ALTE: ALTE: Apparently a Lot of pparently a Lot of Disclosures - PDF document

Beyond SIDS: ALTE 4/18/2013 ALTE: ALTE: Apparently a Lot of pparently a Lot of Disclosures Discl sures Terro Terror for Everyb for Everybody! A P Perennial nnial Conundr undrum – For purposes of For purpo es of this this talk, talk, I I have have A pparent L ife T hreatening E vents nothing to dis nothing to disclose: lose: th Annual A 46 th 46 al Advances & & Controve versie rsies i s in Clin inical ical Pediat atrics rics San F n Francis ancisco, C co, Californ fornia ia May 17, May 17, 201 2013 Pre Presen ente ted by: Tim by: Tim Ke Kelly, y, MD MD Clin Clinical Prof Profes essor of Pe of Pedi diatrics Direct ctor, or, Advan vanced C Clerkships kships a and I Intern rn Sele lect ction ion Pediatri ric H c Hospitalist italist De Depa partment of of Pe Pediatri rics Univ iversit sity o of Californ fornia, S ia, San F Fran ancisco sco Objec Objectives and Goals es and Goals Outline Outline • Understand the contemporary definition of • Speaker perspective and experience “ALTE” • Background/History • Explore the relationship between SIDS, ALTE • Studying ALTE and other historical terms • Epidemiology • Become more adept at creating a case- • Differential Diagnosis specific differential diagnosis and evaluation • Evaluation—focused, specific and economical strategy • Management options (hospitalization, • Incorporate appropriate management monitors, caffeine, CPR classes) options into practice • SIDS counseling • Obtain comprehensive literature references and resources • References • Improve knowledge of SIDS counseling Speake Speaker perspect r perspective ive Backgr Background/H nd/Hist istory and experience and experience • ALTE are always concerning AND consterning, to varying degrees! • Critical care background (attending in PICU • Standardized definition of ALTE offered by for 12 years) and Pediatric Hospitalist since the NIH Consensus Development Conference 1987 1987 • Frightening to the observer, some • Direct involvement in workup and combination of: management of 8-12 cases of ALTE per year • Apnea (central or obstructive) • Regular comprehensive review of the • Color change literature (cyanotic>pallor>red>plethoric) • Muscle tone change (limp) • Presenting as “experienced” rather than • Choking or gagging “expert” Advances & Controversies in Clinical Pediatrics 2006 1

Beyond SIDS: ALTE 4/18/2013 Studying ALTE Studying ALTE Studying ALTE Studying ALTE (cont.) •Definition too broad?—some exclude Study design is complex: obvious choking or include only “major” •Retrospectively, selection bias based on episodes variable inclusion/exclusion criteria as noted •Definition too narrow?--some include above make Multi-Center study problematic— altered Mental Status dyspnea, apnea vs. cyanosis, choking/gagging. •Descriptions often quite subjective by Discharge diagnoses are often determined by frightened, inexperienced caregiver-- “coders” which may further complicate the “objective” and “measurable” criteria selection of appropriate patients. Are causes of elusive ALTE then excluded? •No ICD-9 code—ALTE is NOT a •Prospectively how to capture patients—general diagnosis, rather a symptom complex, vs. specialty services within an institution “chief complaint” or presenting problem— •# needed to draw meaningful conclusions? hard to track or include in studies Epidemiology Epidemiology ARS ARS •Almost half of monitored healthy children had 1 mo boy, brief choking and gagging episode. ED at least one apnea > 20 seconds evaluation is well, normal exam. Observe for a •Estimates are that 1-2% of infants in the while—no spells. Discharge him directly to home general population will have an ALTE and 0.2- from the ED if his ONLY risk factor for having 0.8% will have an apneic event leading to another spell is that: admission A. Nasal swab RSV + •Maternal smoking and single parent households seem to be risk factors B. Frequent spit ups C. Delivered at 32 weeks post conception •Median age 8 weeks, male=female D. One previous similar episode •Post conception age < 44 weeks of age at E. Mother smoked cigarettes throughout the higher risk (immature respiratory center); pregnancy preemies; prior ALTE also higher risk Epidemi Epidemiolo logy gy (con (cont.) ARS ARS •SIDS ≠ ALTE—no causal relationship has ever Previously healthy 1 mo runny nose, cough x 2days. 3 rd day—brief apnea, pale motionless—gentle been found, despite the obvious “frightening” nature of the event. stimulation and he is back to normal. Likely cause?: •SIDS ≠ ALTE—only ~5% of SIDS victims had a prior ALTE (consider recall bias). A. Seizure •SIDS ≠ ALTE—risk of subsequent death among B. Organic acid disorder all infants with ALTE is estimated at most 1-2%, C. RSV but is increased in the (rare) subgroup of infants D. Cardiac dysrhythmia who have ALTE while as ile asleep leep an and w who requir ire e CPR when discovered (“severe”) ALTE. CPR E. Intentional poisoning •SIDS ≠ ALTE—recurrent, severe ALTE is the highest risk group and therefore get the most extensive workups and monitoring. Advances & Controversies in Clinical Pediatrics 2006 2

Beyond SIDS: ALTE 4/18/2013 DDx/Causes DDx/Causes DDx/Causes (cont.) DDx/Causes (cont.) Based on first presentation (ESTIMATES) •Cardiovascular (1%)—arrhythmia •GI (up to 33%)—GERD (beware of the •Metabolic/Endocrine— extraordinarily high prevalence even in electrolyte/glucose alterations, IEM (rare) normal children and be wary of assigning •Infections (5-30% with seasonal “cause” of ALTE), AGE, esophageal variability) dysfunction •Other—SBS, abuse, Munchausen, breath- •Neurological (15%)—seizure, central holding, choking, temperature, apnea, head injury, infections “exaggerated laryngeal chemoreceptor •Respiratory (11%)—RSV, pertussis, FB reflex apnea” associated with reflux? OR •Airway (4%)—malacias, stenoses, OSA •Idiopathic (20-60%) Evaluation/Investigation Evaluation/Investigation ARS ARS 6 week old to the ED after 3 bouts of •History—most important component. choking/gagging previous evening—turned dusky. Caregiver witness issues: presence, overlook Kind of a spitty baby, but no episodes like this or distort due to distressing event. History is before. 3 caregivers at home, each with some particularly focused on ALTE causes, and variation on the story. Appears a little sleepy, include specifics like lighting, proximity and otherwise normal exam. Cause of ALTE provided by: clothes/blankets covering. Details of apnea, choking and feeding also critical. A. Cardiac event monitor B. CT scan of head •Physical examination—extremely detailed, C. EEG thorough and particularly focused on ALTE causes, caretaker interaction, feeding D. pH probe observation, e.g. E. Metabolic screening Eval/Investigation ( nvestigation (cont.) ont.) Eval/Investigation (cont.) Eval/Investigation (cont.) •Evaluation: determine frequency, •Hospitalization for cardiorespiratory severity, nature of the events as well as monitoring and evaluation is extremely underlying cause. common, although readily identifiable (and preventable) causes may be excepted. ALTE •No standard investigative protocol has can cluster or repeat and may be “captured” been tested, only suggested—recent in hospital occasionally. LOS = 23-72 hrs. Dutch recommendations •Workups should be thoughtful, directed and •Challenging number and array of tests case-specific, logical available—cost, risk, convenience, pain, sensitivity and specificity play a role •Screening tests may be indicated (“no clue”): CBC, chemistry panel, venous blood gas, EKG Advances & Controversies in Clinical Pediatrics 2006 3