Am I Bored or Apparently Life-Threatened? – Review!

An Apparent Life Threatening Event, or ALTE, in pediatrics is defined as a frightening event to the observer, consisting of some combination of apnea, color change (blue, pale), change in tone (stiff, limp), choking or gagging.

Apnea must be > 20 seconds. Seems long, but it can be normal for infants not to breath for up to 20 seconds (“periodic breathing”).

Peak incidence is 1 week to 2 months old; males more common (2:1)

An ALTE is only a symptom. Although 25-50% have been termed “idiopathic ALTE” without an attributable cause, ALTEs should prompt investigation into a differential diagnosis including:

• RSV bronchiolitis – apnea may be the first symptom
• pertussis
• GERD
• seizure
• abuse or non-accidental trauma or poisoning
• breath holding spell
• GBS/sepsis

An ALTE alone should not make you jump to immediate admission. As with most EM situations, it depends on the clinical picture and information that you have. Three general groups of diagnoses may help categorize your thinking:

1. Stable patients with a clear / proximal cause  or diagnosis. Treat these patients based on their diagnosis. For example, if they have bronchiolitis and are brought in for apnea, they are at risk for other apneic episodes during their infection and should be admitted. Alternatively, if they had what seemed like a gagging episode related to eating and have a history of reflux but are now clinically well-appearing, they likely do not need admission (feeding-related incidents are generally reassuring).
2. Unstable patients without a clear diagnosis. Stabilize them first and foremost, investigate the cause (i.e. sepsis, metabolic, head injury, respiratory infection), and admit for observation.
3. Stable patients without a clear diagnosis. The workup and disposition of these patients vary. You should obtain a very thorough history, and any aspects that are suspicious or point toward a possible diagnosis should be worked up with an appropriate disposition.

• Any evidence that the infant is still in distress or has not returned to baseline
• Any signs of abuse – bruising or strange marks on the child, blood in the mouth, suspicious caregiver story, etc. Don’t forget to look for retinal hemorrhage when concerned for abuse.
• Any history of ALTE in the past
• History of prematurity, NICU stay, or other prolonged hospitalization
• Any significant family history of early onset metabolic, cardiac, or seizure disorder.
• Congenital anomalies, especially cranio-facial dysmorphism leading to airway issues

Although it was previously thought that ALTE was related to Sudden Infant Death Syndrome (SIDS), evidence does not suggest that having an ALTE is a precursor to SIDS, nor does it put the baby at higher risk for SIDS.

• Berkowitz CD, Claudius I, Tieder JS. Chapter 112. Sudden Infant Death Syndrome and Apparent Life-Threatening Event. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.
• Uptodate.com – Corwin MJ, Apparent life-threatening event in infants.
• Nickelodeon! (always an inspiration)
• As always, Special Thanks to Dr. Willis