• Users Online: 146
  • Print this page
  • Email this page


 
 
Table of Contents
CASE REPORT
Year : 2019  |  Volume : 16  |  Issue : 3  |  Page : 180-181

An unusual case of apparent life-threatening event


Department of Pediatrics, Indraprastha Apollo Hospitals, New Delhi, India

Date of Submission09-Jun-2019
Date of Acceptance17-Jul-2019
Date of Web Publication11-Sep-2019

Correspondence Address:
Prita Trehan
Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi - 110 076
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/am.am_44_19

Rights and Permissions
  Abstract 


Apparent life-threatening event (ALTE) occurs in 0.5–10/1000 live births. ALTEs are defined as episodes characterized by a combination of apnea, color change, altered muscle tone, choking, and gasping. All are very frightening to the observer. The most common ALTE etiologies are gastroesophageal reflux disease, epilepsy, and respiratory tract infections, which make up 50% of all ALTE cases.

Keywords: Gastroesophageal reflux disease, respiratory infection, seizures


How to cite this article:
Trehan P. An unusual case of apparent life-threatening event. Apollo Med 2019;16:180-1

How to cite this URL:
Trehan P. An unusual case of apparent life-threatening event. Apollo Med [serial online] 2019 [cited 2019 Sep 20];16:180-1. Available from: http://www.apollomedicine.org/text.asp?2019/16/3/180/266780




  Introduction Top


Apparent life-threatening event (ALTE) occurs in 0.5–10/1000 live births. ALTEs are defined as episodes characterized by a combination of apnea, color change, altered muscle tone, choking, and gasping. All are very frightening to the observer. The most common ALTE etiologies are gastroesophageal reflux disease, epilepsy, and respiratory tract infections, which make up 50% of all ALTE cases.[1]

Objective

To present the case of a 4-month-old female who presented in the OPD with an apparent life-threatening event (ALTE).


  History Top


A 4-month-old female infant, first of twins, born to a primigravida mother, was brought to the OPD with a history of abnormal, coarse jerky body movements, with uprolling of eyes, lasting almost 2 min the previous day. This was the first time the baby had these symptoms. The second episode, on the same day, was followed by inconsolable crying.

There was no prematurity, nor was the baby small for dates. There was no family history of epilepsy. The patient had no fever. There was no trauma or fall from the bed.

The baby had had a partial feed in the car on the way to the hospital and had not been burped. There was a history of occasional regurgitation (once every 2 weeks); during these episodes, the milk would come out through both the nose and mouth.

There was no history of recurrent vomiting, persistent cough, or wheezing.

Mother said that compared with twin brother, this baby was more fussy. Her weight gain (though adequate) was far less than other twin.

When taking the history, the baby was put on the examination table. She turned blue-black, went limp, and stopped breathing. She required immediate cardio pulmonary resuscitation with mouth-to-mouth resuscitation. Color and activity returned to normal in 2–3 min, by which time code blue had been announced, and the suction machine and oxygen were made available. The baby was shifted to the pediatric intensive care unit for further workup.

The patient at 4 months weighed 5.6 kg (birth weight 2.5, first of twins), height 60 cm, head circumference 39 cm.

Post-ALTE heart rate was 134/minute, and respiratory rate was 34/min.

investigation: (R) Blood Sugar was 127 mg%, SpO2100% in room air, complete blood count hemoglobin 11.5, total leukocyte count 9590, differential leucocyte count N27L61, peripheral smear normal, and C-reactive protein negative.

Sodium 132, potassium 5.5, serum calcium (ionized) 1.27, and normal blood gas; kidney function test and liver function test were normal.

Two-dimensional echo and echocardiography were normal, and a pediatric cardiologist opined this was a noncardiac event.

99mTc GER scan showed reflux of tracer into mid-esophagus intermittently, during the study period of 15 min. Measurement of pH was not done as parents wanted an early discharge. This shows that the acid reflux was at nasopharyngeal level causing irritation of the larynx with constriction of larynx leading to apnoea. Magnetic resonance imaging brain was advised, but would be done later.

The hospital stay was uneventful. The baby was initially kept nil by mouth and received intravenous fluids and injection Pantocid and was discharged on Domstal drops (1 mg/1 ml) 1 ml daily + tablet Lanzol junior (15 mg) ¼ tablet twice/day with advice to keep the baby upright for 40 min after every feed.


  Discussion Top


Gastroesophageal reflux disease (GERD) contributes to up to 35% of ALTEs [2] (to arrive at this conclusion ph studies, barium studies or milk scan in combination with clinical findings, were done), seizures as a cause was reported in 11%, lower respiratory infection (including pertussis in 8%, ENT problems in 3.6%, and cardiac in 0.8%), unknown diagnosis in 28%; these were studies done in 643 patients.

The mechanism of apneic episodes are due to:

  1. Chemoreflex in larynx
  2. Stimulation of distal esophagus when the esophageal pH is <4.


Therefore, pH monitoring is the most useful test for GERD.

The disadvantage is that many refluxes remain unmonitored because of frequent feeding, and often, the pH probe cannot detect reflux postprandially (when episodes are most frequent) because gastric juices are buffered by milk.

The mucosal covering of interarytenoid space at the entrance of larynx has special receptors, which get stimulated when any fluid, especially acidic, comes in contact with them. Usually, aspiration is prevented by swallowing, cough, and airway closure, but a hyperactive laryngeal chemoreflex can cause episodes of prolonged apnea.[3]

Course of reflux starts at 2–4 months, peaks at 4–5 months, and resolves by 12–24 months in 90% of babies. Therefore, <1%–2% of patients have to undergo antireflux surgery (fundoplication if there are repeated severe episodes of ALTE). Severity of GERD influences time of normalization and of giving antireflux therapy.

Because infants cannot complain of heartburn, they respond with intractable crying.

It is heartening to know that GERD is not chronic and never leads to complications such as erosive esophagitis, dysmotility, strictures, or hiatus hernia.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts for interest

There are no conflicts for interest.



 
  References Top

1.
Kiechl-Kohlendorfer U, Hof D, Peglow UP, Traweger-Ravanelli B, Kiechl S. Epidemiology of apparent life threatening events. Arch Dis Child 2005;90:297-300.  Back to cited text no. 1
    
2.
McGovern MC, Smith MB. Causes of apparent life threatening events in infants: A systematic review. Arch Dis Child 2004;89:1043-8.  Back to cited text no. 2
    
3.
Herbst JJ, Minton SD, Book LS. Gastroesophageal reflux causing respiratory distress and apnea in newborn infants. J Pediatr 1979;95:763-8.  Back to cited text no. 3
    




 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
History
Discussion
References

 Article Access Statistics
    Viewed15    
    Printed0    
    Emailed0    
    PDF Downloaded1    
    Comments [Add]    

Recommend this journal