II. Definition

  1. Apparent Life-Threatening Event (ALTE)
    1. Sudden, brief episode with serious findings in an infant under age 1 year
    2. Presents with apnea, Cyanosis or pallor, limp, Choking or gagging
  2. Brief Resolved Unexplained Event (BRUE)
    1. Replaces Apparent Life-Threatening Event (ALTE)
    2. Change in color (pallor, Cyanosis), tone (hyper- or hypotonia) or respirations (apnea, irregular)
    3. Episode occurs in infant <1 year old
    4. Resolves within 1 minute
    5. Reassuring history, Vital Signs and exam
    6. Event unexplained by findings

III. Epidemiology

  1. Incidence: Up to 1 in 400 infants
  2. Occurs in infants under age 1 year (usually <10 weeks old)

IV. Risk Factors

  1. Male gender
  2. Feeding symptoms (rapid feeders, or feeding with cough)
  3. Age under 2 months
  4. Premature Infants especially if accompanied by:
    1. Respiratory Syncytial Virus (RSV)
    2. General anesthesia history

V. Causes

  1. General
    1. ALTE after age 2 months predicts serious cause
    2. Idiopathic in 50% of cases
    3. No longer thought to be near-miss SIDS (older hypothesis)
  2. Gastrointestinal (50% of diagnosed cases)
    1. Pediatric Gastroesophageal Reflux
    2. Bowel disorder (Gastric Volvulus, Intussusception)
    3. Infantile Botulism
  3. Neurologic (30% of diagnosed causes)
    1. Seizure Disorder (e.g. Febrile Seizures)
    2. Vasovagal reflex
    3. Structural Disease (Budd-Chiari Syndrome)
    4. Brain Mass
    5. Meningitis (or other CNS Infection)
    6. Increased Intracranial Pressure (e.g. Hydrocephalus)
    7. Intracranial Hemorrhage or Trauma (e.g. Shaken Baby Syndrome)
  4. Respiratory (20% of diagnosed causes)
    1. Infection (RSV, Pertussis, Croup)
    2. Breath-Holding Spell
    3. Apnea of Prematurity
    4. Obstruction (Sleep Apnea, vocal cord, foreign body)
    5. Laryngotracheomalacia
    6. Facial anomaly
  5. Cardiac (5% of diagnosed causes)
    1. Arrhythmia
    2. Congenital Heart Disease
    3. Cardiomyopathy
  6. Metabolic (<5% of diagnosed causes)
    1. Inborn Errors of Metabolism
    2. Endocrine disorder
    3. Toxic ingestion
    4. Hypoglycemia
    5. Hypocalcemia
  7. Infection
    1. Urinary Tract Infection
    2. Sepsis
  8. Child Abuse (<5% of diagnosed causes)
    1. Smothering
    2. Non-accidental Trauma
    3. Munchausen by proxy
      1. Consider in repeat episodes seen by only 1 person

VI. Symptoms

  1. Apnea
  2. Change in color (e.g. blue or cyanotic)
  3. Altered muscle tone (floppy or stiff)
  4. Coughing, Choking or gagging

VII. History

  1. Event history
    1. Awake or asleep, prone or supine, and location?
    2. Occur with feeding, coughing, Choking, Vomiting?
    3. Respiratory effort? Skin Color? Muscle tone?
    4. Event duration?
    5. Interventions required (stimulation, CPR)?
  2. Recent illness
    1. Fever or rash
    2. Recent poor feeding or weight loss
    3. Irritable or Decreased Level of Consciousness
    4. Contagious contacts
  3. Medical history
    1. Prenatal and birth history
    2. Developmental Milestones met?
    3. Possible Trauma
    4. Prior similar episodes
    5. Family History (SIDS, neurologic or cardiac disorder)

VIII. Exam

  1. Comprehensive examination is critical
  2. Evaluate for underlying condition (see causes above)
  3. Pulse Oximetry

IX. Diagnostics

  1. Individualize testing by history and exam
    1. No routine test is absolutely indicated in BRUE (or ALTEs)
  2. High yield testing in higher risk events
    1. Complete Blood Count (CBC)
      1. However, leads to diagnosis in <5% of cases
    2. Chemistry panel (Chem8)
      1. Serum electrolytes including calcium, Magnesium
      2. Serum Glucose (consider bedside Glucose)
      3. Serum bicarbonate
        1. Low level associated with more serious causes
        2. Consider checking serum lactate
    3. Urinalysis
    4. Chest XRay
    5. Pertussis nasal swab
    6. Respiratory Syncytial Virus (RSV) nasal swab
    7. Electrocardiogram
  3. Additional evaluation to consider
    1. Blood Culture
    2. MRI Brain
    3. Lumbar Puncture
    4. Liver Function Tests

X. Evaluation: Brief Resolved Unexplained Event (BRUE)

  1. Low risk criteria (all must be met)
    1. Age >60 days
    2. Not premature (Gestational age >32 weeks and post-conceptual age >45 weeks)
    3. First and isolated event
    4. Duration <1 minute
    5. CPR not required by trained medical provider
    6. No concerning history or exam
  2. Approach
    1. BRUE episode is high risk if not all low risk criteria are met
    2. Low risk events do not require hospitalization (but may still admit as indicated)
      1. However, if discharged, re-evaluate in 24 hours
    3. Home cardiorespiratory monitoring is not recommended

XI. Management

  1. Hospital observation and monitoring in most cases
    1. Age under 2 months and history of prematurity
    2. Child Abuse risk factors (ALTE is associated with abuse in up to 3% of cases)
  2. Consider home apnea monitor
  3. Treat specific cause if identified
  4. Consider Pediatric GERD management if GERD is suspected
    1. Avoid empirically starting in BRUE (or ALTE) alone

XII. Prognosis: Mortality risk

  1. Increased SIDS risk
  2. Risk significantly increases with serious cause
    1. Central hypoventilation
    2. Seizure Disorders
    3. Cardiac arrhythmia
    4. Shannon (1992) Clin Perinatol 19:861-9 [PubMed]

XIII. References

  1. Claudius and Tieder in Herbert (2012) EM: Rap 12(9):2
  2. Claudius and Orman in Herbert (2016) EM:Rap 16(10): 4-5
  3. Davies (2002) Emerg Med J 19:11-6 [PubMed]
  4. Hall (2005) Am Fam Physician 71:2301-8 [PubMed]
  5. Tieder (2016) Pediatrics 137(5): e20160590 +PMID: 27244835 [PubMed]

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Ontology: Apparent life threatening event in infant (C2712370)

Concepts Disease or Syndrome (T047)
ICD9 799.82
ICD10 R68.13
Dutch duidelijk levensbedreigend voorval, ALTE
French Malaises graves inopinés du nourrisson, MGIN
German Anscheinend lebensbedrohliches Ereignis, ALTE
Italian Evento ad apparente rischio di vita, ALTE
Portuguese Episódio de perigo de vida aparente, ALTE (episódio de aparente ameaça de vida)
Spanish Episodio de aparente amenaza a la vida, EAAV
Japanese ALTE, 乳幼児突発性危急事態, ALTE, ニュウヨウジトッパツセイキキュウジタイ
Czech ALTE, Zjevně život ohrožující příhoda
English Appar life threat-infant, Apparent life threatening event in infant, apparent life-threatening event in infant (diagnosis), apparent life-threatening event in infant, apparent life-threatening event infant, ALTE in infant, Apparent life threatening event in infant (ALTE), ALTE, Apparent life threatening event
Hungarian Nyílvánvalóan életveszélyes esemény, ALTE