Discharge diagnoses in infants with apparent life-threatening event

BACKGROUND: There are various identifiable diseases or conditions that can be associated with an apparent life-threatening event (ALTE) in infancy. The present study was carried out to investigate the etiology of ALTE based on the discharge diagnoses. METHODS: A protocol for the complete work-up used to examine the cause of ALTE was designed, and was carried out for 69 infants with ALTE. RESULTS: Gastroesophageal reflux disease (GERD) was demonstrated in 38 cases, and chronic gastric volvulus (CGV) was diagnosed in 21 (associated with GERD in 13 infants). Four cases of pertussis and two cases each of sepsis, laryngomalacia, respiratory immaturity, and premature ventricular contractions were found. Others cases presented with pneumonia, meningitis, intussuception, food allergy, epilepsy, and adenoid vegetations. In 12 of the 69 infants with ALTE, no abnormalities were found in any of the studies performed, including two patients with breath-holding spells. In 17 cases, two or more possibly contributing findings were diagnosed. CONCLUSION: It is important to recognize that gastroesophageal impairments such as GERD or CGV could be responsible for many incidences of ALTE in infancy. The authors recommend a trial be established to investigate the causes of ALTE, including gastroesophageal evaluations in all infants with ALTE.     

Increased inspiratory effort in infants with a history of apparent life-threatening event

The objective of this study was to compare the results of polysomnography between infants with a history of apparent life-threatening event (ALTE) and controls. In this case-control study, 40 full-term ALTE infants, aged 2-36 wk at the time of the event, were compared with 40 age- and sex-matched randomly selected controls. SaO2, tcpO2, tcpCO2, heart rate (HR), vector of rib cage and abdominal respiratory movements (phase angle, as an index of inspiratory effort) were recorded during natural nocturnal active and quiet sleep (AS, QS). SaO2, tcpO2, tcpCO2 were similar in ALTE and controls in both sleep states. Phase angle was increased in ALTE infants in both AS (59+/-46 vs 26+/-17 degrees) and QS (53+/-46 vs 18+/-14, p < 0.001). Eleven ALTE infants (27.5%) experienced SaO2 < 90%, with a mean decrease in SaO2 to 86+/-1.6% (mean +/- SD), compared with 10% for controls (p=0.003). In eight ALTE infants, SaO2 values <90% were linked to thoracoabdominal asynchrony. SaO2 < 90% in conjunction with HR <100 bpm were detected in three ALTE infants and one control. Periodic breathing was observed in 45% of ALTE infants and 40% of controls. CONCLUSION: The mean values of oxygen saturation, tcpO2 and carbon dioxide levels in ALTE infants are comparable with those of healthy controls but the ALTE infants exhibit more hypoxaemic episodes and increased inspiratory effort during sleep.     

Recommended clinical evaluation of infants with an apparent life-threatening event. Consensus document of the European Society for the Study and Prevention of Infant Death, 2003

Infants with an apparent life-threatening event (ALTE) should not be treated nor monitored without a detailed medical evaluation, as different medical causes may be responsible for the initial clinical presentation. Standard and specific evaluation procedures are listed to help identify a cause for the ALTE. The most frequent problems associated with an ALTE are digestive (about 50%), neurological (30%), respiratory (20%), cardiovascular (5%), metabolic and endocrine (under 5%), or diverse other problems, including child abuse. Up to 50% of ALTEs remain unexplained. The finding of medical or surgical anomalies leads to specific treatments. Surveillance programmes with the use of home monitoring devices may be undertaken, preferably with cardiorespiratory monitors, and when possible, with event monitors, although no currently available home monitoring device is free of false alarms or offers complete protection. Long-term follow-up programmes of infants with an apparent life-threatening event contribute to adapt medical attitudes to the childs needs and to confirm the medical diagnosis. Conclusion: a systematic diagnostic evaluation, together with a comprehensive treatment programme, increases survival and quality of life for most affected infants.Abbreviations ALTE apparent life-threatening event - SIDS sudden infant death syndrome For the European Society for the Study and Prevention of Infant Death (ESPID). Members of the ESPID who contributed to the present consensus statement: Bentele K, Belhadi B, Blair P, Byard RW, Cosmi EV, Fleming PJ, Franco P, Grogaard J, Groswasser J, Huber J, Hurgoiv V, Irgens LM, Jorch G, Jura J, Kaczmorski M, Katz-Salamon M, Kelmanson I, Kerbl R, Kiechl-Kohlendorfer U, Krous HF, Kurz R, LHoir M, Mallet E, Milerad J, Naulaers G, Neubauer D, Perk Y, Piumelli R, Poets CF, Rambaud C, Rognum OR, Sawaguchi T, Schlaud M, Shatz A, Sperl W, Stöllinger O, Stoltenburg-Didinger G, Sutter M, Tonkin S, Van Reempts P, Wasilewska J, Wilske J, Zotter H.Specialists at large who contributed to the present consensus statement: Adamson R, Brooke H, Devlieger H, Follett F, Gaultier C, Gingras J, Gozal D, Harper R, Hessel L, Hunt C, Horne RSC, Jenik A, Keens T, Lahorgue M, Marcus C, Rivarola MR, Sebastiani P, Scaillet S, Thach B, Togari H, Vecchierini MF, Willinger M.     

Heart rate variability in infants with apparent life-threatening events

Heart rate variability (HRV) is often used as an index of sympatho-vagal balance. A decreased HRV has been observed in patients with central hypoventilation and in infants who have later succumbed to sudden infant death syndrome (SIDS). The aim of the present study was to investigate whether HRV is altered in infants with apparent life-threatening events (ALTE), a group with an increased risk of SIDS. Fifty infants with ALTE were compared with 50 age- and sex-matched controls. ECG was recorded overnight in all infants. Two sequences of RR intervals free of artefacts were selected from each sleep state and spectral analysis of RR variability was performed. The mean and SD of RR and the low (LFPow) and high (HFPow) frequency power were analysed. In active sleep (AS) the LF/HF ratio was lower in ALTE infants, but no differences were seen in either the LFPow or the HFPow. In quiet sleep (QS), however, ALTE infants had higher SD-RR (p = 0.006), greater HFPow (p = 0.02) and VLFPow (very low frequency power, p = 0.02) than the control infants. The same results were seen when the two sleep states were combined for analysis, ALTE infants had higher SD-RR (p = 0.004), HFPow (p = 0.006) and VLFPow (p = 0.04). Conclusion: The different HRV pattern in ALTE infants compared to healthy controls suggests an altered autonomic control.     

Abnormal heart rate response to hypercapnia in boys with an apparent life-threatening event

AIM: To determine instantaneous cardiac variability responses to increased carbon dioxide (CO2) during quiet sleep in infants who may be at risk for the Sudden Infant Death syndrome (SIDS). METHODS: The cardiac rate variability before, during and after a CO2 challenge was examined in 41 infants who had experienced an apparent life-threatening event (ALTE) and 41 gender- and age-matched control infants. RESULTS: The ALTE infants responded to CO2 breathing with a significant increase in R-R intervals, i.e. decreases in heart rate, compared to the controls (45.1% increase in R-R intervals vs. 41.4%; p = 0.005). The differences between ALTE infants and controls depended primarily on the boys' responses. CONCLUSION: ALTE infants, particularly ALTE boys, have an autonomic dysfunction-lower sympathetic stimulation and/or inhibited vagal withdrawal when stressed with CO2. The outcome might provide clues to the mechanisms underlying the cardiovascular processes contributing to the terminal event in SIDS.     

Gastro-oesophageal reflux, sleep pattern, apparent life threatening event and sudden infant death. The point of view of a gastro-enterologist

Sudden infant death, apparent life threatening events and regurgitation occur mostly during the first 6 months of life, making it very tempting to suspect a relation between these phenomena. According to epidemiological data, the role of gastro-oesophageal reflux in the aetiology of apparent life threatening events is unclear. It has been demonstrated that sudden infant death is decreased in the supine versus the prone sleeping position. On the contrary, gastro-oesophageal reflux is more pronounced in the supine than in the prone position, both in infants and in older children, both in infants with physiological and with pathological reflux. In the supine position, infants do sleep shorter, have more rapid-eye-movement sleep and have more arousals than in the prone position. Conclusion It is thought that in the majority of infants, gastro-oesophageal reflux stimulates arousals and thus may well be considered as “protective” for rather than “provoking” sudden infant death. However, this hypothesis needs to be validated. Received: 4 April 1999 and in revised form: 28 March 2000 and 14 April 2000 / Accepted: 17 April 2000     

Relationship of the ventilatory response to hypoxia with neonatal apnea in preterm infants

OBJECTIVE: Correlate the ventilatory response of preterm infants to hypoxic exposure with incidence of neonatal apnea.Study design Seventeen stable convalescing premature infants underwent bedside cardiorespiratory monitoring of respiration using respiratory inductance plethysmography, heart rate, and oxygen saturation (SaO(2)) for a 12-hour period. These studies were scored for number of apneas > or =15 and > or =20 seconds. Infants then underwent a 3-minute hypoxic exposure. Minute ventilation (V(E)) was calculated for 30-second epochs from the time inspired oxygen reached 15%. Linear regression analysis was used to correlate the change in V(E) normalized for decrease in SaO(2) (DeltaV(E)/DeltaSaO(2)) during the first and third minutes of hypoxic exposure with the number of apneic episodes during the 12-hour study. RESULTS: The majority of infants exhibited an anticipated biphasic ventilatory response to hypoxia. There was a significant positive correlation between DeltaV(E)/DeltaSaO(2) during the first and third minutes of hypoxic exposure and number of apneic episodes > or =15 and > or =20 seconds during the preceding 12 hours. CONCLUSIONS: Preterm infants with a greater number of apneic episodes exhibit an increased ventilatory response to hypoxic exposure, suggesting that apnea of prematurity may be associated with enhanced peripheral chemoreceptor activity.