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Michael B.H. Smith, MB, FRCPC, FRCPCH
Consultant Pediatrician,
Craigavon Area Group Hospital Trust,
Portadown BT 63 5QQ, Northern Ireland
To the Editor.—
We read the article by Brand et al1 with great interest. In 2002, we also saw the need for an evidence-based diagnostic-testing guideline for evaluating apparent life-threatening events (ALTEs), but we took a different approach. Brand et al looked at the yield of different diagnostic tests to try to establish which are useful. We systematically reviewed the medical literature to determine the diagnoses reported after infants first presented with ALTEs and used these diagnoses to suggest an algorithm of investigation.2
Brand et al conclude that, in infants whose history and examination are unhelpful in directing diagnostic investigations, only the following screening tests are useful: screening for gastroesophageal reflux disease, urine analysis and culture, brain imaging, chest radiograph, pneumogram, and white blood count.
In our review, we looked at 728 diagnoses among 8 studies. Metabolic disease was diagnosed in 4 studies (n = 11 [1.5% of all diagnoses]), ingestion of drugs or toxins was reported in 3 studies (n = 11 [1.5% of all diagnoses]), and factitious illness was diagnosed in 1 study (n = 2 [0.3% of all diagnoses]). Therefore, a wider investigation plan may be particularly useful when the history and physical examination do not suggest a cause. Brand et al note this limitation of the sample size in their article.
In our review, we also encountered the difficulties noted by the authors.
Many studies looking at ALTEs are observational and, as such, lack uniform testing and diagnostic criteria. (In this study, gastroesophageal reflux was diagnosed by different methods [eg, upper gastrointestinal series or by pH probe].) It also can be difficult to determine when diagnoses are causal or coexistent, and long-term follow-up for new diagnoses is often limited.
We strongly agree that a diagnostic-testing strategy should depend on the outcome of the initial clinical assessment as suggested and are encouraged to see that in 70% of the patients studied, the history and examination were helpful. We estimated that >50% of the time this would be true. Our algorithm suggests a stepwise approach, and investigations are initially directed by the history and clinical findings. The possibility of child abuse is highlighted at the first step. When the initial history and examination are not helpful, we suggest that full blood count, blood culture, calcium, magnesium, glucose, blood gas, C-reactive protein, urea, and electrolytes levels, metabolic screen, toxicology screen, urine culture, chest radiograph, electrocardiograph, electroencephalogram, ultrasound brain, investigations for gastroesophageal reflux, and an analysis of respiratory secretions be obtained. In addition, if the ALTE is severe or recurrent, the infant will often require additional specialized investigations.
REFERENCES
Related articles in Pediatrics:
This article has been cited by other articles:
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  R. L. Altman, K. I. Li, and D. A. Brand Infections and Apparent Life-Threatening Events Clinical Pediatrics, May 1, 2008; 47(4): 372 - 378. [Abstract] [PDF]
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