"We’re really stuck without a research source," he said. In the conventional mechanism, government funders "might fund child maltreatment, but [ALTE represents] only a minority of these patients. So when they start to rank priorities in this current austere environment, ALTEs don’t have a lot of cachet."
Grasping the Risks
A better understanding of life-threatening risk in infants with an ALTE, however, could revolutionize the work-up of these infants, just as greater understanding of the risk of myocardial infarction has revolutionized the way adult hospitalists stage the evaluation and management of adults presenting with chest pain.
Based on the current evidence, the panel has concluded that certain features can be used to assess risk and guide diagnostic testing. Factors that may define lower-risk infants are age older than 2 months; a first ALTE; a previously healthy status on no medications; no social concerns; no family history of SIDS or ALTE; and an obstructive event (such as choking, gagging, breath holding, or having a vasovagal episode) that was secondary to emesis, coughing, or crying, Dr. Tieder said. Although this is not set in stone, the panel suggests that routine screening is not indicated in low-risk infants, he added.
Key elements for higher-risk infants are age younger than 2 months, especially with upper respiratory symptoms or exposure; more than one ALTE; a history of prematurity, central apnea, comorbid conditions, or medication use; pertussis exposure/risk; social concerns; family history of SIDS; or unexplained death with physical findings of bruising or bleeding, particularly in the mouth.
Groups that are most likely to benefit from hospital admission include high-risk infants, infants younger than 37 weeks post-conceptual age, those younger than 2 months of age in whom pertussis and respiratory syncytial virus testing is pending, or cases where maltreatment is a concern, he said.
A Gap Filled
No definite timeline has been established for the panel to complete its task, but hospitalists are uniquely qualified to define ALTE and to establish a national standard for inpatient care for ALTEs, according to panel member and pediatric hospitalist Dr. Jack Percelay, who holds the newly created pediatrics seat on the SHM board of directors.
Patrice Wendling/IMNG Medical Media
Dr. Jack Percelay
"It’s very multidisciplinary, so everybody looks at it from their own scope," he said in an interview. "The GI people look at it and say it’s got to be reflux; the neurology people say it looks like it’s going to be seizures. Or it could be trauma. We have that global view, so that’s why we’re the best people for it.
"I’m not sure that we want to be the experts, but no one else has really looked at it, so it was an opportunity for us. It was an orphan disease."
Dr. Tieder reported a relationship with Child Hospital Association, which provides grant support to the Pediatric Research in Inpatient Settings Network. Dr. Percelay reported no conflicts of interest.