Paediatric Clinical Guideline

Emergency

1.7 ALTE

Short Title: / Acute Life Threatening Episodes
Full Title: / Guideline for the assessment and management of acute life threatening episodes in infants and children
Date of production/Last revision: / June 2005
Explicit definition of patient group to which it applies: / This guideline applies to all children and young people under the age of 2 years.
Name of contact author / Simon Robinson, Paediatric SpR
Dr Damian Wood, Consultant Paediatrician
Ext: 67127
Revision Date / June 2008
This guideline has been registered with the Trust. However, clinical guidelines are 'guidelines' only. The interpretation and application of clinical guidelines will remain the responsibility of the individual clinician. If in doubt contact a senior colleague or expert. Caution is advised when using guidelines after the review date.

Acute Life Threatening Episodes

Definition

An infant (i.e. less than 1 year) found with one or more of the following with no obvious cause:

  • Decreased consciousness
  • Abnormal colour (pallor / cyanosis)
  • Abnormal tone (floppy / still)
  • No respiratory effort

Most parents / carers will believe the child is dead and have taken appropriate resuscitative measures.

There is a relationship between ALTE and SIDS in a minority of cases, but so far we cannot predict which children who have had an ALTE are most likely to progress to SIDS. Most children with ALTE do well.

History

  1. Record who witnessed the episode or who found the child
  2. How was the baby prior to this episode:
  3. Any history of illness?
  4. History of recent feeds
  5. Awake or asleep
  6. Previous history suggestive of reflux
  7. Where and in what position was the baby found?
  8. Prone or supine
  9. Positioning and amount of bedclothes / clothing
  10. Was the baby sharing the bed or sofa with the carer?
  11. Accurate description of:
  • Tone
  • Colour
  • Abnormal movements
  • Breathing effort – apnoea, choking
  • Any vomit / mucus / blood in mouth
  • Length of episode
  • Level of consciousness - ? rousable
  1. What exactly did the parents / carers do?
  2. Social History
  • Smokers at home
  • Living conditions
  • Any illness or drug/alcohol ingestion affecting the carer
  1. History of previous ALTE?
  2. Family History:
  • SIDS or neonatal deaths
  • ALTE
  • Cardiac disease, epilepsy
  • Smoking in pregnancy

Examination

A full examination is therapeutic as well as potentially diagnostic:

  1. Undress the child fully
  2. Weight, length, head circumference (ask for the ‘Red Book’)
  3. Careful examination looking for evidence of:
  4. Infection
  5. Respiratory or cardiac disease
  6. Neurological abnormalities
  7. NAI – including fundoscopy
  8. Metabolic problem, e.g. hepatomegaly

Management

All babies presenting with ALTE should be admitted. (The risk of a further ALTE is highest in the next 24 hours, but it is an uncommon occurrence). This provides parental reassurance and allows full assessment of the child.

Initially:

  • Oxygen saturations
  • Temp / pulse / respirations
  • Blood glucose – if they are presented close to the event
  • Urine – MC&S and save for metabolic and / or toxicology screen
  • (Need at least 10 mls for metabolic screen)

If Unwell:

  • FBC
  • U&E’s, LFT’s, Calcium, CRP
  • Septic screen, including lumbar puncture, CXR and NPA
  • Lactate, ammonia, capillary or arterial blood gas

Following Admission:

Apnoea Alarm

  • for 12 – 24 hours
  • IF APPROPRIATE, discontinue at least 12 hours before discharge so as to reassure the parents that an apnoea alarm is not required at home

Consider pulse oximetry

  • for 24 hrs or longer if unwell, or has further episodes
  • discontinue at least 12 hrs prior to discharge

Observe feeding and any difficulties. (Consider oximetry with feeding)

Note episodes of noisy breathing and pallor

Further Investigations -as clinically indicated

Advice to Parents

  • Do not smoke in pregnancy or around your baby (it is carried on you clothes)
  • Place babies on their ‘Back to Sleep’
  • ‘Feet to Foot’ – Keeps babies heads uncovered and prevents them from wriggling down under the covers

  • Do not let babies get too hot or cold
  • Do not share a bed with your baby if you smoke or if they were born prematurely. Also do not share a bed with your baby if you have been drinking or taking drugs
  • If your baby is unwell, seek prompt advice
  • Ensure your baby is fully vaccinated

This advice is all summarised in the Department of Health advice leaflet entitled ‘Reduce the Risk of Cot Death: An Easy Guide’

Discharge

  • Paediatric follow-up should be offered to all
  • Offer all parents training in paediatric resuscitation / basic life support (see guideline)
  • Consider entry onto the CONI Plus scheme (see guideline 1.8 Care of the Next Infant) – note this is a consultant decision.

Apnoea Alarms

  • They can be provided by the hospital (under the CONI or CONI Plus scheme) but there are drawbacks which must be emphasised
  • May be falsely reassured that baby is okay because apnoea alarm is silent eg obstructive apnoeas
  • Appropriate training is needed so parents can respond if their baby is not breathing
  • Tend to be lots of false alarms which can increase anxiety
  • All parents who accept a monitor MUST undergo resuscitation training and sign an appropriate indemnity/equipment loan form.

Simon Robinson1March 2005