COVINGTON, KY. – Evaluation and management of apparent life-threatening events should start with a clear, concise definition and an understanding of the risk for a serious underlying disorder, but so far this has proved elusive.
Despite a deluge of testing, nearly 50% of children leave the hospital with a diagnosis of idiopathic or gastroesophageal reflux, Dr. Joel Tieder said at the Pediatric Hospital Medicine 2012 meeting.
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Dr. Joel Tieder
National efforts by an expert panel of hospitalist researchers and policy makers are underway to standardize inpatient care for an apparent life-threatening event (ALTE), a condition that evokes high anxiety in parents and providers alike and is defined by a loose constellation of symptoms.
The rallying cry for many pediatric hospitalists proved to be the largest multicenter study of ALTE to date (J. Pediatr. 2008;152:629-35). This study identified the frequent use of nonindicated testing – including pH probes, chest x-rays, and EKGs – and inconsistent hospital outcomes among infants admitted with ALTE.
"People really coalesced around this idea that hospitalists should own this disorder and fix it," explained Dr. Tieder, who led the study and sits on the expert panel. "There was just too much variability around the diagnosis and management, and we felt that this might be the first disorder we could tackle with guidelines."
The panel, sponsored by the Society for Hospital Medicine, has summarized and submitted for publication the sparse science there is on ALTE in hopes of soliciting comment and consensus.
Redefinition in Action
The panel also took the ambitious and somewhat unorthodox step of holding workshops at the Pediatric Hospital Medicine 2012 meeting for attendees to pen their own definition of ALTE. The discourse was dynamic and at times deafening, and despite the agreed upon goal among an audience of pediatric hospitalists, consensus on the content was conspicuously absent, which speaks to the difficulty of the task. Common themes did emerge and will be folded into the ongoing dialogue, said Dr. Tieder of Seattle Children’s Hospital.
Currently, clinicians diagnose ALTE using the National Institutes of Health’s definition that was put forth in 1986: an episode in the first year of life that appears potentially life threatening to the observer and is characterized by some combination of color change, apnea, alteration in muscle tone, and choking or gagging.
The crux of the problem is that this definition does not distinguish ALTE as a constellation of symptoms vs. ALTE as a diagnosis, he said. The term is loosely applied when testing proves to be unfruitful, or it is kept as the diagnosis despite an identification of the underlying cause of the event.
The new definition should also make very clear that – despite previous misnomers such as "near-miss SIDS" or "aborted crib deaths" –an ALTE is very different from SIDS, Dr. Tieder said. The two conditions have different risk factors, and interventions to reduce SIDS (such as the "Back to Sleep" campaign) have not reduced ALTEs.
The broad subjective definition of ALTE, the low prevalence of underlying disease, and the anxiety induced by ALTE combine to make "a recipe for testing cascade," Dr. Tieder said. "These are beautiful, healthy-appearing infants, and yet we do all these potentially harmful things to them with little evidence that the results will improve their outcomes."
Patrice Wendling/IMNG Medical News
Pediatric Hospital Medicine meeting attendees brainstorm on a new ALTE definition.
Importantly, the yield for routine diagnostic testing for ALTE is low. In one study of 243 consecutive infants who experienced an ALTE, only 17.7% of 3,776 tests ordered were positive; even worse, just 6% contributed to the diagnosis (Pediatrics 2005;115:885-93).
Common discharge diagnoses for ALTE – such as idiopathic gastroesophageal reflux, respiratory infections (8%-11%), and seizures (9-11%) – are largely self-limiting and nonrecurring. It’s with the less common causes that clinicians start seeing the problem with managing an ALTE, Dr. Tieder said. These include pertussis (0.05%-9%), cardiac arrhythmias (fewer than 1%), bacterial infection (0%-8%), metabolic disorder (1.5%), and – increasingly and especially in infants with recurrent ALTE – child maltreatment (fewer than 1%).
"You need to have a high index of suspicion for child maltreatment," he said. A recent study involving 563 children, average age 2.3 months, who presented to the emergency department following an ALTE found a mortality rate of 9% in victims of child abuse (Pediatr. Emerg. Care 2011;27:591-5).
An Unfunded Conundrum
Despite the potential risk for serious underlying conditions and death, research funding has been lacking. Again, the problem lies with ALTE’s being defined as a constellation of symptoms, not as a disease (which is how government typically allocates research dollars), Dr. Tieder explained.