PHM15: Evidence-Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event

Summary:

Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.

The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.

Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.

Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:

• Multiple events,
• Prematurity,
• Fever/hypothermia,
• Toxic appearance,
• Altered mental status, or
• Clinical signs of pertussis.

From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.

Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.

Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH

Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.

Summary:

Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.

The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.

Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.

Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:

• Multiple events,
• Prematurity,
• Fever/hypothermia,
• Toxic appearance,
• Altered mental status, or
• Clinical signs of pertussis.

From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.

Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.

Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH

Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.

Summary:

Presenters of the PHM15 session "Evidence Based Diagnostic Evaluation of Infants Presenting with an Apparent Life Threatening Event" discussed four main diagnostic categories for ALTEs: cardiac, infectious, non-accidental trauma/neurologic, and gastrointestinal. They reviewed the incidence of each of these diagnoses in infants presenting with ALTE, discussed the utility of various diagnostic modalities, and suggested elements of the history and physical that might make those etiologies higher on the differential.

The evidence shows a 0%-2% rate of cardiac disease in infants presenting with ALTE. Given low sensitivity and low specificity for echocardiograms in these patients, the presenters did not recommend routine echocardiograms in all patients. Given high sensitivity and low specificity for EKGs, they suggested EKGs could be considered to help exclude cardiac etiologies, but cautioned that the high false positive rate could lead to additional unnecessary testing. They did not find a high association between most historical facts and an increased likelihood of cardiac etiologies in patients presenting with an ALTE.

Infectious etiologies discussed included bacteremia (0%-2.5%), UTI (0%-7.7%), meningitis (0%-1.2%) and pertussis (0.6%-9.2%), with rates in ALTE as noted.

Again, the literature does not support the use of routine testing for these diagnoses unless there are suggestive clinical findings. Findings that might warrant further infectious investigations:

• Multiple events,
• Prematurity,
• Fever/hypothermia,
• Toxic appearance,
• Altered mental status, or
• Clinical signs of pertussis.

From their literature review, the speakers found a 1.4%-3.7% rate of non-accidental trauma in infants presenting with an ALTE. They did not feel there was sufficient evidence to support skeletal surveys or dilated ophthalmologic exams as part of a standard ALTE workup. Historical clues that might lead the provider to consider NAT include recurrent events, a history of SIDS or ALTE in siblings, delay in seeking care or a confusing history. Suggestive physical exam findings included blood in the nose/mouth, abnormal neurological exam, ear bruising, oral injuries, or bruising in a non-mobile child.

Regarding GE reflux, the presenters discussed the difficulty in identifying the incidence since temporal association does not necessarily equate with causation. They did not recommend routine testing for GER or acid suppression in low risk patients, but said patients could be counseled on various behavioral interventions such as avoiding tobacco and overfeeding, providing frequent burping and upright positioning and exclusive breastfeeding.

Finally, the speakers discussed the upcoming practice guideline for the management of patients with ALTE. They reviewed the proposed change in nomenclature, with the transition to "BRUE" (brief resolved unexplained event), as well as a new algorithm for the evaluation of low-risk patients. The new guidelines currently are being reviewed, with plans to be published and available for general dissemination within the next 12 months. TH

Amanda Rogers, MD, is a hospitalist and assistant professor in the Department of Pediatrics, Section of Hospital Medicine, at the Medical College of Wisconsin in Milwaukee.