Consensus Statement

Section I - Diagnosis and Medical Management

Diagnostic Groups for which Monitoring may be Appropriate

Apparent Life-Threatening Event (ALTE)

A variety of identifiable diseases or conditions can cause such episodes (e.g. ALTE secondary to gastroesophageal reflux or ALTE secondary to seizures), but in approximately half the cases, despite extensive work-up, no cause can be identified. These episodes can occur during sleep, wakefulness, or feeding and generally occur in infants who are over 37 weeks gestational age at the time of onset. By definition, ALTE is not a fatal syndrome, but it may represent the presentation of a condition that might prove fatal. A detailed history of the event should be obtained as soon as possible directly from the individual or individuals who witnessed any part of the event. Such stories often change with time and are notoriously inaccurate when obtained secondhand. Since these episodes are rarely witnessed by medical personnel, obtaining an accurate history from untrained observers is difficult, but critically important.

Initial Evaluation and History

• Exact time of event
• Duration of event
• Location of event
• Time lapse between the event and the time the infant was brought to medical attention (check a blood gas if less than 30 minutes and, if indicated, beyond that)
• Was child on memory monitor during the event?
• Who was in the domicile when the event took place?
• What initially alerted the caregiver to assess the infant?
• Describe the event
• state of activity (awake, asleep, feeding, etc.)
• breathing (gasping, choking, apneic)
• formula/food in the mouth and/or nose
• color (pale, blue, plethoric, etc.)
• skin (hot, cold, sweaty, mottled, etc.)
• muscle tone (limp, floppy, stiff)
• other (smell, bloody discharge, etc.)
• Under what conditions were observations made? Type of bedding? Lighting?
• Child's clothing and position
• Caregiver's responses to the event
• Temporal relation of event to previous feeding or other events
• Attitude of reporting adult
• Have the same or other similar events occurred before? When? Where? Frequency? Who witnessed?

Management

• If the infant is already on a memory monitor, the data should be downloaded and analyzed as soon as possible as part of the patient evaluation.
• If the history of ALTE is sufficiently convincing and/or the home monitor revealed recent pathologic apnea, hospital admission is warranted for observation, documentation and evaluation.
• During the hospitalization, memory cardiorespiratory monitoring should be part of the ongoing assessment. Further memory monitoring will aid the medical staff including apnea professionals in their observations and evaluations which are structured to determine whether the infant is symptomatic and if a home monitor will be needed. Consideration should be given to the use of covert video monitoring - see Section I - Glossary - Munchausen's Syndrome by Proxy.
• Appropriate therapy should be prescribed for those conditions amenable to treatment. Conditions that resolve which had apnea as a symptom or those which are controlled with specific treatment do not require home monitoring.
• If a monitor is prescribed for home use, it should be recognized that home monitoring is not only a component of the management plan, but is also a continuation of the evaluative process.
• Complex physiologic studies are not meant to be used as screening tools in the asymptomatic patient recovering from known causes of apnea, including pertussis, respiratory syncytial virus infection, influenza, sepsis and seizures.
• If a monitor is used, teaching and follow-up should be done as described in Section I - About Home Monitoring and Section II - Discharge Planning and Home Management.
• If the patient is asymptomatic for a 1-2 month period of time, the monitor may be discontinued. If symptoms persist, evaluate and consult with an Apnea Program.