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.

ALTE in the NEONATE

• 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.

References