Management of Apparent Life-Threatening Events in Infants: A Systematic Review

doi:10.1016/j.jpeds.2012.12.086

The Journal of Pediatrics

Volume 163, Issue 1, July 2013, Pages 94-99.e6

https://doi.org/10.1016/j.jpeds.2012.12.086 Get rights and content

Objective

To determine in patients who are well-appearing and without a clear etiology after an apparent life-threatening event (ALTE): (1) What historical and physical examination features suggest that a child is at risk for a future adverse event and/or serious underlying diagnosis and would, therefore, benefit from testing or hospitalization? and (2) What testing is indicated on presentation and during hospitalization?

Study design

Systematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE.

Results

The final analysis was based on 37 studies; 18 prospective observational, 19 retrospective observational. None of the studies provided sufficient evidence to fully address the clinical questions. Risk factors identified from historical and physical examination features included a history of prematurity, multiple ALTEs, and suspected child maltreatment. Routine screening tests for gastroesophageal reflux, meningitis, bacteremia, and seizures are low yield in infants without historical risk factors or suggestive physical examination findings.

Conclusion

Some historical and physical examination features can be used to identify risk in infants who are well-appearing and without a clear etiology at presentation, and testing tailored to these risks may be of value. The true risk of a subsequent event or underlying disorder cannot be ascertained. A more precise definition of an ALTE is needed and further research is warranted.

Section snippets

Methods

Pertinent articles were identified using the stepwise approach specified in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement.⁴ PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched to identify articles published in the English-language from January 1970 through May 2011 that addressed ALTEs in children less than 24 months of age. We conducted keyword searches to identify articles with at

Results

The review identified 37 studies. Fourteen studies investigated historical and physical examination features as potential indications for hospitalization or predictors of subsequent adverse events (Table I; available at www.jpeds.com). These studies evaluated age, sex, ethnicity, history of prematurity, occurrence of multiple ALTEs, concern for child maltreatment, concern for seizures, presence of upper respiratory tract (URI) symptoms, smoke exposure, severity of the ALTE event or need for

Discussion

None of the 37 studies identified in this systematic review satisfied a high level of evidence for diagnostic or prognostic investigations, and there was little consistency in study populations, outcomes, follow-up periods, and measurement.7, 8 Nonetheless, after critical appraisal, we were able to identify some historical and physical exam features—prematurity, multiple ALTE, suspected child maltreatment—that are associated with risk for a future adverse event and/or serious underlying

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: The Society of Hospital Medicine sponsored the conference calls and an online data management platform for this study; however, it was not involved in the study design, writing of the report, decision to submit the manuscript for publication, or collection, analysis, and interpretation of data. The authors declare no conflicts of interest.

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Original ArticleManagement of Apparent Life-Threatening Events in Infants: A Systematic Review

Objective

Study design

Results

Conclusion

Section snippets

Methods

Results

Discussion

Am J Emerg Med

J Pediatr

Ann Emerg Med

J Pediatr

Am J Med

National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring, Sept 29 to Oct 1, 1986

Pediatrics

Vulnerable child syndrome and its variants

Pediatr Rev

Variation in inpatient resource utilization and management of apparent life-threatening events

J Pediatr

Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

Ann Intern Med

McMaster Premium Literature Service (PLUS) Project. Second-order peer review of the medical literature for clinical practitioners

JAMA

Prediction of citation counts for clinical articles at 2 years using data available within 3 weeks of publication: retrospective cohort study

BMJ

Users’ guides to the medical literature. III. How to use an article about a diagnostic test. A. Are the results of the study valid? Evidence-Based Medicine Working Group

JAMA

Users’ guides to the medical literature. V. How to use an article about prognosis. Evidence-Based Medicine Working Group

JAMA

Do all infants with apparent life-threatening events need to be admitted?

Pediatrics

Risk factors for extreme events in infants hospitalized for apparent life-threatening events

J Pediatr

Apparent life threatening events in infants presenting to an emergency department

Emerg Med J

Death, child abuse, and adverse neurological outcome of infants after an apparent life-threatening event

Pediatrics

Abusive head injury as a cause of apparent life-threatening events in infancy

Arch Pediatr Adolesc Med

Clinical characteristics of an apparent life-threatening event (ALTE) and the subsequent occurrence of prolonged apnea or prolonged bradycardia

Clin Pediatr (Phila)

Prevalence of retinal hemorrhages and child abuse in children who present with an apparent life-threatening event

Pediatrics

Retinal hemorrhages and apparent life-threatening events

Pediatr Emerg Care

Covert video recordings of life-threatening child abuse: lessons for child protection

Pediatrics

Considering suffocatory abuse and Munchausen by proxy in the evaluation of children experiencing apparent life-threatening events and sudden infant death syndrome

Child Maltreat

Ophthalmologic findings in infants after an apparent life-threatening event

Eur J Ophthalmol

Seizures in children following an apparent life-threatening event

J Child Neurol

Original Article
Management of Apparent Life-Threatening Events in Infants: A Systematic Review