Can I d/c kids with ALTE?

[Interpolfanclub]

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Had a pt a few days ago who was 2 mos old, no PMHx. Mom brought him in for an episode of "choking on his milk, looked like he couldn't breathe and his lips turned blue." Mom flipped out and handed him to someone else who patted him on the back and he was then ok. Mom doesn't think it lasted more than 20 secs but she isn't sure. He had been fine for about 4 hours when I saw him and had been eating well. History and physical were normal. I felt we could discharge him but when I said that my attending looked at me like I had two heads.

Which got me thinking, when can we discharge these kids vs who to admit. Obviously if something is concerning on history (multiple ALTEs) or physical (decreased BS on right) then we work up and admit. But if vital signs are WNL, and so is history and physical can we send them home? I've read a few articles which appear to say that a kid with no PMHx and nothing concerning on physical can be observed and D/C'd. Routine labs seem to yield nothing that wasn't found on h and P.

Be glad to hear anyone's thoughts. I realize the huge downside to D/C'ing a kid with a scary CC and that standard of care in most places is to just admit. Just trying to think out loud.

 

[WallowaWanderer]

I hate the ALTE😱

 

[CueDoc]

We usually admit them and have no problems from the peds end. 99% of the time they are fine, I guess it just depends on if you feel that a 1% chance of an adverse event occuring is an acceptable risk in a child who is discharged. If something does happen you are going to get hosed. Does anyone have any data on what percentage of ALTE actually have future adverse events?

 

[roja]

I asked this question about few years back, when I was a resident. We have a peds EM guy who is also a PICU doc. ALTE=admission

 

[oldbearprofessor]

We usually admit them and have no problems from the peds end. 99% of the time they are fine, I guess it just depends on if you feel that a 1% chance of an adverse event occuring is an acceptable risk in a child who is discharged. If something does happen you are going to get hosed. Does anyone have any data on what percentage of ALTE actually have future adverse events?

There are 2 excellent recent studies about this topic:

Edner et al. Why do ALTE infants not die in SIDS? Acta Paediatrica
Volume 96 Issue 2 Page 191-194, February 2007

and

Apparent life-threatening events and sudden infant death syndrome: comparison of risk factors. Esani N, Hodgman JE, Ehsani N, Hoppenbrouwers T. J Pediatr. 2008 Mar;152(3):365-70. Epub 2007 Nov 5


I think it is best to read each of these recent articles and form your own opinion as to this issue. As a neonatologist I have never been ASKED about whether an ALTE was to be admitted, I assume they all are. Although the crossover risk is low, I have no problems with admitting nearly all of the infants unless there was a clear history of gagging that wasn't really serious.

Most of these infants do not need home monitoring. My child, who had an ALTE several decades ago did need and deserve a home monitor. It was a horrible experience. . I would do it again and would gladly work up 100 babies with ALTE to prevent one SIDS death if that really is the ratio.

 

[12R34Y]

At our children's hospital ALTE also = admission ALWAYS. They are easy. Kiddo always looks perfect, then admit. done.

however, having said that I have absolutely no data/evidence to support this practice.

like most of medicine we just "do" stuff because......someone taught us that....been done for years that way..........got burned once.....etc.. (does that sound cynical?)😀

 

[GeneralVeers]

ALTE is the easiest peds diagnosis ever. They have a normal history and physical (except for the color change). The workup is straightforward and formulaic, and there's no thought involved. If Mom says kid turned ANY color, just admit.

 

[EM_Rebuilder]

Had a pt a few days ago who was 2 mos old, no PMHx. Mom brought him in for an episode of "choking on his milk, looked like he couldn't breathe and his lips turned blue." Mom flipped out and handed him to someone else who patted him on the back and he was then ok. Mom doesn't think it lasted more than 20 secs but she isn't sure. He had been fine for about 4 hours when I saw him and had been eating well. History and physical were normal. I felt we could discharge him but when I said that my attending looked at me like I had two heads.

Which got me thinking, when can we discharge these kids vs who to admit. Obviously if something is concerning on history (multiple ALTEs) or physical (decreased BS on right) then we work up and admit. But if vital signs are WNL, and so is history and physical can we send them home? I've read a few articles which appear to say that a kid with no PMHx and nothing concerning on physical can be observed and D/C'd. Routine labs seem to yield nothing that wasn't found on h and P.

Be glad to hear anyone's thoughts. I realize the huge downside to D/C'ing a kid with a scary CC and that standard of care in most places is to just admit. Just trying to think out loud.

I just worked in our Peds ER this past month. A few shifts in, I had one of these. Didnt think it was nothing.. reassured mom, go home, babies just do this, probably chocked on some spit, etc... went out and told the pedi ED attending and he about crapped a brick that I thought baby could just go home! He said color change per history, admit...no questions asked.

 

[oreosandsake]

Claudius I, Keens T.
Do all infants with apparent life-threatening events need to be admitted?
Pediatrics. 2007 Apr; 119(4):679-83.

Objective: The goal was to identify criteria that would allow low-risk infants presenting with an apparent life-threatening event to be discharged safely from the emergency department. Methods: We completed data forms prospectively on all previously healthy patients <12 months of age presenting to the emergency department of an urban tertiary care children's hospital with an apparent life-threatening event over a 3-year period. These patients were then observed for subsequent events, significant interventions, or final diagnoses that would have mandated their admission (eg, sepsis). Results: In our population of 59 infants, all 8 children who met the aforementioned outcome measures, thus requiring admission, either had experienced multiple apparent life-threatening events before presentation or were in their first month of life. In our study group, the high-risk criteria of age of <1 year and multiple apparent life-threatening events yielded a negative predictive value of 100% to identify the need for hospital admission.
Conclusions: Our study suggests that >30-day-old infants who have experienced a single apparent life-threatening event may be discharged safely from the hospital, which would decrease admissions by 38%.
Full-text available at: http://www.pediatrics.org

http://pediatrics.aappublications.org/cgi/content/full/119/4/679

 

[oldbearprofessor]

Claudius I, Keens T.
Do all infants with apparent life-threatening events need to be admitted?
Pediatrics. 2007 Apr; 119(4):679-83.

Objective: The goal was to identify criteria that would allow low-risk infants presenting with an apparent life-threatening event to be discharged safely from the emergency department. Methods: We completed data forms prospectively on all previously healthy patients <12 months of age presenting to the emergency department of an urban tertiary care children's hospital with an apparent life-threatening event over a 3-year period. These patients were then observed for subsequent events, significant interventions, or final diagnoses that would have mandated their admission (eg, sepsis). Results: In our population of 59 infants, all 8 children who met the aforementioned outcome measures, thus requiring admission, either had experienced multiple apparent life-threatening events before presentation or were in their first month of life. In our study group, the high-risk criteria of age of <1 year and multiple apparent life-threatening events yielded a negative predictive value of 100% to identify the need for hospital admission.
Conclusions: Our study suggests that >30-day-old infants who have experienced a single apparent life-threatening event may be discharged safely from the hospital, which would decrease admissions by 38%.
Full-text available at: http://www.pediatrics.org

http://pediatrics.aappublications.org/cgi/content/full/119/4/679

Just FYI, the following letter was published in response in the journal: PEDIATRICS Vol. 120 No. 2 August 2007, pp. 448 (doi:10.1542/peds.2007-1159)

To the Editor.&#8212;

In the April 2007 issue of Pediatrics, Claudius and Keens reported ........... They wrote in their abstract that these infants "may be discharged safely from the hospital."

The authors must be well aware of the fact that a study based on 50 infants is not powered to detect significant effects with a frequency of <2%. Hence, in the discussion section they stipulated their recommendation to discharge low-risk infants "if the results of this pilot study are borne out in a larger, multicenter population." However, this condition is not mentioned in the abstract. This omission could lead to the immediate adoption of a practice guideline for which sufficient evidence is still lacking.

My note on this is that a study of 50 infants has a wider error margin for what it could miss than 2% (which is still too high to accept). Read the other 2 articles and make up your own mind. I'm still with the "admit" unless a truly trivial event (no real color change, etc) group on this one.

 

[EctopicFetus]

I had one of these not too long ago.. basically worked him up.. kid looked like a million bucks. We decided to call peds to get their opinion and they admitted. easiest admit ever.

Also as far as the above study.. their N is quite small and if we are talking about 1% then you might have missed it with only 59 enrolled patients.

 

[WallowaWanderer]

Hmm . . . sounds like when I become an attending my opinion of ALTE's is going to change.

 

[J-Rad]

From the Peds end, I don't think you need to admit every ALTE. A straightforward, quickly self (or with minimal intervention) resolving reflux/choking event in an otherwise pristine Hx & PE. Why admit? So they can pick up whatever respiratory or GI bug that's floating around on the ward? When I'm the resident on call, I don't fight admissions, but thinking that every benign but scary thing needs admission is akin to saying every ailment needs a medicine. Sometimes reassurance and appropriate precautions (raise head of bed, etc.) suffice. Just like most medicines, hospital admission is not a risk-less proposition for multiple reasons. I understand and agree with having a low threshold for admission, but don't agree than all of them need admission.

 

[NKMU]

I discharged one a couple nights ago. 2 month-ish old choked while taking meds. "Got pale" Came in via EMS advertised as respiratory distress. Had tube and blade in hand when in rolls a pink, healthy, crying baby. CXR, po challenge, reassurement, d/c home. Pt seen with a Peds-EM attending who is very into EBM.

 

[EctopicFetus]

I discharged one a couple nights ago. 2 month-ish old choked while taking meds. "Got pale" Came in via EMS advertised as respiratory distress. Had tube and blade in hand when in rolls a pink, healthy, crying baby. CXR, po challenge, reassurement, d/c home. Pt seen with a Peds-EM attending who is very into EBM.

where is the EBM? N of 56 isnt EBM for something like this..

 

[BatmanMD]

I def agree that most parents exagerate their childs condition, but in this case, you have to admit. If the child was yours, and this happened, what would you expect?

A pat on the back, and go home, dont worry..
Or admission for maybe only the night..

We've all admitted a lot softer cases than an infant turning a different color.
Plus, not to bring out the lawyers, but how can you even try to defend this? Any and all peds attendings will easily take the admission, even a neonatologist earlier said it's an easy decision.

ALTE=admit

 

[deleted109597]

Had a combined peds-EM grand rounds on this last fall. Peds attending said, effectively, admit for color change, don't admit simply for short apneic events (IIRC).

 

[WilcoWorld]

From the Peds end, I don't think you need to admit every ALTE. A straightforward, quickly self (or with minimal intervention) resolving reflux/choking event in an otherwise pristine Hx & PE. Why admit? So they can pick up whatever respiratory or GI bug that's floating around on the ward? When I'm the resident on call, I don't fight admissions, but thinking that every benign but scary thing needs admission is akin to saying every ailment needs a medicine. Sometimes reassurance and appropriate precautions (raise head of bed, etc.) suffice. Just like most medicines, hospital admission is not a risk-less proposition for multiple reasons. I understand and agree with having a low threshold for admission, but don't agree than all of them need admission.

OK, I agree that I don't need to admit every kid who momentarily chokes on his apple sauce, but I don't consider that an ALTE.

If you truly believe your recommendations, then your practice should be to discharge these ALTE's without any testing (in ED or on the floor) after a negative H&P? Is that your practice? If not, why not?

ALTE is like the Peds equivalent of Chest Pain. A negative physical & a relatively unimpressive history can put a patient into a low risk category, but there is essentially no tollerance for missing the possible badness in even just 1% of the "low risk" population. As such, Pediatricians, Cardiologists, and EP's have all agreed that standard of care is to do more than just the H&P.

So, yes, when a kid under 1 year has a very clear story of something unconcerning, or when an adult over 30 has a very clear non-cardiac cause for chest pain, I will d/c without any testing, but when these things can't be elucidated, we are essentially forced to entertain the possibility of serious causes.

P.S.: Sweet avatar.

 

[J-Rad]

So, yes, when a kid under 1 year has a very clear story of something unconcerning, or when an adult over 30 has a very clear non-cardiac cause for chest pain, I will d/c without any testing, but when these things can't be elucidated, we are essentially forced to entertain the possibility of serious causes.

P.S.: Sweet avatar.

An ALTE is something of a perceptual event. An event that is perceived to be life threatening and is accompanied by either color change, apnea, or tonal change or some combination.
I think we are actually in agreement. I think you can only discharge without w/u when you have a clear etiology. But a THOROUGH history can elucidate a few things that are perfectly benign: simple (quickly resolving) choking spell, breath holding spell (pallid or cyanotic), respiratory pauses (which scare the bejesus out of some parents). I would still not hesitate to admit any of the above for any squirreliness (ex. loss of tone with a choking spell: loss of tone is more suspicious for seizure than increased tone which is usually seen with choking). Yes, significant parental anxiety should influence the admission decision (but some parents can be reassured). And if I admit something with a perfect history for a benign cause, I do not order any workup and just put them on monitors overnight. I admit that I may do some things differently than some (I try to keep admitted bronchiolytics off of continuous pulse ox if possible and I'm one of the few parents who didn't bring my kid to the hospital when he siezed for the first time [febrile all day, super strong fam hx of febrile sz, and back to nl in 20minutes]🙂) but I'm not cavalier and like I said, the story has to be perfect.
PS Thanks.

 

[roja]

I am with WilcoWorld here. (perhaps because it coincides with what I was taught in our peds ED attending- which is staffed by all peds EM trained attendings). a choking episode is not an ALTE, as it was taught to me. An ALTE, as I was taught, was a perception of life threatening that was not precipitated by anything.

Regarding the EBM, you can not, from an evidence standpoint, use this study as an EBM grounds for discharge. an n of 52 is not powered enough to make anything. At a rough glance, you have to look at the number of deaths associated with apparant ALTE (you could probably use SIDS deaths as a proxy), you would probably need upwards of 5-10K enrollments (similar to cardiac resusc literature).


This is an inappropriate power analysis and thus makes the rest of the data not very useful.

It might show a *trend* that it might be safe to send these kids home, but nothing I could base sending a 2 month home on. The risk/benefit is waaaaaaaaaaaaaaaay to high in my opinion. As pandabear stated, although the yield would be really low on the admissions, I would rather admit 100 healthy babies who ended up having nothing and just had to stay in the hospital a night than have one go home and die.

 

[oldbearprofessor]

As pandabear stated, although the yield would be really low on the admissions, I would rather admit 100 healthy babies who ended up having nothing and just had to stay in the hospital a night than have one go home and die.

Assuming you are referring to my statement to that effect in post #5 of this thread, you have just delivered the most substantive insult ever hurled at me in my many years on SDN.

I am not Pandabear. I may be DKM/Dienekes,😉 but never, ever, Pandabear.😡

And yes, small studies like the n=50 with sweeping conclusions are problematic. The peer-review process does an inadequate job at times at preventing this type of misinterpretation of data.

 

[nonesuchgirl]

I am not Pandabear. I may be DKM/Dienekes,😉 but never, ever, Pandabear.😡

😱 And I'd only like you more if you were either of them. 🙂

 

[J-Rad]

I am with WilcoWorld here. (perhaps because it coincides with what I was taught in our peds ED attending- which is staffed by all peds EM trained attendings). a choking episode is not an ALTE, as it was taught to me. An ALTE, as I was taught, was a perception of life threatening that was not precipitated by anything.

www.emedicine.com:
”... ALTE was defined by the 1986 National Institutes of Heath Consensus Development Conference on Infantile Apnea and Home Monitoring as follows:

"An episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking or gagging. In some cases, the observer fears that the infant has died. Previously used terminology, such as 'aborted crib death' or 'near miss SIDS' should be abandoned as it implies a, possibly, misleading close association between this type of spell and SIDS."

15Jun05 American Family Physician article on ALTE:

“By definition, an ALTE refers to a sudden event, often characterized by apnea or other abrupt changes in the child's behavior (Table 1).1 Symptoms of an ALTE include one or more of the following: apnea, change in color or muscle tone, coughing, or gagging.2 These episodes may necessitate stimulation or resuscitation to arouse the child and reinitiate regular breathing.
table 1
Definitions from the 1986 National Institutes of Health Consensus Panel on Infantile Apnea and Home Monitoring

Apparent life-threatening event (ALTE): sudden event, frightening to the observer, in which the infant exhibits a combination of symptoms, including apnea, change in color (pallor, redness, cyanosis, plethora), change in muscle tone (floppiness, rigidity), choking, gagging, or coughing”

Up To Date:
INTRODUCTION — ALTE is the abbreviation for "apparent life-threatening event", a poorly defined term to describe an acute, unexpected change in an infant's breathing behavior that was frightening to the infant's caretaker and that included some combination of the following features [1] :
&#61623; Apnea — usually no respiratory effort (central) or sometimes effort with difficulty (obstructive)
&#61623; Color change — usually cyanotic or pallid, but occasionally erythematous or plethoric
&#61623; Marked change in muscle tone (usually limpness or rarely rigidity)
&#61623; Choking or gagging

Rosen’s Emergency Medicine:
:An apparent life-threatening event is “an episode that is frightening to the observer and is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually limpness), choking, or gagging.” Often the observer fears that the infant has died.[9] ALTE is a term used until a precise causative diagnosis can be established, but more than 50% of ALTEs never receive a definitive diagnosis despite an extensive workup. Previously used terms such as near-miss SIDS or aborted crib death should not be used because they imply an unproven, misleading association between an ALTE and SIDS.”


I would argue that the Peds ED attendings that you worked with altered the generally accepted definition of ALTE then. In their definition, then, yes, probably all of what they define as ALTE should be admitted. In the more accepted definition of ALTE, I still believe that there are narrow circumstances in which discharge in the hands of comfortable parents is acceptable and has less potential for harm.

 

[J-Rad]

BTW, I've admitted multiple kids for ALTE who had clear (and often minor sounding) choking event who got chest compressions. I'd have a hard time not calling that an "apparent life threatening event" (most ED docs in the local area will request admission if they got chest compressions...I can't argue with that logic. And I have seen Peds ED trained attendings at the local children's hospital d/c an ALTE under the above narrow circumstances). I've also seen parents bring their kid to the ED (some via EMS) because their child stopped breathing for 5 seconds and they were convinced the child would die (still meets definition of ALTE)

 

[roja]

Assuming you are referring to my statement to that effect in post #5 of this thread, you have just delivered the most substantive insult ever hurled at me in my many years on SDN.

I am not Pandabear. I may be DKM/Dienekes,😉 but never, ever, Pandabear.😡

And yes, small studies like the n=50 with sweeping conclusions are problematic. The peer-review process does an inadequate job at times at preventing this type of misinterpretation of data.

Oooops. I am so sorry. I was working, multitasking, and just remmbered the icon of a teddybear. brainfart on my part. 🙂