ALTE in Neonate

ALTE in Neonate Something that is certainly unique about the practice of emergency medicine is the approach to problems from the “worst first” perspective.  Now, generally, I would consider myself as someone who minimizes testing and prefers to spend a few extra minutes getting a solid history and performing a detailed exam.  Through this approach, I find that I am able to contemplate the “Big, Bad, and Ugly” issues often without ordering a million tests (don’t get me started about the white count!).

One group, however, often requires me to accept my limitations and operate on the more conservative side of caution. The neonate may be super cute, but is also extremely tricky!  We have discussed numerous neonatal topics previously (there is an entire category for them — Hypothermia in a Neonate, Interosseous Access, No Need for Atropine, Neonatal Analgesia, and Necrotizing Enterocolitis to name a few).  We have also discussed ALTE (Apparent Life Threatening Events) previously.  While we have noted that the evaluation of an ALTE is best determined by a thorough history and physical, the neonate warrants a slightly more conservative approach.

 ALTE Basics

  • ALTE is NOT a diagnosis. It is a collection of symptoms.
  • ALTE is defined as an episode that is “frightening” to the care provider and is characterized by some combination of pathologic apnea, color change, change in muscle tone, choking, or gagging.
  • Pathologic Apnea = apnea associated with cyanosis, pallor, hypotonia, or bradycardia (which would only be known if on a monitor really) OR apnea of greater than 20 seconds in duration (which is a really long time for a parent to count when their kid is not breathing).
  • The rather broad “definition” of ALTE leads to some difficulty in researching it and in interpreting the results of the research.


ALTE Differential Diagnosis is VAST

  • Since ALTE represents a collection of symptoms, numerous conditions can be responsible.
  • A thorough H+P often points toward a diagnosis and directs the work-up.
  • GERD, Seizures, and Lower Respiratory Tract Infections are the most common diagnoses found after evaluation of ALTE.
  • Many ominous conditions have been associated with ALTE as well:
    • Serious Bacterial Infections
    • Congenital Heart Disease
    • Inborn Errors of Metabolism
    • Ondine’s Curse (Congenital Central Hypoventilation Syndrome)
    • Abuse
    • Poisoning
  • Many times no diagnosis is found (idiopathic ALTE).


ALTE Evaluation

  • In general, it is known that broad and expansive testing is often of limited value.
  • It is best to tailor the evaluation based on a thorough history and physical exam.
  • Currently there are investigations to better determine who benefits from admission; however, there is currently no validated study that reliably identifies this group of children.



  • Neonates are tough to figure out!
    • They can’t tell you what really happened.
    • They’re repertoire to demonstrate any illness is limited.
      • Neonates who are seriously ill may only demonstrate that fact by being hypothermic.
      • We all know that the “well appearing” neonate can still be hiding serious illness.
    • Your physical exam is less helpful in determining an etiology of the event.
      • You cannot rely on finding meningismus.
      • Even paradoxical irritability can be difficult to discern in the neonate.
    • Neonates often have a different breathing pattern that can alarm care providers.
      • Periodic Breathing is a normal variation of breathing.
      • It is characterized by pauses of breathing for less than 20 seconds (more typically less than 10 seconds).
      • Often followed by some increased respiratory rate.
      • There is no change in color or tone.
      • This is NOT pathologic apnea, but often catches the attention of the care giver.
  • Neonates that do Weird Things Make Me Nervous!
    • Yes, the literature would argue that the overall incidence of serious bacterial infections in all cases of ALTE is low.
      • Meningitis 0-1.6%
      • Bacteremia 0-2.5%
      • UTI 0-7.6%
      • Respiratory Tract Infection 0-10%
    • If the story fits neither a simple gagging episode with feeding nor periodic breathing, then I have to ask myself why did this neonate have Pathologic Apnea.
      • While the numbers may not favor a serious bacterial infection… I have a hard time proving that to myself in a neonate.
      • Perhaps it was a seizure… hmmm… why did the neonate have a seizure… once again infection is high on that list.
      • Therefore, I still vote for the “worst first” approach and look to have someone tell me in two days that the neonate did not have a serious bacterial infection.
      • In short, these neonates I perform a full sepsis work-up on.
      • ALTE in Neonate = Full Sepsis Work-up!
    • If the story is a little odd… you know the one where you just can’t seem to get your hands around what happened.
      • Then I would favor a cautious, but reasonable approach.
      • Sepsis screen with Urine studies and Urine Culture and admission for close observation.
      • Naturally, a conversation with the admitting team to develop a joint plan is always appreciated.
    • Aside from serious bacterial infections… don’t forget other badness in neonates!!
      • Inborn Errors of Metabolism
      • Abuse
      • Congenital Heart Disease


So, in the end, when evaluating the neonate for an ALTE, don’t just resort to the common approach of “that’s an easy admission” and admit for “obs.”  Rather, be a little fearful… and start looking for those needles in the haystack of disease.


Claudius I1, Mittal MK2, Murray R3, Condie T3, Santillanes G4. Should infants presenting with an apparent life-threatening event undergo evaluation for serious bacterial infections and respiratory pathogens? J Pediatr. 2014 May;164(5):1231-1233. PMID: 24484770. [PubMed] [Read by QxMD]

Kadivar M1, Yaghmaie B1, Allahverdi B1, Shahbaznejad L2, Razi N1, Mosayebi Z1. Apparent life-threatening events in neonatal period: clinical manifestations and diagnostic challenges in a pediatric referral center. Iran J Pediatr. 2013 Aug;23(4):458-66. PMID: 24427501. [PubMed] [Read by QxMD]

Kaji AH1, Claudius I, Santillanes G, Mittal MK, Hayes K, Lee J, Gausche-Hill M. Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med. 2013 Apr;61(4):379-387. PMID: 23026786. [PubMed] [Read by QxMD]

Tieder JS1, Altman RL, Bonkowsky JL, Brand DA, Claudius I, Cunningham DJ, DeWolfe C, Percelay JM, Pitetti RD, Smith MB. Management of apparent life-threatening events in infants: a systematic review. J Pediatr. 2013 Jul;163(1):94-9. PMID: 23415612. [PubMed] [Read by QxMD]

Grylack LJ1, Williams AD. Apparent life-threatening events in presumed healthy neonates during the first three days of life. Pediatrics. 1996 Mar;97(3):349-51. PMID: 8604268. [PubMed] [Read by QxMD]

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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  1. […] the “important” issue revolves around a typical oddity of being a young child (like periodic breathing).  Being comfortable with some minor issues, particularly neonatal issues (currently, there are 26 […]

  2. […] issues with one of my “favorite” topics: Apparent Life Threatening Events (See ALTE and Never Trust a Neonate).  Recently, it has been recommended that the term “Apparent Life Threatening Event / […]

    • Great question!
      A breath holding spell may present to you initially as an ALTE. An ALTE is not a diagnosis, but rather a collection of symptoms. Those symptoms may, in the end, be attributed to an etiology like Seizures, GERD, or even Breath Holding Spells.

      Breath Holding Spells typically occur in kids 6mos – 18 mos. They can be quite alarming to the family. A good history is what is needed to make the diagnosis. Usually there is either a painful stimuli or a period of frustration and / or anger (think of the toddler throwing a tantrum).

      Hope that helps a little.
      Thank you,

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