ALTE case?

[Rendar5]

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Hey peds guys, wanted your opinion on a case I saw recently in my ED. Had a very healthy 8mo baby with only perinatal hx of note being a nuchal cord requiring emergent C/S at time of FT delivery with a short nursery stay. Parents brought him to me in the middle of the night because he had woken up crying, was easily consolable, but had 2 separate spells lasting about 8 seconds per parents of apnea and complete loss of tone. Neither one had any color change associated with it. Nor was the kid crying at the time or had any trauma associated with it, so it didn't seem like a breath-holding spell to me. Normal v/s, normal exam, happy smiling baby. As I'm an EP at a non-peds facility, I transferred him to the local peds hospital for eval and possible apneic monitoring. But I don't get to f/u on these, nor do I get much training on these kids outcomes (ALTEs never came to the PICU when I was in residency).

Since this wasn't the usual ALTE that I'm used to (usually it's a poor history from frightened parents of color change), I was wondering from those with experience what they might consider the differential to be, and if you'd consider any testing to be done before sending this out to a peds hospital. Hell, curious if anyone out there wouldn't consider this an ALTE.

 

[SB100]

How did the baby look after the spells? Back to baseline, any changes, etc?

 

[Rendar5]

How did the baby look after the spells? Back to baseline, any changes, etc?

Per the parents was acting completely appropriate with near instantaneous return to baseline.
The only unusual factors were constipation resolved 2 days ago after starting the kid on cereal the week before, and the fact taht their kid doesn't wake up after 8pm normally but woke up crying at midnight shortly before these 2 episodes happened.

Kid was awake, alert, interactive, smiling, nontoxic. Parents were dependable, articulate, and knew their child well (impressive given the fact that they were 1st time parents).

The only dx other than ALTE that crossed my mind aft er the H&P was some sort of atypical seizure.

 

[KidDr]

Hey peds guys, wanted your opinion on a case I saw recently in my ED. Had a very healthy 8mo baby with only perinatal hx of note being a nuchal cord requiring emergent C/S at time of FT delivery with a short nursery stay. Parents brought him to me in the middle of the night because he had woken up crying, was easily consolable, but had 2 separate spells lasting about 8 seconds per parents of apnea and complete loss of tone. Neither one had any color change associated with it. Nor was the kid crying at the time or had any trauma associated with it, so it didn't seem like a breath-holding spell to me. Normal v/s, normal exam, happy smiling baby. As I'm an EP at a non-peds facility, I transferred him to the local peds hospital for eval and possible apneic monitoring. But I don't get to f/u on these, nor do I get much training on these kids outcomes (ALTEs never came to the PICU when I was in residency).

Since this wasn't the usual ALTE that I'm used to (usually it's a poor history from frightened parents of color change), I was wondering from those with experience what they might consider the differential to be, and if you'd consider any testing to be done before sending this out to a peds hospital. Hell, curious if anyone out there wouldn't consider this an ALTE.

I'm PEM trained working in a big city peds ED. The 8 seconds of apnea doesn't worry me so much, but the complete loss of tone does. I'd definitely be concerned for seizure. If the baby looked great in the ED, I wouldn't necessarily obtain any labs/imaging studies on an urgent basis. I would probably admit for monitoring and likely EEG. We have a great relationship with our 2 hospitalist groups, and I can tell you that I wouldn't get any pushback on admitting this baby. We admit well-appearing babies for ALTE/rule out seizure all the time. Many of them end up being nothing, but I think that in many cases admission is the right way to go.

 

[generic]

I agree--the hypotonic episode would seem to argue for a central (CNS) process more than the usual GERD or whatever. Loss of central tone could give a limp baby and obviously apnea so that seems to make sense.

I would agree that admit/obs seems very reasonable since we usually admit ALTE's even when we think there's really nothing wrong with the baby anyway. This case seems a little more concerning. A video on the parents' smartphone might be helpful if feasible for future reference..

 

[Stitch]

I'm PEM trained working in a big city peds ED. The 8 seconds of apnea doesn't worry me so much, but the complete loss of tone does. I'd definitely be concerned for seizure. If the baby looked great in the ED, I wouldn't necessarily obtain any labs/imaging studies on an urgent basis. I would probably admit for monitoring and likely EEG. We have a great relationship with our 2 hospitalist groups, and I can tell you that I wouldn't get any pushback on admitting this baby. We admit well-appearing babies for ALTE/rule out seizure all the time. Many of them end up being nothing, but I think that in many cases admission is the right way to go.

I also agree. ALTE is pretty tough to even define, let alone sort out. I think admitting for 24 hour obs is reasonable and warrants at least a discussion with neuro as to whether this represents a seizure. Most ALTE admits and work ups are negative, but in the ED, especially an adult facility without peds subspecialty available, you can't sort it out safely. In this case, more is less and exposing the kid to radiation and blood tests is very unlikely to be helpful if your exam is normal.

 

[Sweet Tea]

I'm PEM trained working in a big city peds ED. The 8 seconds of apnea doesn't worry me so much, but the complete loss of tone does. I'd definitely be concerned for seizure. If the baby looked great in the ED, I wouldn't necessarily obtain any labs/imaging studies on an urgent basis. I would probably admit for monitoring and likely EEG. We have a great relationship with our 2 hospitalist groups, and I can tell you that I wouldn't get any pushback on admitting this baby. We admit well-appearing babies for ALTE/rule out seizure all the time. Many of them end up being nothing, but I think that in many cases admission is the right way to go.

As a pediatric hospitalist, I would have no problem admitting this baby for obs. I likely wouldn't order any labs or radiation therapy unless the kid decided to have another episode. Best case scenario is what I call the "extremely boring admission" (and this is what I tell the parents just so that they're aware that they can expect a whole lot of nothing as far as work up/tests go), and they go home after 23 hours of sitting in the hospital, with close followup with their PCP.

 

[eviorr]

Coming from the perspective of a pediatric neurologist, I disagree somewhat with the idea that hypotonia = CNS process. Most sources state that hypotonia is more common than hypertonia in ALTE. From a prospective study of children presenting with ALTE in London:

"Cyanosis and apnoea were the predominant presenting symptoms, occurring in 46 (71%) and 45 (70%) of infants respectively. Difficulty in breathing occurred in 40 (62%), pallor in 33 (51%), stiffness in 30 (46%), floppiness in 28 (43%), choking in 23 (35%), red face in 19 (29%), limb jerking in 14 (22%) and vomiting in 12 (18%). None of these symptoms in particular correlated significantly with the final diagnosis (1).

Even though these authors found about an equal number of cases with increased and decreased tone, that did not predict etiology. They also note that limb jerking did not predict a diagnosis of seizure - neurologists will readily agree with this, but in my experience it is difficult to make non-neurologists believe it. Ultimately, 6 infants were found to have seizures (about 10%) - this fits with other estimates I have seen for seizures as a cause for ALTE. In almost all case series and studies, 50% of ALTE's remain idiopathic.

Where I trained, we had a dedicated pediatric neurology service, but the standard of care was for ALTE's to be admitted to the general pediatric service with neurology following as consultants. These infants need a lot more than a rule-out seizure work-up. I do think that an EEG is important, but I usually recommend a 24-hour EEG, not a routine 30-60 minute study, since many of the cases that were seizure do not have interictal abnormalities evident on a short study. Another central cause that needs to be ruled-out is infection, however in my experience most providers suffer from MFLP (morbid fear of lumbar puncture). In an 8 month old, absence of fever and well-appearance on exam makes watching without LP reasonable, but in the infants under 2 months, being afebrile and well-appearing does not rule out meningitis and I would not hesitate to obtain CSF and cover with antibiotics and acyclovir until culture and HSV PCR rules out infection.

My only other bias regarding ALTE is that we need to accept that 50% will be idiopathic - too often have I seen non-neurologists, wanting to provide some diagnosis to the family, tell them that the episode must have been a seizure since everything else had been ruled out. My colleagues in gastroenterology have even more frustration with the use of GERD as a stand-in for the frustrating diagnosis of "idiopathic".

(1) Davies F, Gupta R. "Apparent life threatening events in infants presenting to an emergency department." Emerg Med J 2002;19:11-16