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ALTE Audit

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Pardeep Gahunia

on 30 January 2013

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Transcript of ALTE Audit

Audit on
(ALTEs) Background Where to go now? Dr Leonie Perera
Dr Frances Howsam
Dr Pardeep Kaur Gahunia
Dr Dharam Dickinson Methods Results References Thank you
Any Questions? Differentials Introduction Adverse Life Threatening Events (ALTE) is

a) ‘‘an episode that is frightening to the observer and...

b) that is characterised by some combination of: 1. Apnoea
2. Colour change
3. Marked change in muscle tone
4. Choking or gagging’’. Investigations
Management Variations Audit Aims: Definition: Links to SIDS? Incidence: At the time of defining ALTEs, NICE rejected an association between ALTE and
Suudden Infant Death Syndrome (SIDH) ALTE is a diagnosis based on symptomatology rather than pathophysiology, hence the differential diagnosis and medical evaluation of ALTEs can be broad. 0.6 - 2.46 per 1,000 live births

0.6 - 0.8% of all emergency visits for children under the age of one.

Occurs equally between boys and girls.

Estimated 7.6% of ALTEs (from all causes) have resulted in death. Neurological ENT Respiratory Cardiovascular Other
Infections Gastrointestinal Metabolic Non Accidental Incident Summary:

50% known diagnosis, other 50% Unknown

Although mortality rate small, majority of these are secondary to child abuse

Diagnosis may not remain stagnant Larynomalacia

Obstructive sleep apnoea Congenital Heart Disease


Arrhythmias Electrolyte Disturbance


Inherited Metabolic Disorders UTI

Sepsis Gastro-oesophageal reflux


Intussusception/other surgical causes

Swallowing Difficulties Respiratory infections (RSV, pertusis, penumonia, coup)

Foreign body aspiration

Congential anomalies Seizure disorder

Causes of central apnoea (prematurity,
central hypoventilation)

Intracranial bleeding


Brain tumour

CNS Malformations Child Abuse An example At the Royal Alexander

Recurrent ALTEs

Child's mother eventually smothered her to death. Recent evidence has shown that one of the key contributing factors to mortality secondary to ALTEs is child abuse.

Parker K and Pitetti R (2011) conducted a study over 9 years involving 563 patients.

They concluded that child abuse should therefore be seriously considered when evaluating ALTEs. 'Idiopathic ALTEs' Approximately 50% of causes are unknown.

This does not include those patients who have been potentially misdiagnosed. 1. Service Evaluation

a) Current practice - analysis of history
b) Variations in history taking and

2. Attention to social issues - particularly
child abuse. Investigations Initial assessment maybe sufficient in finding the cause.

Important to point out here that History taking is one of the most important parts of finding the diagnosis.

If diagnosis is not apparent then the usual baseline investigations include:
Yield of Diagnostic
Testing Initial Investigations

1. Haemoglobin
2. Electrolytes/bicarbonate
3. Glucose
4. Blood Gas
5. Lactate (prolonged hypoxia, metabolic disorders).
6. CXR (infections, cardiomegaly)
7. ECG
8. Nasopharyngeal aspirate for RSV/otehr viral infections
9. Pernasal swab for pertussis
10. Urine microscopy
Further Investigations

1. Infection screen (blood culture, LP)
2. Liver Function Tests
4. Oesophageal pH study
5. Cranial US scan/CT scan
6. EEG
7. Urine toxicology
8. Plasma and urine for metabolic disorders
9. Skeletal survey
10. Sleep study
11. Videoflouroscopy Brand et al. Yield of Diagnostic testing in Infants who have had an ALTE. Pediatrics 2005;115-885
Management A total 243 patients involved in the study, with 3776 tests ordered of these.

Of 3776, 669 (17.7%) were positive) and 224 (5.9%) contributed to the diagnosis. Tieder J.S. et al. Variation in Inpatient Resource Utilization and Management of Apparent Life-Threatening Events. Journal of Pediatrics 2008;629-35 Study group comprised 12,067 patients where the following variances were analysed:
1. Length of Stay
2. Diagnostic studies
3. Adjusted charges
Ross Russell R, Ravikumar K Apparent life-threatening episodes in children. Paediatrics and Child Health. 2007 17:5. Systematic Review of 643 children the following differentials were found.
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