open
Abstract
In 2016, the American Academy of Pediatrics published a clinical practice guideline that more specifically defined apparent life-threatening events as brief resolved unexplained events (BRUEs) and provided evidence-based recommendations for the evaluation of infants who meet lower-risk criteria for a subsequent event or serious underlying disorder. The clinical practice guideline did not provide recommendations for infants meeting higher-risk criteria, an important and common population of patients. Therefore, we propose a tiered approach for clinical evaluation and management of higher-risk infants who have experienced a BRUE. Because of a vast array of potential causes, the initial evaluation prioritizes the diagnosis of time-sensitive conditions for which delayed diagnosis or treatment could impact outcomes, such as child maltreatment, feeding problems, cardiac arrhythmias, infections, and congenital abnormalities. The secondary evaluation addresses problems that are less sensitive to delayed diagnosis or treatment, such as dysphagia, intermittent partial airway obstruction, and epilepsy. The authors recommend a tailored, family-centered, multidisciplinary approach to evaluation and management of all higher-risk infants with a BRUE, whether accomplished during hospital admission or through coordinated outpatient care. The proposed framework was developed by using available evidence and expert consensus.
Collapse
Affiliation(s)
- J Lawrence Merritt
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - Ricardo A Quinonez
- Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Joshua L Bonkowsky
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah.,Brain and Spine Center, Primary Children's Hospital, Salt Lake City, Utah
| | - Wayne H Franklin
- Department of Pediatrics, Stritch School of Medicine, Loyola University, Maywood, Illinois
| | - David A Gremse
- Department of Pediatrics, University of South Alabama, Mobile, Alabama
| | - Bruce E Herman
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Carole Jenny
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Eliot S Katz
- Department of Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Leonard R Krilov
- Department of Pediatrics, New York University Winthrop, Mineola, New York; and
| | - Chuck Norlin
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Robert E Sapién
- Department of Emergency Medicine, Health Sciences Center, University of New Mexico, Albuquerque, New Mexico
| | - Joel S Tieder
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| |
Collapse
|
13
|
BRUE. JAAPA 2019; 32:14. [DOI: 10.1097/01.jaa.0000558360.08858.5b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
14
|
Brief resolved unexplained events in infants. JAAPA 2019; 32:38-40. [DOI: 10.1097/01.jaa.0000558336.70739.aa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
15
|
Colombo M, Katz ES, Bosco A, Melzi ML, Nosetti L. Brief resolved unexplained events: Retrospective validation of diagnostic criteria and risk stratification. Pediatr Pulmonol 2019; 54:61-65. [PMID: 30549452 DOI: 10.1002/ppul.24195] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/25/2018] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES This study retrospectively evaluated the AAP guidelines for diagnosis and risk stratification of Brief Resolved Unexplained Events (BRUE) in a well-characterized cohort of infants admitted with an Apparent Life Threatening Event (ALTE). Further, using prospective follow-up, we endeavored to determine the safety of implementing ambulatory care for the lower risk BRUE population (LR-BRUE) and estimate the cost-savings of this practice. METHODS Retrospective application of the BRUE criteria on infants younger than 12 months of age who had been admitted with an ALTE from 2006 to 2016 at a single tertiary care center in Lombardy, Italy. ALTE patients were classified into three groups; (1) Not a BRUE; (2) Lower-risk (LR)-BRUE; and (3) Higher-risk (HR)-BRUE. Patients were contacted prospectively to obtain long-term follow-up outcomes and medical records and billing databases were reviewed. RESULTS Among the 84 infants admitted for an ALTE, 35 (42%) were not a BRUE, 16 (19%) were a LR-BRUE, and 33 (39%) were a HR-BRUE. Only one of the LR-BRUE patients had a subsequent LR-BRUE event, and was later diagnosed with a seizure disorder. Two HR-BRUE babies had also previously presented with a LR-BRUE. Application of the LR-BRUE guidelines would have decreased health expenditure by 20%. There were no deaths or significant morbidities in either BRUE group. CONCLUSIONS Applying the recent AAP BRUE guidelines and risk stratification to a well-characterized cohort of admitted ALTE patients is a safe and cost-effective approach. Careful out-patient follow-up is recommended as one of our patients with a LR-BRUE had a recurrence, and was subsequently diagnosed with a seizure disorder.
Collapse
Affiliation(s)
- Marco Colombo
- Department of Pediatrics, ASST Sette Laghi, Del Ponte Hospital, Varese, Italy
| | - Eliot S Katz
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, Massachusetts
| | | | - Maria L Melzi
- Department of Pediatrics, MBBM Foundation, Monza, Italy
| | | |
Collapse
|
16
|
Tate C, Sunley R. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants. Arch Dis Child Educ Pract Ed 2018; 103:95-98. [PMID: 28923986 DOI: 10.1136/archdischild-2016-311249] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 05/02/2017] [Accepted: 05/14/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Chris Tate
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
| | - Rachel Sunley
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
| |
Collapse
|
17
|
Piumelli R, Davanzo R, Nassi N, Salvatore S, Arzilli C, Peruzzi M, Agosti M, Palmieri A, Paglietti MG, Nosetti L, Pomo R, De Luca F, Rimini A, De Masi S, Costabel S, Cavarretta V, Cremante A, Cardinale F, Cutrera R. Apparent Life-Threatening Events (ALTE): Italian guidelines. Ital J Pediatr 2017; 43:111. [PMID: 29233182 PMCID: PMC5728046 DOI: 10.1186/s13052-017-0429-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/22/2017] [Indexed: 02/07/2023] Open
Abstract
Five years after the first edition, we have revised and updated the guidelines, re-examining the queries and relative recommendations, expanding the issues addressed with the introduction of a new entity, recently proposed by the American Academy of Pediatrics: BRUE, an acronym for Brief Resolved Unexplained Events. In this manuscript we will use the term BRUE only to refer to mild, idiopathic cases rather than simply replace the acronym ALTE per se.In our guidelines the acronym ALTE is used for severe cases that are unexplainable after the first and second level examinations.Although the term ALTE can be used to describe the common symptoms at the onset, whenever the aetiology is ascertained, the final diagnosis may be better specified as seizures, gastroesophageal reflux, infection, arrhythmia, etc. Lastly, we have addressed the emerging problem of the so-called Sudden Unexpected Postnatal Collapse (SUPC), that might be considered as a severe ALTE occurring in the first week of life.
Collapse
Affiliation(s)
- Raffaele Piumelli
- Sleep Breathing Disorders and SIDS Center, Meyer Children's Hospital, Firenze, Italy.
| | - Riccardo Davanzo
- Department of Perinatal Medicine, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Niccolò Nassi
- Sleep Breathing Disorders and SIDS Center, Meyer Children's Hospital, Firenze, Italy
| | | | - Cinzia Arzilli
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Firenze, Italy
| | - Marta Peruzzi
- Sleep Breathing Disorders and SIDS Center, Meyer Children's Hospital, Firenze, Italy
| | - Massimo Agosti
- Neonatal Intensive Care Unit, Del Ponte Hospital, Varese, Italy
| | - Antonella Palmieri
- SIDS Center, Pediatric Emergency Department, "G. Gaslini" Children's Hospital, Genova, Italy
| | - Maria Giovanna Paglietti
- Pneumology Unit - University Hospital Pediatric Department, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Luana Nosetti
- Paediatric Department, University of Insubria, Varese, Italy
| | - Raffaele Pomo
- SIDS/ALTE Center, Buccheri la Ferla Hospital, Palermo, Italy
| | | | | | | | - Simona Costabel
- Emergency Department of Paediatrics, G. Gaslini Children's Hospital, Genova, Italy
| | | | - Anna Cremante
- National Neurological Institute IRCCS C, Mondino, Pavia, Italy
| | | | - Renato Cutrera
- Pneumology Unit - University Hospital Pediatric Department, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| |
Collapse
|
18
|
Abstract
OBJECTIVES The aim of the present study was to investigate the prevalence of oropharyngeal dysfunction with resultant aspiration in patients admitted after apparent life-threatening events (ALTE) and to determine whether historical characteristics could predict this oropharyngeal dysphagia and aspiration risk. METHODS We retrospectively reviewed the records of all patients admitted to Boston Children's Hospital between 2012 and 2015 with a diagnosis of ALTE to determine the frequency of evaluation for oropharyngeal dysphagia using video fluoroscopic swallow studies (VFSS) and clinical feeding evaluations, to determine the prevalence of swallowing dysfunction in subjects admitted after ALTE and to compare presenting historical characteristics to swallow study results. RESULTS A total of 188 children were admitted with a diagnosis of ALTE of which 29% (n = 55) had an assessment of swallowing by VFSS. Of those who had a VFSS, 73% (n = 40) had evidence of aspiration or penetration on VFSS. Of all of the diagnostic tests ordered on patients with ALTEs, the VFSS had the highest rate of abnormalities of any test ordered. None of the historical characteristics of ALTE predicted which patients were at risk for aspiration. In patients who had both clinical feeding evaluations and VFSS, observed clinical feedings incorrectly identified 26% of patients as having no oropharyngeal dysphagia when in fact aspiration was present on VFSS. CONCLUSIONS Oropharyngeal dysphagia with aspiration is the most common diagnosis identified in infants presenting with ALTEs. The algorithm for ALTE should be revised to include an assessment of VFSS as clinical feeding evaluations are inadequate to assess for aspiration.
Collapse
|
19
|
Macchini F, Morandi A, Cognizzoli P, Farris G, Gentilino V, Zanini A, Leva E. Acid Gastroesophageal Reflux Disease and Apparent Life-Threatening Events: Simultaneous pH-metry and Cardiorespiratory Monitoring. Pediatr Neonatol 2017; 58:43-47. [PMID: 27262544 DOI: 10.1016/j.pedneo.2015.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/10/2015] [Accepted: 12/03/2015] [Indexed: 11/25/2022] Open
Abstract
AIM To investigate the prevalence and the characteristics of gastroesophageal reflux disease (GERD) in infants with apparent life threatening events (ALTE). MATERIALS AND METHODS Infants with at least one episode of ALTE in absence of predisposing factors were included. All infants underwent a cardiorespiratory recording with simultaneous 24-hour pH-monitoring. Patients were divided into 3 groups according to the severity of GERD: A. Reflux Index (RI) <3%, B. RI = 3-7%, C. RI >7%. Monthly evaluations were performed and the anti-reflux therapy was maintained till normalization of monitoring and clinic. RESULTS 41 infants were enrolled. GERD was found in 80% of patients (moderate in 54%, severe in 27%). A normalization of the cardiorespiratory tracks was recorded on average after 1 month for group A, 7 months for the group B and 9.5 months for group C. A significant difference was registered between group A and both group B and C (P < 0.0001), as well as between the group B and C (P < 0.05). CONCLUSION GERD influences significantly the time of normalization of the cardiorespiratory monitoring in infants with ALTE. GERD diagnosis and treatment are mandatory in these patients.
Collapse
Affiliation(s)
- Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Anna Morandi
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.
| | - Paola Cognizzoli
- Department of Pediatrics, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Farris
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Valerio Gentilino
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrea Zanini
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Ernesto Leva
- Department of Pediatric Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| |
Collapse
|
20
|
Choi HJ, Kim YH. Apparent life-threatening event in infancy. KOREAN JOURNAL OF PEDIATRICS 2016; 59:347-354. [PMID: 27721838 PMCID: PMC5052132 DOI: 10.3345/kjp.2016.59.9.347] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 09/29/2015] [Accepted: 10/07/2015] [Indexed: 11/27/2022]
Abstract
An apparent life-threatening event (ALTE) is defined as the combination of clinical presentations such as apnea, marked change in skin and muscle tone, gagging, or choking. It is a frightening event, and it predominantly occurs during infancy at a mean age of 1–3 months. The causes of ALTE are categorized into problems that are: gastrointestinal (50%), neurological (30%), respiratory (20%), cardiovascular (5%), metabolic and endocrine (2%–5%), or others such as child abuse. Up to 50% of ALTEs are idiopathic, where the cause cannot be diagnosed. Infants with an ALTE are often asymptomatic at hospital and there is no standard workup protocol for ALTE. Therefore, a detailed initial history and physical examination are important to determine the extent of the medical evaluation and treatment. Regardless of the cause of an ALTE, all infants with an ALTE should require hospitalization and continuous cardiorespiratory monitoring and evaluation for at least 24 hours. The natural course of ALTEs has seemed benign, and the outcome is generally associated with the affected infants' underlying disease. In conclusion, systemic diagnostic evaluation and adequate treatment increases the survival and quality of life for most affected infants.
Collapse
Affiliation(s)
- Hee Joung Choi
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Yeo Hyang Kim
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| |
Collapse
|
21
|
Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MBH. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics 2016; 137:peds.2016-0591. [PMID: 27244836 DOI: 10.1542/peds.2016-0591] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
|
22
|
Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MBH. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics 2016; 137:peds.2016-0590. [PMID: 27244835 DOI: 10.1542/peds.2016-0590] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.
Collapse
|
23
|
Naud J. [Apparent life-threatening events and sudden unexpected death in infancy: Two different entities]. Arch Pediatr 2015; 22:1000-4. [PMID: 26228810 DOI: 10.1016/j.arcped.2015.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 04/04/2015] [Accepted: 05/29/2015] [Indexed: 12/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- J Naud
- Service mobile d'urgence et de réanimation (SMUR) pédiatrique, centre de référence de la mort inattendue du nourrisson (CRMIN), CHU de Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux cedex, France.
| |
Collapse
|
24
|
Choi HJ, Kim YH. Relationship between the Clinical Characteristics and Intervention Scores of Infants with Apparent Life-threatening Events. J Korean Med Sci 2015; 30:763-9. [PMID: 26028930 PMCID: PMC4444478 DOI: 10.3346/jkms.2015.30.6.763] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 03/18/2015] [Indexed: 11/29/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Hee Joung Choi
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Yeo Hyang Kim
- Department of Pediatrics, Kyungpook National University School of Medicine, Daegu, Korea
| |
Collapse
|
25
|
Kaminska A, Cheliout-Heraut F, Eisermann M, Touzery de Villepin A, Lamblin M. EEG in children, in the laboratory or at the patient's bedside. Neurophysiol Clin 2015; 45:65-74. [DOI: 10.1016/j.neucli.2014.11.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Accepted: 11/09/2014] [Indexed: 10/24/2022] Open
|
26
|
Horne RSC, Nixon GM. The role of physiological studies and apnoea monitoring in infants. Paediatr Respir Rev 2014; 15:312-8. [PMID: 25304428 DOI: 10.1016/j.prrv.2014.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 09/15/2014] [Indexed: 11/18/2022]
Abstract
There is evidence that failure of cardio-respiratory control mechanisms plays a role in the final event of the Sudden Infant Death Syndrome (SIDS). Physiological studies during sleep in both healthy term born infants and those at increased risk for SIDS have been widely used to investigate how the major risk and protective factors for SIDS identified from epidemiological studies might alter infant physiology. Clinical polysomnography (PSG) in infants who eventually succumbed to SIDS however demonstrated abnormalities that were neither sufficiently distinctive nor predictive to support routine use of PSG for infants at risk for SIDS. PSG findings have also been shown to be not predictive of recurrence of Apparent Life Threatening Events (ALTE) and thus international guidelines state that PSG is not indicated for routine evaluation in infants with an uncomplicated ALTE, although PSG may be indicated when there is clinical evidence of a sleep related breathing disorder. A decision to undertake home apnoea monitoring should consider the potential advantages and disadvantages of monitoring for that individual, in the knowledge that there is no evidence of the efficacy of such devices in preventing SIDS.
Collapse
Affiliation(s)
- Rosemary S C Horne
- The Ritchie Centre, Monash Institute of Medical Research and Prince Henry's Institute and Department of Paediatrics, Monash University, Level 5, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria, Australia 3168.
| | - Gillian M Nixon
- The Ritchie Centre, Monash Institute of Medical Research and Prince Henry's Institute and Department of Paediatrics, Monash University, Level 5, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria, Australia 3168
| |
Collapse
|
27
|
[French guidelines on electroencephalogram]. Neurophysiol Clin 2014; 44:515-612. [PMID: 25435392 DOI: 10.1016/j.neucli.2014.10.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2014] [Accepted: 10/07/2014] [Indexed: 12/11/2022] Open
Abstract
Electroencephalography allows the functional analysis of electrical brain cortical activity and is the gold standard for analyzing electrophysiological processes involved in epilepsy but also in several other dysfunctions of the central nervous system. Morphological imaging yields complementary data, yet it cannot replace the essential functional analysis tool that is EEG. Furthermore, EEG has the great advantage of being non-invasive, easy to perform and allows control tests when follow-up is necessary, even at the patient's bedside. Faced with the advances in knowledge, techniques and indications, the Société de Neurophysiologie Clinique de Langue Française (SNCLF) and the Ligue Française Contre l'Épilepsie (LFCE) found it necessary to provide an update on EEG recommendations. This article will review the methodology applied to this work, refine the various topics detailed in the following chapters. It will go over the summary of recommendations for each of these chapters and underline proposals for writing an EEG report. Some questions could not be answered by the review of the literature; in those cases, an expert advice was given by the working and reading groups in addition to the guidelines.
Collapse
|
28
|
[Relevance of electroencephalography in infants presenting to an emergency department who have had an apparent life-threatening event]. Arch Pediatr 2014; 21:1206-12. [PMID: 25282457 DOI: 10.1016/j.arcped.2014.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 05/30/2014] [Accepted: 08/07/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVES 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. MATERIAL AND METHODS 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. RESULTS 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). CONCLUSIONS 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.
Collapse
|
29
|
Claudius I, Mittal MK, Murray R, Condie T, Santillanes G. Should infants presenting with an apparent life-threatening event undergo evaluation for serious bacterial infections and respiratory pathogens? J Pediatr 2014; 164:1231-1233.e1. [PMID: 24484770 DOI: 10.1016/j.jpeds.2013.12.027] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 11/18/2013] [Accepted: 12/12/2013] [Indexed: 10/25/2022]
Abstract
We sought to identify which patients with an apparent life-threatening event require infectious evaluation through an analysis of infants aged ≤12 months brought to an emergency department with an apparent life-threatening event. Among the 533 children evaluated, there were no cases of meningitis, 1 case of bacteremia, 17 cases of urinary tract infection, 22 cases of bacterial pneumonia, 22 cases of respiratory syncytial virus, and 2 cases of influenza virus identified in respiratory specimens.
Collapse
Affiliation(s)
- Ilene Claudius
- Department of Emergency Medicine, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, Los Angeles, CA; Department of Pediatrics, Keck School of Medicine, LAC+USC Medical Center, University of Southern California
| | - Manoj K Mittal
- Perelman School of Medicine, University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ryan Murray
- Medical School, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Timothy Condie
- Medical School, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Genevieve Santillanes
- Department of Emergency Medicine, Keck School of Medicine, LAC+USC Medical Center, University of Southern California, Los Angeles, CA
| |
Collapse
|
30
|
Diagnostic findings in infants presenting to a pediatric emergency department for lethargy or feeding complaints. Pediatr Emerg Care 2014; 30:151-6. [PMID: 24583575 DOI: 10.1097/pec.0000000000000083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Lethargy is a common complaint among infants in the pediatric emergency department (ED), yet there is little data to guide appropriate evaluation. The objectives of the study were (1) to determine the frequency of diagnoses requiring intervention/monitoring and (2) to identify predictors of these diagnoses. METHODS A retrospective chart review of patients aged 0 to 6 months with a chief complaint of lethargy or poor feeding from January 2004 to December 2009 was performed. Patients were excluded if they had a fever, hypothermia, a chronic medical condition, or a history of trauma. Charts were reviewed by a single investigator; 10% were reviewed by a second investigator for agreement. History, examination, laboratory and radiology results, ED and inpatient diagnoses, as well as return visits within 7 days were recorded. Frequencies of diagnoses and interventions were described, and history and examination findings associated with these categories were determined. RESULTS Two hundred seventy-two patients were included; 34 patients (12.5%; 95% confidence interval [CI], 8.8%-17%) required intervention/monitoring. These patients were classified into 6 categories. Eighteen had hematologic disorders (6.6%; 95% CI, 4.0%-10.3%), 8 had dehydration (2.9%; 95% CI, 1.3%-5.7%), 2 had intracranial bleeds (0.7%; 95% CI, 0.09%-2.6%), 3 had serious bacterial infections (1%; 95% CI, 0.2%-3.2%), 1 had a cardiac disorder (0.4%; 95% CI, 0.009%-2%), and 2 had neurologic disorders (0.7%; 95% CI, 0.9%-2.6%). Of the patients, 76% had conditions that were clinically evident (dehydration and hyperbilirubinemia requiring phototherapy). The patients with cardiac disorders, neurologic disorders, and intracranial bleeds all had abnormal examination findings in the ED. The 3 patients with serious bacterial infections were younger than 2 months of age and ill appearing; all had urinary tract infections. CONCLUSIONS Infants with lethargy or poor feeding who require an intervention are likely to have conditions that are clinically evident or focal examination findings that lead to the diagnosis. Well-appearing infants with normal findings in examinations are unlikely to have a condition requiring intervention and should receive minimal testing.
Collapse
|
31
|
Kaji AH, Santillanes G, Claudius I, Mittal MK, Hayes K, Lee J, Gausche-Hill M. Do infants less than 12 months of age with an apparent life-threatening event need transport to a pediatric critical care center? PREHOSP EMERG CARE 2014; 17:304-11. [PMID: 23734987 DOI: 10.3109/10903127.2013.773111] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Some emergency medical services (EMS) systems transport infants with an apparent life-threatening event (ALTE) directly to hospitals capable of pediatric critical care (PCC) monitoring. OBJECTIVE To describe factors identifiable by EMS providers that distinguish ALTE patients who may require PCC monitoring and management. METHODS This was an observational analysis of ALTE patients who were transported by EMS and presented to four emergency departments (EDs). ED data were prospectively collected. Hospital records or reports from contacted parents were reviewed for interventions that mandated PCC management. We defined a priori the criteria by which PCC monitoring and management were required: if the subject needed 1) airway intervention with bag-valve-mask ventilation or advanced airway (e.g., endotracheal intubation) in the field, ED, or pediatric intensive care unit (PICU); 2) administration of vasopressors; 3) invasive monitoring; 4) surgery during the hospitalization; or 5) subspecialty consultation. Univariate analysis was performed to describe factors associated with requiring PCC management, and a multivariable model, accounting for within-hospital correlations, was developed. RESULTS A total of 513 patients were enrolled. Of these, 51 (9.9%) had an intervention warranting PCC management. Univariate predictors for requiring PCC management included prematurity, past medical history, resuscitation attempt, upper respiratory infection, apnea, previous ALTE, more than one ALTE in 24 hours, and cyanosis. The multivariable model yielded the following independent predictors for requiring PCC management: resuscitation attempt before EMS arrival, cyanosis, and more than one ALTE in 24 hours. This model demonstrated a sensitivity of 96.3%, a specificity of 25.8%, a negative predictive value of 98.3%, and a positive predictive value of 13.5%. CONCLUSION Only 9.9% of infants presenting in the field with ALTE had an intervention warranting PCC management, suggesting that many ALTE patients may be safely transported to hospitals without PCC capability. This would allow for better resource utilization of specialty care hospitals and still provide an option for secondary transports for those few patients not correctly identified in the field as requiring PCC. History of resuscitation attempt, cyanosis, and more than one ALTE in 24 hours are independent risk factors for requiring PCC management.
Collapse
Affiliation(s)
- Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance , CA 90509, USA.
| | | | | | | | | | | | | |
Collapse
|
32
|
Tieder JS, Altman RL, Bonkowsky JL, Brand DA, Claudius I, Cunningham DJ, DeWolfe C, Percelay JM, Pitetti RD, Smith MBH. Management of apparent life-threatening events in infants: a systematic review. J Pediatr 2013; 163:94-9.e1-6. [PMID: 23415612 DOI: 10.1016/j.jpeds.2012.12.086] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 11/27/2012] [Accepted: 12/27/2012] [Indexed: 12/27/2022]
Abstract
OBJECTIVE 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? STUDY DESIGN Systematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE. RESULTS 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. CONCLUSION 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.
Collapse
Affiliation(s)
- Joel S Tieder
- Department of Pediatrics, Division of Hospital Medicine, Seattle Children's Hospital and the University of Washington, Seattle, WA 98105, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Mittal MK, Donda K, Baren JM. Role of pneumography and esophageal pH monitoring in the evaluation of infants with apparent life-threatening event: a prospective observational study. Clin Pediatr (Phila) 2013; 52:338-43. [PMID: 23393308 DOI: 10.1177/0009922813475704] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
Collapse
Affiliation(s)
- Manoj K Mittal
- The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | | | | |
Collapse
|
34
|
Kant S, Fisher JD, Nelson DG, Khan S. Mortality after discharge in clinically stable infants admitted with a first-time apparent life-threatening event. Am J Emerg Med 2013; 31:730-3. [PMID: 23399327 DOI: 10.1016/j.ajem.2013.01.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2012] [Revised: 01/01/2013] [Accepted: 01/05/2013] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The objective of this study is to review the mortality after discharge in clinically stable infants admitted with a first apparent life-threatening event. METHODS DESIGN Retrospective chart review of all infants 0 to 6 months presenting with a first apparent life-threatening event (ALTE) over a 5-year period using explicit criteria. Patients with an emergency department (ED) diagnosis of ALTE, seizure, choking spell, or cyanosis were reviewed by 2 of 3 physicians. Level of agreement between reviewers was monitored. Mortalities were identified by a review of the county death record database and hospital records. RESULTS Three hundred sixty-six charts were reviewed; 176 cases met inclusion criteria. All apparent life-threatening event (ALTE) cases were admitted; 1 signed out against medical advice. Blood cultures were obtained in 111 patients (63%)-no pathogens were identified. Cerebrospinal fluid analysis and culture was performed in 65 patients (37%)-no pathogens were identified. One patient had pleocytosis. Chest radiographs were obtained in 115 patients (65%); 12 patients had infiltrates. Respiratory syncytial virus nasal washings were obtained in 32% of patients and were positive in 9 patients. The average length of follow-up was 34 months; 2 patients (1.1%) had died at the time of follow-up. Both deaths occurred after hospital discharge and within 2 weeks of the ED visit. Neither of the fatalities had a positive diagnostic evaluation in the ED. The cause of death by coroner report was pneumonia in both instances. CONCLUSIONS The risk of subsequent mortality in infants admitted from our pediatric ED with an ALTE is substantial. Emergency physicians should consider routine admission for patients with ALTE.
Collapse
Affiliation(s)
- Shruti Kant
- Department of Pediatric Emergency Medicine, University of Alabama-Birmingham School of Medicine, Birmingham, AL, USA
| | | | | | | |
Collapse
|
35
|
Affiliation(s)
- Alison Chu
- Pritzker School of Medicine, University of Chicago, IL, USA
| | | |
Collapse
|
36
|
Romaneli MTDN, Baracat ECE. Evento com aparente risco de morte: uma revisão. REVISTA PAULISTA DE PEDIATRIA 2012. [DOI: 10.1590/s0103-05822012000400017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJETIVO: Realizar uma revisão crítica reunindo informações disponíveis a respeito dos eventos com aparente risco de morte. FONTES DE DADOS: Revisão bibliográfica dos artigos (em português, inglês e espanhol) obtidos dos bancos de dados eletrônicos Medline, Lilacs e SciELO, utilizando as palavras-chave: eventos com aparente risco de morte, evento com aparente risco de vida infantil, lactente, apneia, monitorização e cianose. SÍNTESE DOS DADOS: Os eventos com aparente risco de mortesão súbitos e caracterizados por uma combinação de apneia, alteração na coloração da pele e tônus muscular, com inúmeras causas subjacentes. Sua incidência verdadeira é desconhecida e a faixa etária mais acometida é de 11 a 12 semanas. Não há correlação entre o evento com aparente risco de morte e a síndrome da morte súbita do lactente, embora já tenham sido consideradas manifestações da mesma doença. Muitas vezes, o lactente tem aparência saudável ao ser avaliado pelo pediatra após apresentar eventos com aparente risco de morte, porém, isso não afasta a possibilidade de existir uma doença grave associada ao evento, que deve ser investigada e tratada. Quando não são encontradas as causas, o evento é idiopático, geralmente com boa evolução. CONCLUSÕES: É necessário investigar os lactentes levados ao pronto-socorro após apresentarem eventos com aparente risco de morte, devido ao risco de sequelas e mortalidade. Não há uma padronização das condutas a serem realizadas diante de um lactente com aparência saudável que tenha evento com aparente risco de morte, mas recomenda-se que o paciente seja internado e a causa do evento, investigada. A observação e o monitoramento em ambiente hospitalar devem ocorrer no mínimo 24 horas após o evento.
Collapse
|
37
|
Kaji AH, Claudius I, Santillanes G, Mittal MK, Hayes K, Lee J, Gausche-Hill M. Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med 2012; 61:379-387.e4. [PMID: 23026786 DOI: 10.1016/j.annemergmed.2012.08.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2012] [Revised: 08/23/2012] [Accepted: 08/31/2012] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE We identify factors in emergency department (ED) patients presenting with apparent life-threatening events that distinguish those safe for discharge from those warranting hospitalization. METHODS Data were prospectively collected on all subjects presenting to 4 EDs with apparent life-threatening events. Patients were observed for subsequent events or interventions, defined a priori, which would have mandated hospital admission (eg, hypoxia, apnea, bradycardia that is not self-resolving, or serious bacterial infection). For patients discharged from the ED, telephone follow-up was arranged. Classification and regression tree analysis was performed to delineate admission predictors. RESULTS A total of 832 subjects were enrolled. The overall median age was 31.5 days (interquartile range 10 to 90 days); 427 (51.3%) were male patients, and 513 (61.7%) arrived by emergency medical services. One hundred ninety-one (23.0%) infants had a significant intervention warranting hospitalization. One hundred thirty-seven patients (16.5%) met predetermined criteria that would obviously mandate hospital admission (eg, persistent hypoxia requiring oxygen) by the end of their ED stay. In addition to these patients for whom it was obvious that admission would be necessary in the ED, classification and regression tree analysis (receiver operating curve=0.90) yielded 2 factors predictive of hospitalization: having a significant medical history and having greater than 1 apparent life-threatening event in 24 hours. The sensitivity was 89.0% (95% confidence interval 83.5% to 92.9%); specificity was 61.9% (95% confidence interval 58.0% to 65.7%). CONCLUSION We found 3 variables (obvious need for admission, significant medical history, >1 apparent life-threatening event in 24 hours) that identified most but not all infants with apparent life-threatening events necessitating admission. These variables require external validation and reliability assessment before clinical implementation.
Collapse
Affiliation(s)
- Amy H Kaji
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA.
| | | | | | | | | | | | | |
Collapse
|
38
|
Zimbric G, Bonkowsky JL, Jackson WD, Maloney CG, Srivastava R. Adverse outcomes associated with gastroesophageal reflux disease are rare following an apparent life-threatening event. J Hosp Med 2012; 7:476-81. [PMID: 22532496 DOI: 10.1002/jhm.1941] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2011] [Revised: 03/02/2012] [Accepted: 03/12/2012] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To evaluate for adverse outcomes associated with gastroesophageal reflux disease (GERD) following an apparent life-threatening event (ALTE) and potential risk factors of these outcomes. STUDY DESIGN Retrospective cohort study of well-appearing infants (<12 months) admitted for ALTE. Patients were followed for adverse outcomes associated with GERD (including aspiration pneumonia, failure-to-thrive, or anti-reflux surgery), second ALTE, or death. Risk factors evaluated included: age, prematurity, gender, previous event, diagnosis of GERD, gastrointestinal (GI) testing positive for gastroesophageal reflux, length of stay (LOS), and neurologic impairment diagnosed in follow-up. RESULTS Four hundred sixty-nine patients met inclusion criteria, mean age was 45 days, 110 (22%) were premature. Patients were followed for an average of 7.8 years; 3.8% of all patients had an adverse outcome associated with GERD. The only significant risk factors were a longer LOS, and development of neurological impairment. A diagnosis of GERD and positive reflux testing during the initial hospitalization were not associated with adverse outcomes associated with GERD. CONCLUSIONS Adverse outcomes associated with GERD are rare following an ALTE. Patients who developed neurological impairment and a longer initial LOS were at higher risk for developing these outcomes. Positive testing for gastroesophageal reflux during hospitalization for ALTE did not predict adverse outcomes associated with GERD.
Collapse
Affiliation(s)
- Gabrielle Zimbric
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA.
| | | | | | | | | |
Collapse
|
39
|
Mittal MK, Sun G, Baren JM. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care 2012; 28:599-605. [PMID: 22743742 DOI: 10.1097/pec.0b013e31825cf576] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to formulate a clinical decision rule (CDR) to identify infants with apparent-life threatening event (ALTE) who are at low risk of adverse outcome and can be discharged home safely from the emergency department (ED). METHODS This is a prospective cohort study of infants with an ED diagnosis of ALTE at an urban children's hospital. Admission was considered warranted if the infant required significant intervention during the hospital stay. Logistic regression and recursive partitioning were used to develop a CDR identifying patients at low risk of significant intervention and thus suitable for discharge from the ED. RESULTS A total of 300 infants were enrolled; 228 (76%) were admitted; 37 (12%) required significant intervention. None died during hospital stay or within 72 hours of discharge or were diagnosed with serious bacterial infection. Logistic regression identified prematurity, abnormal result in the physical examination, color change to cyanosis, absence of symptoms of upper respiratory tract infection, and absence of choking as predictors for significant intervention. These variables were used to create a CDR, based on which, 184 infants (64%) could be discharged home safely from the ED, reducing the hospitalization rate to 102 (36%). The model has a negative predictive value of 96.2% (92%-98.3%). CONCLUSIONS Only 12% of infants presenting to the ED with ALTE had a significant intervention warranting hospital admission. We created a CDR that would have decreased the admission rate safely by 40%.
Collapse
Affiliation(s)
- Manoj K Mittal
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | | | | |
Collapse
|
40
|
Abstract
This article reviews the mechanisms responsible for gastroesophageal reflux disease (GERD), available techniques for diagnosis, and current medical management. In addition, it extensively discusses the surgical treatment of GERD, emphasizing the use of minimally invasive techniques.
Collapse
|
41
|
A matched case control study with propensity score balancing examining the protective effect of paracetamol against parentally reported apnoea in infants. Resuscitation 2012; 83:440-6. [DOI: 10.1016/j.resuscitation.2011.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2011] [Revised: 10/07/2011] [Accepted: 12/07/2011] [Indexed: 11/19/2022]
|
42
|
Kundra M, Duffy E, Thomas R, Mahajan PV. Management of an apparent life-threatening event: a survey of emergency physicians practice. Clin Pediatr (Phila) 2012; 51:130-3. [PMID: 21903620 DOI: 10.1177/0009922811419495] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The etiology of an apparent life-threatening event (ALTE) has been attributed to a wide range of causes. Physicians rely on caregiver narratives, which are often unreliable given the distressing nature of the event, which in turn leads to variation in the evaluation and management. The objective of this study was to study this variation in the management of ALTE among emergency physicians in Michigan. DESIGN AND METHODS The authors developed and conducted a survey that contained questions on the evaluation and management of 2 common ALTE scenarios. These surveys were then mailed to 1000 randomly selected emergency physicians from a comprehensive physician database. RESULTS A total of 25.5% responded. Majority of the respondents were trained in emergency medicine residency. Fourth-seven percent of the respondents work in suburban areas. Most respondents said that they would perform diagnostic laboratory workup on children presenting with ALTE although there is wide variation in the extent of the workup. Ninety-two percent of ALTE patients are likely to get pediatric subspecialist consultation from the emergency department. CONCLUSIONS There is a wide variation in the evaluation and management of ALTE among emergency medicine physicians in Michigan. These children with ALTE are very likely to be seen by pediatric subspecialists subsequently.
Collapse
Affiliation(s)
- Manu Kundra
- Children's Hospital of Michigan, Detroit, MI, USA.
| | | | | | | |
Collapse
|
43
|
Berkowitz CD. Sudden infant death syndrome, sudden unexpected infant death, and apparent life-threatening events. Adv Pediatr 2012; 59:183-208. [PMID: 22789579 DOI: 10.1016/j.yapd.2012.04.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Carol D Berkowitz
- Department of Pediatrics, Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance, CA 90509, USA.
| |
Collapse
|
44
|
Koivusalo AI, Pakarinen MP, Wikström A, Rintala RJ. Assessment and treatment of gastroesophageal reflux in healthy infants with apneic episodes: a retrospective analysis of 87 consecutive patients. Clin Pediatr (Phila) 2011; 50:1096-102. [PMID: 21997146 DOI: 10.1177/0009922811410872] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This retrospective study sought to assess whether gastroesophageal reflux (GER) is associated with recurrent infant apneic episodes (AEs) and whether its treatment prevents AEs. Symptoms, diagnostic measures, and treatment of GER in 87 infants admitted for AEs were recorded. The effect of GER on recurrent AEs and survival were assessed. Esophageal pH monitoring was done to 58/87 (67%) patients, of whom 53/58 (91%) had a pathological finding; 48 patients had treatment for GER (medical 43%/49%; surgical 5%/6%) with continuing AEs during hospitalization (25%/29% patients) as the main indication. Follow-up (65 patients) disclosed recurrent AEs in 12 (18%) patients (no treatment 4/21, medical 8/39, surgical 0/5, P = NS). All 87 patients survived. Recurrent AEs after discharge was predicted by AEs during hospitalization but not by pathological GER. AEs observed during hospitalization predicted postdischarge AE recurrence. Of GER treatment modalities, only surgery prevented recurrent AEs.
Collapse
|
45
|
Abstract
BACKGROUND Children who present to the emergency department following an apparent life-threatening event (ALTE) often appear well, have a normal physical examination, and usually do well. The incidence of mortality following an event appears to occur infrequently, but has not been well described. However, it has been our experience that children who are victims of occult child abuse have a high mortality rate. METHODS Children younger than 24 months who presented to the emergency department following an ALTE were prospectively enrolled and followed up for a period of 12 months. Mortality rate was recorded. RESULTS During the study period of 9 years, 563 patients were enrolled. The mean age of the patients was 2.6 months. Eleven patients (2%) were diagnosed with child abuse. Those diagnosed with child abuse were more likely to have focal findings on physical examination (54% vs 17%, P < 0.01). Three children died; the overall mortality rate was 0.5% (3/563). One of the 3 deaths was secondary to child abuse. The other 2 deaths were reported at autopsy to be secondary to sudden infant death syndrome. One of the 11 cases of child abuse ended in a death, which is a 9% mortality rate of child abuse victims who present with an ALTE. CONCLUSIONS Although the subsequent mortality rate for children who present with an ALTE is low, child abuse was one of the identifiable causes of death and should be considered during evaluation of all children who present with an ALTE.
Collapse
|
46
|
Abstract
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.
Collapse
Affiliation(s)
- Naif Al Khushi
- Department of Pediatrics and Respiratory Medicine Division, The Montreal Children's Hospital, McGill University Health Centre, Montreal Canada
| | | |
Collapse
|
47
|
Duffy SO, Squires J, Fromkin JB, Berger RP. Use of skeletal surveys to evaluate for physical abuse: analysis of 703 consecutive skeletal surveys. Pediatrics 2011; 127:e47-52. [PMID: 21149429 PMCID: PMC4466842 DOI: 10.1542/peds.2010-0298] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The goals were to assess the use of the skeletal survey (SS) to evaluate for physical abuse in a large consecutive sample, to identify characteristics of children most likely to have unsuspected fractures, and to determine how often SS results influenced directly the decision to make a diagnosis of abuse. METHODS A retrospective, descriptive study of a consecutive sample of children who underwent an SS at a single children's hospital over 4 years was performed. Data on demographic characteristics, clinical presentation, SS results, and effects of SS results on clinical diagnoses were collected. A positive SS result was defined as a SS which identified a previously unsuspected fracture(s). RESULTS Of the 703 SSs, 10.8% yielded positive results. Children <6 months of age, children with an apparent life-threatening event or seizure, and children with suspected abusive head trauma had the highest rates of positive SS results. Of children with positive SS results, 79% had ≥1 healing fracture. CONCLUSIONS This is the largest study to date to describe the use of the SS. Almost 11% of SS results were positive. The SS results influenced directly the decision to make a diagnosis of abuse for 50% of children with positive SS results. These data, combined with the high morbidity rates for missed abuse and the large proportion of children with healing fractures detected through SS, suggest that broader use of SS, particularly for high-risk populations, may be warranted.
Collapse
Affiliation(s)
- Shanna O. Duffy
- Boonshoft School of Medicine, Wright State University, Dayton, Ohio; and
| | - Janet Squires
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Janet B. Fromkin
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Rachel P. Berger
- Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| |
Collapse
|
48
|
Guenther E, Powers A, Srivastava R, Bonkowsky JL. Abusive head trauma in children presenting with an apparent life-threatening event. J Pediatr 2010; 157:821-5. [PMID: 20955853 DOI: 10.1016/j.jpeds.2010.04.072] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2009] [Revised: 03/04/2010] [Accepted: 04/30/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To identify rates of abusive head trauma and associated clinical risk factors in patients with an apparent life-threatening event (ALTE). STUDY DESIGN Retrospective study of infants, 0 to 12 months, admitted for an apparent life-threatening event (ALTE; 1999-2003). Patients with abusive head trauma were identified at presentation or on follow-up; statistical analysis identified characteristics associated with abusive head trauma. RESULTS Of 627 patients with ALTE, 48% were male. Nine (1.4%) were diagnosed with abusive head trauma, of whom 5 were diagnosed in the emergency department. All cases detected in the emergency department had physical examination findings indicative of abusive head trauma. Patient age, male sex, or ethnicity were not significantly different between those with and without abusive head trauma. More children with abusive head trauma had a documented 911 call (56% vs 22%, P = .029), vomiting (56% vs 19%, P = .018), or irritability (22% vs 3%, P = .033). Multivariate analysis revealed odds ratio for abusive head trauma were 4.9 with a 911 call (P = .037), 5.3 with vomiting (P = .024), and 11.9 with irritability (P = .0197). CONCLUSIONS Abusive head trauma is in the differential for infants with an ALTE, although almost half of the cases are missed by current emergency department management. Vomiting, irritability, or a call to 911 are significantly associated with heightened risk for abusive head trauma.
Collapse
Affiliation(s)
- Elisabeth Guenther
- Division of Pediatric Emergency Medicine, University of Utah, School of Medicine, Salt Lake City, UT 84158, USA.
| | | | | | | |
Collapse
|
49
|
Barnes PD, Galaznik J, Gardner H, Shuman M. Infant acute life-threatening event--dysphagic choking versus nonaccidental injury. Semin Pediatr Neurol 2010; 17:7-11. [PMID: 20434683 DOI: 10.1016/j.spen.2010.01.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
A 4-month-old male infant presented to the emergency room with a history of choking while bottle feeding at home, and was found by emergency medical services (EMS) to be apneic and pulseless. He subsequently developed disseminated intravascular coagulopathy and died. Computed tomography (CT) and magnetic resonance imaging (MRI) showed subdural hemorrhages (SDHs), subarachnoid hemorrhage (SAH), and retinal hemorrhages (RHs), along with findings of hypoxic-ischemic encephalopathy (HIE). The caretaker account appeared to be inconsistent with the clinical and imaging features, and a diagnosis of nonaccidental injury with "shaken baby syndrome" was made. The autopsy revealed diffuse anoxic central nervous system (CNS) changes with marked edema, SAH, and SDH, but no evidence of "CNS trauma." Although NAI could not be ruled out, the autopsy findings provided further evidence that the child's injury could result from a dysphagic choking type of acute life threatening event (ALTE) as consistently described by the caretaker.
Collapse
Affiliation(s)
- Patrick D Barnes
- Department of Radiology, Lucile Salter Packard Children's Hospital at Stanford, Palo Alto, CA 94304, USA.
| | | | | | | |
Collapse
|
50
|
Semmekrot BA, van Sleuwen BE, Engelberts AC, Joosten KFM, Mulder JC, Liem KD, Rodrigues Pereira R, Bijlmer RPGM, L’Hoir MP. Surveillance study of apparent life-threatening events (ALTE) in the Netherlands. Eur J Pediatr 2010; 169:229-36. [PMID: 19544071 PMCID: PMC2797405 DOI: 10.1007/s00431-009-1012-2] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Accepted: 06/08/2009] [Indexed: 11/24/2022]
Abstract
SIDS and ALTE are different entities that somehow show some similarities. Both constitute heterogeneous conditions. The Netherlands is a low-incidence country for SIDS. To study whether the same would hold for ALTE, we studied the incidence, etiology, and current treatment of ALTE in The Netherlands. Using the Dutch Pediatric Surveillance Unit, pediatricians working in second- and third-level hospitals in the Netherlands were asked to report any case of ALTE presented in their hospital from January 2002 to January 2003. A questionnaire was subsequently sent to collect personal data, data on pregnancy and birth, condition preceding the incident, the incident itself, condition after the incident, investigations performed, monitoring or treatment initiated during admission, any diagnosis made at discharge, and treatment or parental support offered after discharge. A total of 115 cases of ALTE were reported, of which 110 questionnaires were filled in and returned (response rate 97%). Based on the national birth rate of 200,000, the incidence of ALTE amounted 0.58/1,000 live born infants. No deaths occurred. Clinical diagnoses could be assessed in 58.2%. Most frequent diagnoses were (percentages of the total of 110 cases) gastro-esophageal reflux and respiratory tract infection (37.3% and 8.2%, respectively); main symptoms were change of color and muscle tone, choking, and gagging. The differences in diagnoses are heterogeneous. In 34%, parents shook their infants, which is alarmingly high. Pre- and postmature infants were overrepresented in this survey (29.5% and 8.2%, respectively). Ten percent had recurrent ALTE. In total, 15.5% of the infants were discharged with a home monitor. In conclusion, ALTE has a low incidence in second- and third-level hospitals in the Netherlands. Parents should be systematically informed about the possible devastating effects of shaking an infant. Careful history taking and targeted additional investigations are of utmost importance.
Collapse
Affiliation(s)
- Ben A. Semmekrot
- Department of Pediatrics, Canisius-Wilhelmina Hospital, P. O. Box 9015, 6500 GS Nijmegen, The Netherlands
| | - Bregje E. van Sleuwen
- Netherlands Pediatric Surveillance Unit, TNO Quality of Life, Prevention and Health, P. O. Box 2215, 2301 CE Leiden, The Netherlands
| | - Adele C. Engelberts
- Department of Pediatrics, Orbis Medical Centre, P. O. Box 5500, 6130 MB Sittard, The Netherlands
| | - Koen F. M. Joosten
- Erasmus Medical Centre, Sophia Children’s Hospital, P. O. Box 2060, 3000 CB Rotterdam, The Netherlands
| | - Jaap C. Mulder
- Rijnstate Hospital, P. O. Box 9555, 6800 TA Arnhem, The Netherlands
| | - K. Djien Liem
- Department of Neonatology, Radboud University Medical Centre, P. O. Box 9101, 6500 HB Nijmegen, The Netherlands
| | - Rob Rodrigues Pereira
- Netherlands Pediatric Surveillance Unit, TNO Quality of Life, Prevention and Health, P. O. Box 2215, 2301 CE Leiden, The Netherlands
| | | | - Monique P. L’Hoir
- Netherlands Pediatric Surveillance Unit, TNO Quality of Life, Prevention and Health, P. O. Box 2215, 2301 CE Leiden, The Netherlands
| |
Collapse
|