Pediatric Case of the Week #3: Stopped Breathing

A previously healthy 1-month-old boy is brought to the emergency department by ambulance. His mother (pictured:Kimberly Erickson Mrs Montana International...read on) reports that he stopped breathing for 20 seconds and appeared limp and blue around his lips. Once she picked him up, he began to cry and breathe normally. She was very worried and immediately called EMS.

EMS reports no additional history. 

On physical examination, the baby is well-perfused and in no apparent distress.  

Vital signs are normal for age.

What are your initial questions for Mom?

Initial actions?

I had initially given a long list of questions and physical exam.  I will try to better summarize. 

This case is brief (don’t be deceived). If you are thinking ALTE ‘Apparent Lift Threatening Event’ there are already some important points available in this brief history.  The challenge to you, the clinician, is to DIG DEEPER.  Slow down and be thorough. 

For starters, it sounds like the infant had an episode of central cyanosis. It is important to differentiate “What kind of Blue?”  Lips/mucous-membranes or hands/feet. Also, it is important to distinguish the duration of apnea.  It is relatively common for neonates to have brief episodes of ‘periodic breathing’ lasting 3-20 seconds.  Anything greater than 20 seconds or associated with cyanosis, bradycardia, pallor, or hypotonia is considered ‘pathologic apnea’ and necessitates further workup/admission.

Also, Mom was noted to be very worried.  This is important and included in the definition of ALTE: An episode frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change, (usually cyanotic or pallid, but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, and gagging.

You may also want to ask about any events preceding the episode, what position the child was in during the episode, .

In any 1 month old you should always ask about birth history: term or preterm?, complications/infections?, Was newborn screen normal? Any family history of metabolic disorders?

Finally you want to ask about any seizure activity, family history of seizures, history of gastroesophogeal reflux,  or family history of SIDS.

There are not many initial actions required.  The VS are normal and the infant appears stable.  If any respiratory distress were present you would have evaluate the airway and consider intubation (but most cases of ALTE present as stable and healthy appearing…again, don’t be deceived.

Do a thorough physical exam: Look over the skin for any bruises, assess the fontanelle, perform a funduscopic exam and look for retinal hemorrhage,  examine nose/mouth for blood. Evaluate respiratory for rate and breathing pattern.  Note any strider, wheeze, or crackles. Listen to the heart for murmurs and palpate pulses.  Examine the abdomen and note any distension or tenderness.  Evaluate for inguinal hernia or testicular torsion. Neurologically you should comment on the infants responsiveness.  Note any lethargy, abnormal muscle tone, or reflexes.  

It is reasonable to check a FSG.  I would also consider lytes to eval for inborn errors of metabolism. A CBC, UA/UC, and EKG are also reasonable.  Consider RSV swab if respiratory symptoms are present.  Consider skeletal survey (xray) if you suspect non-accidental trauma.  Most studies suggest that in patients without a suggestive history, we avoid an extensive work up in the ED. 

In a child less than 1 month of age we have to consider full septic workup.  This child is 1 month old…so the decision to perform full septic workup (ie LP) is muddy at best.

Would you admit this child?

In this case, as with most ALTE’s, I would admit. 

The pseudo-celebrity? Kimberly Erickson Mrs Montana International who is an ALTE and SIDS advocate. http://www.mrsinternational.com/contestantdetails.php?id=214 

But remember, according to EMedicine: Previously used terminology such as "near-miss sudden infant death syndrome" (SIDS) or (this is a grrreeat one) "aborted crib death" should be abandoned because their use implies a possibly misleading close association between this type of spell and SIDS.

 

Some references:

http://www.aafp.org/afp/2007/0701/p124.html

http://www.aafp.org/afp/2005/0615/p2301.html

http://emedicine.medscape.com/article/1418765-overview#a1

http://pediatrics.uchicago.edu/chiefs/inpatient/ALTE.htm

http://pedemmorsels.com/apparent-life-threatening-event/