Practice Based Learning: ALTEs – who needs admission and who needs home monitoring?

Soohee Cho MD

Presented by Soohee Cho, MD PGY-1

Clinical Questions:

  • Can we safely identify patients with an Apparent Life-Threatening Event (ALTE) who needs inpatient observation vs. discharge home with reassurance & signs to bring child back?
  • Can we safely identify patients who would benefit home apnea monitoring?

Background:

  • ALTE has mortality of 0-6%
    • With more recent studies show less mortality
  • No death from SIDS on ALTE cohorts
    • SIDS prevalence decreased since “back to sleep” but no change in ALTE prevalence
  • 76-93% of ALTE admitted (DePiero and Claudis & Keens)
    • 2012 Pediatrics in Review recommends majority of infants with ALTE to be admitted for obs x 23hrs
  • Only 7-13.5% needed significant intervention

Summary of Mittal MK, et al. (2012)

  • Prospective cohort study
  • Measured significant intervention, recurrent of ALTE leading to visit or any other major event in 72 hrs
  • Significant intervention defined a priori
    • Parenteral abx, hypoxia <95% requiring supplemental O2, intubation, repeated airway suctioning, ICU admission, repeat ALTE, abnormal pneumogram & d/c with apnea monitor, cards consult & ECHO, abnl EEG & antiepileptic, or any other major illness
  • Bivariate relationships between predictor variables and the need for significant intervention examined
  • Clinical decision rule (CDR) made based on predictor variables:
    • Prematurity
    • Abnormal result in the examination
    • Color change to cyanosis
    • No history of URI symptoms in the previous 24 h
    • No history of choking during the episode
  • Strengths of study:
    • One of the largest prospective studies in ALTE
      • Previous prospective studies with 50-60s enrollment
    • Large tertiary children’s ED, similar to our facility
    • Also included large premature population (34%)
    • Smaller prospective studies in the past, but first one to make CDR based on predictors
  • Weaknesses of study:
    • Single institution – population diversity?
    • “abnormal PE” – poor definition
    • Theoretical study – would 40% less admission lead to more ED visits, etc.?

So who needs home monitoring?

  • Short answer is there’s a no good answer:
    “Although there is a large body of literature describing AOP (apnea of prematurity) and ALTEs, there is no consensus on the use of home monitoring.” (Silvestri, 2009)
  • For idiopathic ALTE, the decision to use home monitoring should be individualized
  • Goal of evaluation of ALTE is to ID a treatable cause
  • No study has demonstrated that monitors save lives and prevent sudden, unexpected death
  • Home monitoring should have a memory capability (to review true vs false events)

Emotional burden of home monitoring:

References:

Mittal MK, Sun G, Baren JM. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care. 2012 Jul;28(7):599-605.

Silvestri JM. Indications for home apnea monitoring (or not). Clin Perinatol. 2009 Mar; 36(1):87-99.

Committee on Fetus and Newborn. American Academy of Pediatrics. Apnea, sudden
infant death syndrome, and home monitoring. Pediatrics. 2003 Apr;111(4 Pt 1):914-7.

Weese-Mayer DE, et al. Assessing validity of infant monitor alarms with event recording. J Pediatr. 1989 Nov;115(5 Pt 1):702-8.

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