ALTE – apparent life threatening events

Case Scenario:
A family bring their 8 month old to the Emergency Department. The child has had a recent respiratory infection with episodes of coughing. Tonight whilst being held, the mother states that the child stopped breathing and went blue and limp, then soon after, made a strange breathing noise and started breathing again.

Do any parts of this story concern us? Should we be concerned about ALTE (apparent life threatening event)?

My response would be that there are several things in this story that concern me in terms of ALTE as a potential diagnosis.

The first thing to clear up, is that ALTE is NOT related to SIDS. The definition of ALTE includes:

• apnoea
• colour change
• muscle tone change
• gagging or coughing
• and it is frightening to the observer

Let’s look at these:

• apnoea is self explanatory
• colour change may be red, which MAY indicate upper airway or pale or blue, which may indicate central causes
• muscle tone change is usually that the child becomes limp, however there could also be an increased muscle tone that may give clues to a possible seizure
• gagging or choking are also part of the definition

By far the most common causes are gastrointestinal, with gastroesophageal disease making up almost one third of cases. Seizures and lower respiratory tract infections, make up sizeable proportions, but in up to a quarter of the cases the cause is unknown.

In many cases the history and examination will reveal the cause. Investigations tend to be targeted to reflux screens and infective
screens(white cell count and urine analysis). Other investigations may include head CT.

Who needs admission? I admit all premature, ill-appearing babies, especially if they have had multiple episodes. I also consider admitting all children in whom no likely cause has been discovered and where I am concerned. In many cases we admit for social reasons i.e. where the parents may not cope with taking the child home.

Remember to always think of non-accidental injury. In one study by Bonkowsky (2008), non-accidental injury was involved in 11% of cases. Although this is somewhat high, in comparison to other studies, the lesson is to consider it as a diagnosis.