Objecti tives and Goals Understand the contemporary definition of - PDF document

Beyond SIDS: ALTE 5/17/13 Objecti tives and Goals • 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 Advances & Controversies in Clinical Pediatrics 2006 1

Beyond SIDS: ALTE 5/17/13 • 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” • 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 “coders” which may further complicate the caregiver--“objective” and “measurable” selection of appropriate patients. Are causes of criteria 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 Advances & Controversies in Clinical Pediatrics 2006 2

Beyond SIDS: ALTE 5/17/13 1 mo boy, brief choking and gagging episode. ED 1 mo boy, brief choking and gagging episode. ED evaluation is well, normal exam. Observe for a while evaluation is well, normal exam. Observe for a while —no spells. Discharge him directly to home form —no spells. Discharge him directly to home form the ED if his ONLY risk factor for having another the ED if his ONLY risk factor for having another spell is that: 
 spell is that: 
 A. Nasal swab RSV + A. Nasal swab RSV + B. Frequent spit ups B. Frequent spit ups C. Delivered at 32 weeks post conception C. Delivered at 32 weeks post conception D. One previous similar episode D. One previous similar episode E. Mother smoked cigarettes throughout the E. Mother smoked cigarettes throughout the pregnancy pregnancy • Almost half of monitored healthy children had • SIDS ≠ ALTE—no causal relationship has ever at least one apnea > 20 seconds been found, despite the obvious “frightening” • Estimates are that 1-2% of infants in the nature of the event. general population will have an ALTE and • SIDS ≠ ALTE—only ~5% of SIDS victims had a 0.2-0.8% will have an apneic event leading to prior ALTE (consider recall bias). admission • SIDS ≠ ALTE—risk of subsequent death among all infants with ALTE is estimated at most 1-2%, • Maternal smoking and single parent but is increased in the (rare) subgroup of infants households seem to be risk factors who have ALTE whi while asl sleep and nd who who requi uire • Median age 8 weeks, male=female CPR CPR when discovered (“severe”) ALTE. • Post conception age < 44 weeks of age at • SIDS ≠ ALTE—recurrent, severe ALTE is the higher risk (immature respiratory center); highest risk group and therefore get the most preemies; prior ALTE also higher risk extensive workups and monitoring. Advances & Controversies in Clinical Pediatrics 2006 3

Beyond SIDS: ALTE 5/17/13 Previously healthy 1 mo runny nose, cough x 2days. Previously healthy 1 mo runny nose, cough x 2days. 3 rd day—brief apnea, pale motionless—gentle 3 rd day—brief apnea, pale motionless—gentle stimulation and he is back to normal. Likely cause?: stimulation and he is back to normal. Likely cause?: A. Seizure A. Seizure B. Organic acid disorder B. Organic acid disorder C. RSV C. RSV+ D. Cardiac dysrhythmia D. Cardiac dysrhythmia E. Intentional poisoning E. Intentional poisoning Based on first presentation (ESTIMATES) • Cardiovascular (1%)—arrhythmia • GI (up to 33%)—GERD (beware of the • Metabolic/Endocrine—electrolyte/ extraordinarily high prevalence even in 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%) Advances & Controversies in Clinical Pediatrics 2006 4

Beyond SIDS: ALTE 5/17/13 6 week old to the ED after 3 bouts of choking/ 6 week old to the ED after 3 bouts of choking/ gagging previous evening—turned dusky. Kind of a gagging previous evening—turned dusky. Kind of a spitty baby, but no episodes like this before. 3 spitty baby, but no episodes like this before. 3 caregivers at home, each with some variation on the caregivers at home, each with some variation on the story. Appears a little sleepy, otherwise normal story. Appears a little sleepy, otherwise normal exam. Cause of ALTE provided by: 
 exam. Cause of ALTE provided by: 
 A. Cardiac event monitor A. Cardiac event monitor B. CT scan of head B. CT scan of head C. EEG C. EEG D. pH probe D. pH probe E. Metabolic screening E. Metabolic screening • History—most important component. • Evaluation: determine frequency, Caregiver witness issues: presence, overlook severity, nature of the events as well as or distort due to distressing event. History is underlying cause. particularly focused on ALTE causes, and • No standard investigative protocol has include specifics like lighting, proximity and been tested, only suggested—recent clothes/blankets covering. Details of apnea, Dutch recommendations choking and feeding also critical. • Challenging number and array of tests • Physical examination—extremely detailed, available—cost, risk, convenience, pain, thorough and particularly focused on ALTE sensitivity and specificity play a role causes, caretaker interaction, feeding observation, e.g. Advances & Controversies in Clinical Pediatrics 2006 5

Beyond SIDS: ALTE 5/17/13 • Hospitalization for cardiorespiratory • Polysomnography with or without EEG; monitoring and evaluation is extremely echocardiogram; airway or brain imaging; pH common, although readily identifiable (and probe each may occasionally be indicated but preventable) causes may be excepted. ALTE rarely if ever are ALL such tests performed can cluster or repeat and may be “captured” initially. in hospital occasionally. LOS = 23-72 hrs. • Study published concluded “for many tests • Workups should be thoughtful, directed and used in the evaluation of ALTE, the likelihood case-specific, logical of a positive result is low and the likelihood of a contributory result is even lower”. • Screening tests may be indicated (“no clue”): CBC, chemistry panel, venous blood gas, EKG • Recurrent and/or severe apnea=high priority • Strong consideration for hospitalization for • Home monitoring is generally unwarranted monitoring, evaluation and counseling • Obstructive apnea is not identified until the • Specifically treat any identified cause terminal event (decreased HR) (anticonvulsants, GERD, infections, caffeine, etc.) • No proven efficacy to prevent SIDS • “Back to Sleep” reinforcement • Adverse effects: false alarms, increased • Modify other risk factors such as smoking, anxiety, depression and hostility, unsafe sleep practices developmental implications • Strongly consider infant CPR certification • IF monitoring, strongly consider event course (American Red Cross, e.g.): greatly recorders that can download data for analysis enhances parental confidence in preparedness in “what to do” IF… Advances & Controversies in Clinical Pediatrics 2006 6