Definition (Pediatr Clin North Am 2005;52:1127)
• Described as an event frightening to the observer and including any of the following:
• Apnea: Central (no resp effort) or obstructive (breath w/ paradox inverse motion of chest/abd and ↓ O2 sat by 3%). Apnea >20 sec or shorter w/ ↓ HR or hypotonia
• CHIME study (1,079 infants on home card-resp monitors) – 43% w/ apnea and bradycardia >20 sec w/o diff in freq btw “healthy” infants and those w/ Hx idiopathic ALTE requiring vigor stim and CPR. # events >30 sec similar in both groups (Pediatr Rev 2007;28:203)
• Change in color: Central cyanosis (>5 g/dL deoxy-hgb) w/ bluish lips or tongue
• Distinguished from acrocyanosis (bluish color of hands and feet) & circumoral cyanosis; both of which are benign in the absence of other signs of shock or sepsis
• Change in muscle tone
• Coughing or gagging
• May or may not require stimulation to resolve (includes being picked up by caregiver)
• Uncomplicated ALTEs not related to SIDS (in fact, ALTEs and SIDS have different risk factors. Campaigns that have dec rates of SIDS have not had impact on ALTEs)
Incidence (Am Fam Physician 2005;71:2301; Pediatr Clin North Am 2005;52:1127)
• 0.01–0.5%; by definition <1 yo (most <10 wk); though limited data
• Etiology determined in 77% of cases in 1 meta-analysis (though ranging from 9–83% among the studies evaluated) (Arch Dis Child 2004;89:1043)
• Risk factors: Repeated apnea, pallor, Hx of cyanosis, feeding difficulties, prematurity
Diagnostic Studies
• Review of 239 cases; 17.7% of tests + 5.9% contributed to dx (Pediatrics 2005;115:885)
• High-yield testing: Suggested by H&P. If nothing is suggested, consider U/A and Ucx, WBC, GERD screen (pH probe), neuroimaging, pneumogram, nasal washing (esp RSV and B. pertussis) (Curr Opin Pediatr 2007;19:288) toxicology (not looked at in this study)
• Low-yield testing: Lytes, ABG, full septic w/u, EKG, EEG, lat neck films, CXR, barium swallow, “milk scan” (contrast scintigraphy), CVR monitoring o/n
Management
• Admission: Study (59 infants) w/ use of high-risk criteria (age <30 d old and multi-ALTEs in 24 hr) predicted w/ 100% sens all cases needing hospitalization (Pediatrics 2007;119:679). Also high risk if premature or <43 wk corrected (J Pediatr 2008; 154:332)
• Proposes that nontoxic full-term pts w/ nml exam & >30 do p/w 1st ALTE w/ likely breath-holding spell safe to discharge home (Pediatrics 2007;120:448)
• Criteria for breath-holding spells
• Physically healthy pt btw the ages of 6 and 24 mo
• Spell follows orderly tetrad of provocative emotional stimulus, expiratory apnea & cyanosis, opisthotonic rigidity, & then stupor
• Entire sequence of events up to stupor phase lasts a few minutes. Stupor can last a variable length of time
• Child may have many attacks per day or only a few at irregular intervals
• FHx often discloses breath-holding spells, particularly if grandparents are questioned
• PE, including careful cardiac evaluation, is normal
• EEG, ECG & MRI nml, if obtained; generally Hx establishes dx w/o these tests
• Consider social work consult
• Consider admission if complex resuscitation required, abn PE, lab test, or social concerns
• Other: Consider CPR training for parents
• Home monitoring appt in preterm at-risk, high-risk recurrent apnea, bradycardia, and hypoxemia following discharge or w/ infants who are equipment dependent, have conditions affecting resp reg, or those w/ unstable airways (Pediatrics 2005;115:885)
Prognosis
• No developmental diff in f/u studies at 10 yr, some ↑ breath-holding at 3 yr. ↑ risk of subsequent SIDS, only if recurrent episodes require CPR