So in this lecture, we’ll review
what to do when babies come in
and the parents say, “My
baby stopped breathing.”
This is so incredibly common
and yet can be caused by
so many different things,
but the vast majority,
it’s no big deal.
So figuring this out
can be very confusing.
I’ll briefly review what an ALTE is,
although that word has now
been replaced by a BRUE
and I will also talk about SIDS
or sudden infant death syndrome.
Sp let’s get through the terminology.
ALTE stands for apparent
This is what we call it when the patient
came in, a baby came in and parents say,
“Oh, my baby stopped
breathing and turned blue.”
And so you’ll just say,
“Okay, this is an ALTE.”
We got rid of the word ALTE
because the concern was that parents were
misinterpreting the phrase life-threatening
as actually life-threatening.
The whole point is ALTEs
were not life-threatening.
So they’ve replaced this with the term
brief resolved unexplained event,
which is now the term we use
and describe these events,
although the definitions are slightly
different between ALTE and BRUE
and I’ll get into that.
And then SIDS is sudden
infant death syndrome,
that’s what we used to think was
associated with ALTEs and BRUEs,
but in fact is not.
So we’ll talk about that separately.
First let’s start about ALTE.
ALTE was defined in 1986 as an episode
that is frightening to the observer
and it had to last for
more than 20 seconds.
Remember, young babies will hold their
breath frequently for up to 20 seconds
and that’s normal.
They had to have a change in color
and they have marked in muscle
tone, usually they go floppy.
They have a choking episode and they have
gagging or something along those lines
and then it was
defined as an ALTE.
And then we would say, “Your baby had
an apparent life-threatening event”
and the parent would only hear
life-threatening and they are very scared.
Well, in fact, the vast majority of time,
these are not at all life-threatening and
they are almost normal baby behavior.
So we’ve changed the ALTE to BRUE.
A BRUE is a brief resolved
and we put this out in
a guideline in 2016.
So brief means it lasted
less than one minute.
Resolved means the child has
now returned to baseline.
They have normal vital signs.
They have normal appearance.
It was an event, it’s over.
Unexplained means there is no
other diagnosis to explain this.
If they had this because they
had bronchiolitis or pneumonia,
well it was bronchiolitis or
pneumonia that caused the problem.
And event, it had to be an event and the
event had to include pallor or cyanosis,
absent or decreased breathing,
a change in tone,
and altered responsiveness.
If a child meets these
criteria, they had a BRUE.
So we used to think of
these entities like this.
Before the invention of the
word BRUE, we thought,
“Well jeez, some of these who
have ALTE may go on develop SIDS
or sudden infant death syndrome.”
In fact, in the 1970s, we might
have called it pre-SIDS.
It turns out there is no connection
or whatsoever between ALTEs and SIDS.
This is really what it is,
babies who have ALTE and
babies who have SIDS.
Well, of course, a baby who
had SIDS might have an ALTE,
but in general, if your babies
had an ALTE and my baby hasn’t,
the risk of SIDS has nothing
to do with the ALTE,
it has to do whether we’re smoking
or whether the baby has
good sleep hygiene, et cetera.
Babies who have a BRUE
are subset of the babies
who we would previously
have called an ALTE.
For example, a baby with
bronchiolitis who held their breath
would previously have been considered to
have an ALTE caused by bronchiolitis,
whereas now that baby is not having
a BRUE, that’s just bronchiolitis.
So what are some diagnoses
that can cause a BRUE?
Well, it turns out there are thousands of
diagnoses that can cause this problem.
So we have to be thoughtful about what do
you think is going on with this patient
that might be putting this child at risk
or was this just a normal
baby doing baby-like things.
So how do we do this?
When the vast majority of
these kids are normal,
how do we rule out literally
hundreds of diagnoses?
Okay, here’s an example
of a case we might see.
An infant comes in who is three weeks old.
There is no significant
pregnancy or birth history.
The child has a strong history of spitting
up after feeds and has Sandifer sign.
Remember from our GI lectures,
Sandifer sign is when
babies arch their back
and turn their head to their side
as a response to refluxing acid.
So the parents were at home
and the baby had just fed
and then he arched his back and his eyes
bulged and he turned blue around the mouth.
Mom patted him on the back and
he started breathing again,
but the episode lasted
for way too long.
She was terrified, maybe 45 seconds,
so she came rushing
into the emergency room
because she is afraid something
is wrong with her baby.
We see this all the time.
So does reflux, which this baby
clearly have, cause apnea in babies?
So they did a retrospective study of
119 premature infants who had ALTE.
This study was done when
we are using the word ALTE
and they measured 6,000 episodes
of reflux with a polysomnography
which is lots of probes
measuring respiratory rate
and airflow with the nose
and heart rate and pulse ox
and they also did a pH probe
which could measure acid coming
up the esophagus inside.
And what this showed is that 1%
of infants had a reflux episode
that was associated with holding
their breath more than 15 seconds.
So I said, "Oh, look, there were some
infants who had a refluxy episode
and they held their breath."
The problem was that a third of
those cases, they held their breath
and then had the refluxy episode.
So that is not clear that
this causes a problem,
it may be that babies hold their
breath and then they reflux.
That said, we see this so commonly,
many of us are fairly confident
that reflux can cause babies
to hold their breath.
So maybe we should treat
these infants for reflux,
prevent them from holding
their breath again.
The answer is probably not.
So blocking stomach acid in babies
increases risk of pneumonia six folds,
increases the risk of
gastroenteritis two folds,
increases the risk of C. diff infections
and increases the risk in tiny
babies of necrotizing enterocolitis.
So if blocking acid is bad, we have to ask
ourselves, was this event so significant
that this child really needs to go on, say,
a proton pump inhibitor
when there’s a risk?
But remember, these infants
are not at increased risk
for something like death
from holding their breath.
So oftentimes, we will try other tricks
in terms of helping them with reflux.
We will say, "How about we thicken
the feeds in severe cases?"
This can reduce reflux events
without adding acid blockade,
however, thicken the feed
does cause infantile obesity
which can in turn increases
risk of adult onset diabetes.
So we only want to thicken the
feeds in very severe cases.
Most of the time, we recommend positioning
tricks which probably don’t work,
but more commonly what we recommend
is smaller feeds more frequently.
That may be all this child
needs and good burping.
Okay, let’s do another case.
An infant is five months
old and comes in with
two weeks of upper respiratory
There have been worsening
cough, it’s worse at night
and then last night or tonight, there was
an episode where the baby was coughing
and arched his back and his eyes bulged
and he turned blue around the mouth.
And it lasted 45 seconds and mom was terrified
and she rushed into the emergency room.
He’s all better now.
Well one thing we have to
worry about is pertussis.
Pertussis causes infants to
die from coughing episodes.
In adults, it just causes prolonged cough
but in infants, it can
actually cause death.
Children and in infants with pertussis
can have feeding difficulties,
tachypnea, cough and gagging.
It is not associated with fever.
These infants lack the whoop
from the whooping cough
because they lack a respiratory musculature
that helps them breath in quickly.
They may appear very well and
have sudden paroxysmal cough
and apnea and cyanosis is typical
in infants under six months of age.
So infants may become apneic or have
cyanosis as often as 15-30% of the time
when they get pertussis.
So, we need to make sure this
infant doesn’t have pertussis,
if the story is
consistent with that.
Certainly, if somebody else in the
family has been coughing for a long time
and this infant has predominantly cough,
we will probably check them for pertussis.
That said, treating pertussis
doesn’t make the child get better,
so we often hospitalize
these children and watch
them for signs of worsening
and once they are deemed to be
stable, they might be sent home.
Here’s what is happening
with the United States
right now in terms of
rates of pertussis.
You can see at the beginning of this
chart, there was high rate of pertussis
and in around 1948, the pertussis
vaccine was introduced.
And you can see there was a dramatic reduction
in rates of pertussis which were caused,
which saved countless lives
and this vaccine was working really
great until about the year 2000
and now, we’re starting
to have an upswing.
This upswing is mostly because the strains
of pertussis seemed to be changing.
We probably need to reorganize our vaccine,
but that said, we are now
seeing outbreaks of pertussis.
So if you see case of pertussis,
you have to report it
because we can control spreads
That doesn’t help the patient
but it controls spread maybe
and that way, we can limit the extent
and the spread of the disease.
Another more common cause of apnea in
infants is just plain old bronchiolitis.
This is a viral infection of
the lower airways of children
and they frequently causes infants
to have an apneic episode.
Here’s another case, a five-week-old
was afebrile and had no URI symptoms,
this is not bronchiolitis.
The brother died suddenly as
an infant of an unknown cause,
so the family is scared of SIDS
and tonight, there was an episode
where the baby was acting normally
and then became completely limp
and turned blue around the mouth.
Mom patted on the back, he
started breathing, called 911,
and she was terrified.
This is very concerning.
We’ve got a problem here.
There’s a history of SIDS in the family,
may be there’s a genetic problem
and this baby wasn’t really
doing something where
we can explain why this
child suddenly became limp.
We're worried in this case perhaps of
cardiac causes of apnea in children.
So around 2% in infants who have an
apneic event may have a cardiac cause,
it’s more common in those children
with known structural heart disease
or structural heart disease
that is obvious on exam.
So realistically, when you examined this
child, if you hear a wild whopping murmur,
chances are this is
a cardiac cause.
If you notice nothing on exam,
it’s unlikely this is cardiac.
But in this case, we might
worry about an arrhythmia.
Arrhythmias, SVT is the most common
and sometimes in families, they can have a
gene which causes a prolonged QT interval.
This can present in patients and families,
especially in patients with deafness,
they can have Jervell and
or they may have Romano-Ward
which is a little more common
and is not associated
If you’re worried about a prolonged
QT, you want to get an EKG
to check and check that QT interval
and also look for other signs.
If the EKG is normal and the
exam of that child is normal,
and the child has been growing well,
this is not cardiac disease
causing this apneic episode.
Another diagnosis for this
child is child abuse.
This is terrifying,
but it’s true.
Between 2 and 11% of patients in
two different studies with ALTE
had it from undiagnosed
You should think about subdural hematoma
as a potential cause of altered
mental status in a child.
And as you can see, this
can be fairly common.
They don’t always have clear
bruising about the head.
Sometimes, patients have shaken baby
will have no external findings,
but you only see it on
a head CT such as this
where you can see the blood is
accruing in the subdural space.
So if a baby has one of these brief
resolved unexplained events,
what do you do?
Okay, so the baby has a BRUE,
you can find nothing on history
and physical to explain it,
then we’re going
to risk stratify.
If the child is greater than 60 days,
born after 32 weeks gestation
so is not too premature,
there was no CPR provided and lasted less
than a minute and it was a first event,
this child is low risk.
And with appropriate counseling and provision
of CPR training, maybe as an outpatient,
that child can
probably be sent home.
So for low risk children, we probably
don’t require labs or imaging.
They can be sent home with reassurance
and we can refer them for CPR training.
As effective as live CPR
trainings are CD sets
that you can sell that will train people
how to use CPR, and that is effective.
However, if they meet any of these
criteria, they are high risk
and we typically will admit these
patients and watch them overnight.
We will do testing if something shows
up on either history or physical
or something happens overnight that
cues us into underlying cause,
one of those hundreds of causes
we went through earlier.
And then, we will discharge them
typically after 24 hours of observation
if there is no clear cause,
again, with CPR training.
Remember, multiple instances of
ALTEs and/or BRUEs in children
may be a sign of child abuse,
so screen the parents
How is it getting along with their
child is really important question.