Contemporary Pediatrics - November 2009 - (Page 54)
A pragmatic approach to ALTEs JOSHUA L. BONKOWSKY, MD, PHD JOEL S. TIEDER, MD, MPH Does your patient’s ALTE indicate an underlying problem? Probably not, but a careful history, clinical acumen, and judicial testing should be your guide. he infant who arrives for medical care after an apparent life-threatening event (ALTE) presents the pediatrician with a host of uncertainties. Such infants, usually 2 to 3 months old, often appear well after the ALTE and may not have distinguishing features in their exam or history. Even extensive testing may fail to reveal a cause of the ALTE. But parents are frightened and want to make sure nothing is wrong with their child. And you want to rule out the rare possibility of an underlying etiology without subjecting the patient and family to unnecessary testing. Although numerous recommendations for ALTE management are available, they have not been tested rigorously, and little consensus has been reached about medical management of this condition.1,2 As a result, ALTE care across the country is quite variable.3 We offer some commonsense recommendations on tests to perform, when to hospitalize, and how to follow up with the child who has had an ALTE. T A little background ALTEs manifest with a wide range of symptoms, such as a change in breathing (for example, apnea or choking), tone (such as the infant suddenly becoming limp), or appearance or color. ALTEs used to be described by such phrases as aborted sudden infant death syndrome (SIDS) or near-miss SIDS. Then, in 1986, a National Institutes of Health (NIH) What to do when c o n s e n s u s an ALTE is not what it seems? work ing group Read about the that was largely blue wheezer in f o c u s e d o n a recent Puzzler. t h e i s s u e o f contemporarypediatrics.com/pz/0709 SI DS f o r m a l l y defined an ALTE as “an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid), marked change in muscle tone, choking, or gagging. In some cases, the observer fears that the infant has died.”4 Most clinicians and researchers still adhere to this definition. Studies conducted before this formal definition was adopted provided limited information on the epidemiology and causes of ALTEs, because they relied on a nonspecific definition that focused on the events’ relationship to SIDS. Although the incidence of ALTEs is still unclear, they are reported to occur in about 0.6 to 9.4/1,000 live-born infants and account for almost 1% of emergency department (ED) visits for children younger than 1 year.5,6 CONTINUED ON IMAGES: GET T Y IMAGES/ BRAND X PICTURES /TRBFOTO/ COMSTOCK IMAGES/COMSTOCK RYAN MCVAY (MM BOX) PAGE 56 DR. BONKOWSKY is an Assistant Professor in the Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City. DR. TIEDER is a pediatric hospitalist at the Seattle Children’s Hospital and The University of Washington Division of Inpatient Medicine and Clinical Effectiveness, Department of Pediatrics, Seattle. The authors have nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.C O N T E M P O R A R Y P E D I AT R I C S NOVEMBER 2009 VOL. 26 NO. 11
Table of Contents for the Digital Edition of Contemporary Pediatrics - November 2009
Contemporary Pediatrics - November 2009
Editorial Advisory Board
Dermatology: What's Your DX?
Then and Now: ADHD Treatments
Cardiovascular Risk in ADHD Pharmacotherapy
Transitioning Adolescents to Adult Care and Adulthood: Is it Time Yet? Part 1 of 2
A Pragmatic Approach to ALTEs
Developmental Surveillance and Screening Part 1 of 3
Contemporary Pediatrics - November 2009
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