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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 3  |  Page : 131-135

Apparent life-threatening events in infants: a single-center experience


1 Department of Pediatrics, Pediatric Gastroenterology, Hepatoplogy, and Nutrition Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt
2 Department of Pediatrics, Pediatric Nephrology and Dialysis Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt
3 Department of Pediatrics, Mansoura University Children’s Hospital, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt
4 Department of Pediatrics, Pediatric Cardiology Unit, Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission09-Jun-2019
Date of Decision15-Jul-2019
Date of Acceptance15-Jul-2019
Date of Web Publication27-Apr-2020

Correspondence Address:
MD Mona A.L Alsayed
Mansoura University Children’s Hospital, El Gomhoria Street, Mansoura 35516
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJOP.AJOP_13_19

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  Abstract 


Background Apparent life-threatening events (ALTEs) occur with diverse underlying medical conditions.
Objective We aimed to assess the clinico-epidemiological characteristics of ALTEs in our locality in the Delta region located in Northern Egypt.
Patients and methods A prospective cohort study included 53 patients younger than 1 year, who presented with ALTEs in emergency department of Mansoura University Children’s Hospital. All patients were subjected to full history taking, physical examination, and basic laboratory panel. Further investigations were individualized. All patients had 1-year follow-up for recurrence and outcome.
Results The study included 53 patients, comprising 28 (52.8%) females, and the median age was 6 weeks (range, 2 days–11 months). Thirty-nine (73.6%) patients were defined as high-risk age group (below 2 months). Most of the patients had normal vital signs and stable medical condition at the time of their examination in the emergency department (40 cases, 75.5%). Recurrent ALTE was observed in 35 (66%) patients. Cardiac arrest occurred in 20.8% of patients, and eight of them died. Multivariate analysis revealed a significant effect of the cardiac arrest (odds ratio, 24; 95% confidence interval, 3.8–152.2; P=0.001) and abnormal physical examination (odds ratio, 15.5; 95% confidence interval, 1.74–138.2; P=0.014) on the number of deaths.
Conclusion ALTE in our locality turned out not to be a rare condition. Its recognition and appreciation of the abnormal symptoms reported by the parents are important to promptly define any underlying etiology. Structured history and examination with tailored investigations have a high diagnostic yield.

Keywords: apparent life-threatening event, Egypt, etiology, infants, recurrence


How to cite this article:
Alsayed MA, El Refaey AM, Othman SG, Abo Elkheir MM. Apparent life-threatening events in infants: a single-center experience. Alex J Pediatr 2019;32:131-5

How to cite this URL:
Alsayed MA, El Refaey AM, Othman SG, Abo Elkheir MM. Apparent life-threatening events in infants: a single-center experience. Alex J Pediatr [serial online] 2019 [cited 2020 Jun 2];32:131-5. Available from: http://www.ajp.eg.net/text.asp?2019/32/3/131/283320




  Introduction Top


Apparent life-threatening events (ALTEs) represent a great challenge since their first definition in 1986. They are defined as a combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid, occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging, and they are extremely frightening to the observer [1]. ALTE is not a specific diagnosis and has diverse pathophysiology. In one systematic review for etiology of ALTE, the researchers found that gastroesophageal reflux (GER), respiratory infections, and seizures are the most common reported causes. Other diagnoses were cardiovascular, metabolic, and endocrine, child abuse, substance exposure, and factitious illness, whereas 23–50% remain with no definitive diagnosis [2].

Evidence has shown that most of the patients with ALTE had good outcome [3]. The clinical challenge is to identify infants with medically significant ALTE and diagnose any underlying disease if possible. The appropriate evaluation either in the emergency department (ED) or after admission is also controversial. There is currently no standard minimal workup for evaluation of ALTE [4].

Studies have shown that 10% of patients with ALTEs experienced a recurrence of ALTE episodes [5],[6],[7]. The association of ALTE and sudden infant death syndrome (SIDS) was assumed previously, as 5% of victims with SIDS experienced episodes of ALTE [8]. However, most recent research failed to confirm such a cause-effect relationship [9],[10].

There is a paucity of studies on the magnitude of this problem in our geographic region [11],[12].


  Aim Top


We aimed to assess the clinico-epidemiological characteristics of ALTEs in our locality in the Delta region in Northern Egypt.


  Patients and methods Top


This is a prospective cohort study comprising 53 patients younger than the age of 1 year. All participants were recruited from Mansoura University Children’s Hospital, Emergency Department, Mansoura, Egypt, from March 2016 to March 2017. Informed consents were obtained from the caregivers of all patients. The study was approved by the Institutional Review Board of Mansoura Faculty of Medicine (protocol no. MS/15.10.36, approved on December 24, 2015), and it followed the principles of Helsinki Declaration. Inclusion criteria were any infant below 1 year of age and has a combination of the following: apnea (central or obstructive), color change (usually cyanotic or pallid, or plethoric), marked change in muscle tone (hypotonia or hypertonia), choking, or gagging [1]. Exclusion criteria included infants older than 1 year, and patients known to have uncorrected cardiac disease, epileptic disorder, or chronic lung disease requiring treatment. All patients were followed up for 1 year either by clinical visits or phone calls for recurrence of ALTE.

All enrolled patients were subjected to thorough history taking including the condition of the baby before the episode; time, duration, and recurrence of this episode; related symptoms, such as color changes, gasping, choking, gagging, cough, vomiting, loss of consciousness, or fits; and cautious family history about SIDS or arrhythmias. Full clinical examination was done to assess the patient’s general condition and included measuring vital signs with oxygen saturation, signs of trauma such as bruises or bulging fontanels, development assessment, and offering an observational period during feeding. Basic workup included complete blood count, differential leukocytic count, arterial blood gases, serum electrolytes (sodium, potassium, and calcium), random blood glucose, chest radiograph, and urine analysis. Further investigations were tailored according to the initial evaluation as in [Figure 1].
Figure 1 Flow chart of investigations done for the included infants.

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Statistical analysis

Data were analyzed with SPSS, version 21 (IBM Corp., Armonk, New York, USA). Qualitative data were described using number and percent. Association between categorical variables was tested using χ2 test. Continuous variables were presented as mean±SD for parametric data, and median and interquartile range for nonparametric data. The two groups were compared with Student t test (parametric data) and Mann–Whitney test (nonparametric data). Statistical significance is considered when the probability of error is less than 5% (P<0.05).


  Results Top


The study included 53 patients, comprising 28 (52.8%) females and 25 (47.2%) males, and the median age was 6 weeks (range, 2 days–11 months). Thirty-nine (73.6%) patients were below the age of 2 months and defined as high-risk age group, whereas 14 (26.4%) were above 2 months and defined as low-risk age group. Clinico-epidemiologic characteristics of the patients are listed in [Table 1].
Table 1 Clinico-epidemiologic characteristics of the patients

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Positive past history of medical condition was reported in 22 (41.5%) patients, as illustrated in [Table 2]. Most of our patients showed normal vital signs and stable medical condition at time of their examination at ED (40 cases, 75.5%). The final diagnosis was reached in all patients except one (1.9%) who remained undiagnosed ([Table 3]). No statistically significant difference was found between high-risk and low-risk age groups regarding their final diagnosis albeit the higher number of GERD, pertussis, and epilepsy in the younger age group.
Table 2 Past medical history of patients with apparent life-threatening event

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Table 3 Final diagnosis of apparent life-threatening event

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Recurrent ALTE was observed in 35 (66%) patients; recurrence was significantly higher in patients diagnosed with GERD (9/10, P=0.042). There was no statistically significant difference between the two age groups regarding both recurrence and death ([Table 4]). There was no identifiable factor for recurrence, and there was no significant effect of age, sex, gestational age, nursery admission, past medical history, or respiratory tract infection (RTI) symptoms (P=0.140, 0.148, 0.414, 0.146, 0.146, and 0.922, respectively). The recurrence rate was significantly higher in patients with normal vital signs when compared with those with abnormal vital signs (32/35, P<0.001)
Table 4 Difference of recurrence and death in both age groups

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Cardiac arrest occurred in 11 (20.8%) patients who required cardiopulmonary resuscitation (CPR), and eight of them eventually died. Multivariate analysis revealed a significant effect of the need for CPR and the presence of abnormal physical findings on the number of death ([Table 5]).
Table 5 Multivariate analysis of statistically significant parameters in the history and examination of apparent life-threatening event on death

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  Discussion Top


ALTE is not a distinct disorder rather than an expression of a group of alarming symptoms that occur in infants for diverse underlying medical conditions. To the best of our knowledge, there is no study for the elucidation of ALTEs in Egyptian infants. The aim of our study is to assess the clinico-epidemiological characteristics of ALTEs in our locality in Mansoura University Children’s Hospital and to find the underlying etiologies for these events.

The current work is a prospective cohort study that included 53 patients with ALTE defined according to the American Academy of Pediatrics [1]. Twenty-five (47%) were male, which is in agreement with previous studies [11],[12],[13],[14]. The median age of our patients was 6 weeks, and 75% of them were below 2 months. Previous studies showed that peak incidence of ALTE was during the first 2 months of life [9]. In our study, 40/53 (75%) of the infants showed stable vital signs and 32/53 (60%) of them were physically normal at ED. This comes in concordance with other studies [11],[14],[15],[16] which reported stable vital signs in most of the patients. This makes it important to clearly define and record the symptoms and signs noted by caregivers when evaluating infants with a potential ALTE even if they do not match the observations of the medical personnel.

The final diagnosis was made in 98% of our cases; the most frequent diagnoses were lower RTI (26.4%), epilepsy (24.5%), and GERD (18.9%). The final diagnosis was reached after offering initial workup followed by the targeted investigation for individualized cases, as there is no standard panel of investigations for case with ALTEs [17].

The difficulty in dealing with infants with ALTE and negative physical findings comes from the difficulty of predicting recurrence of the frightening event. In our study, recurrence was observed in 35/53 (66%) of the patients, most of them happened during admission and within 24 h of the initial episode. Romaneli et al. [18] reported recurrence in 44.1% of ALTE cases, whereas lower rates of recurrence (10–16%) were found in other studies [19],[20].

There was a statistically significant increase in recurrence of ALTE attacks in patients diagnosed as having GERD compared with those without GERD (P=0.042). This was in contrast with Ueda et al. [20], as there was no statistical significance between ALTE definitive diagnosis and recurrence of the event. On trying to determine risk factors for recurrence in patients with ALTE, we found no significant effect of age, sex, gestational age, nursery admission, past medical history, or RTI symptoms on recurrence of ALTE episode. On the contrary, there was a significant relationship between normal vital signs and recurrence as the total number of cases with recurrence was 35 and 91% of them had normal vital signs (P<0.001). So we cannot predict recurrence in cases of ALTE according to our study. This was in contrast with Ueda et al. [20], who defined RTI symptoms as a risk factor for recurrent ALTE (44 vs. 14%, P =0.0055). Other factors including level 1 triage (P=0.0132), and the need for intensive care (P<0.0001) were concluded as significant risk factors for recurrent ALTE in the same study. Previous studies have suggested that recurrent ALTE episodes were a significant predictive factor for hospitalization. However, those studies did not indicate which patients more likely to experience recurrence [5].

The different risk factors of both ALTE and SIDS make them as different entities [9],[21]. Moreover, the applied strategies to decrease SIDS had no effect on the occurrence of ALTE [21]. Cardiac arrest occurred in 11/53 (20.8%) of our cohort. Effective CPR was carried out, but eventually, eight (15%) patients died. Cardiac arrest was related to an underlying serious medical condition as all patients were diagnosed and related to a medical condition. This may be the explanation to the death rate in our study, which is higher than previous reports [17],[22],[23]. Although the number of deaths was higher in the high-risk age group (6 vs. 2), the difference was not statistically different (P=0.9). This finding comes in agreement with previous reports which considered age less than 2 months as a high-risk group for serious conditions that warrant closer observation [24],[25],[26].In the current work, we found that there is a statistically significance difference of cardiac arrest (odds ratio, 24; 95% confidence interval, 3.8–152.2; P=0.001) and abnormal physical examination (odds ratio, 15.5; 95% confidence interval, 1.74–138.2; P=0.014) on the number of deaths. In a previous study, long event duration and cardiovascular arrest had a significant relation to patient death (P=0.047, 0.015, respectively) [18].

This study is based on a single, tertiary children’s hospital site and included a relatively small number of patients, thus limiting the generalizability of our results.


  Conclusions Top


Although not studied before, ALTE is suggested to be documented in our locality. Its recognition and appreciation of the abnormal symptoms reported by the parents are important to promptly define any underlying etiology. Structured history and examination with tailored investigations have a high diagnostic yield.There are no conflicts of interest

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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