Published online December 1, 2005
PEDIATRICS Vol. 116 No. 6 December 2005, pp. 1600 (doi:10.1542/peds.2005-2074)
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Yield of Diagnostic Testing in Infants Who Have Had an Apparent Life-Threatening Event: In Reply

Donald A. Brand, PhD
Robin L. Altman, MD
Deparment of Pediatrics,
New York Medical College,
Vahalla, NY 10595

In Reply.—

We welcome the systematic review by McGovern and Smith,1 which offers an important contribution to the apparent life-threatening event (ALTE) literature. We were not able to cite their work originally because it was published while our article2 was in press.

Based on their review, McGovern and Smith proposed a list of diagnostic tests for patients with a history and physical examination that do not suggest a cause of the ALTE. They compiled their list based on the inventory of 728 final diagnoses reported in the 8 research studies they examined in detail (643 patients, 50 different diagnoses). The authors seem to be recommending that, unless a patient's history or examination points to a likely diagnosis, the physician should test for most or all of the 50 conditions.

Investigating all of these possibilities requires many tests, which the authors enumerate. They call into question the adequacy of our much shorter list of tests, based evidently on the argument that our list would fail to detect many of the 50 conditions. The problem with that argument is that it neglects to consider which of those conditions might present as an occult cause of an ALTE, that is, without suggestive findings at the outset. One of the main goals of our study was to distinguish the occult causes so that it would be possible to obtain a limited subset of diagnostic tests in patients with nonsuggestive presentations, avoiding the need for an exhaustive testing protocol. We identified a minimum set of tests that would have detected all occult causes that occurred in our sample (N = 243), the largest consecutive series of ALTE patients of which we are aware.

Our series did include ALTEs caused by metabolic disease or drug ingestion, but the history or physical examination provided reasons to test for these conditions. It seems that the 8 studies reviewed by McGovern and Smith provided insufficiently detailed data on patients' presentations to apply a similar analysis to the 643 cases. If future investigations identify other occult causes of an ALTE that occur with sufficient frequency to warrant routine testing for them, that would justify expanding our short list to include such testing.

REFERENCES

  1. McGovern MC, Smith MBH. Causes of apparent life threatening events in infants: a systematic review. Arch Dis Child. 2004;89 :1043 –1048[Abstract/Free Full Text]
  2. Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. 2005;115 :885 –893.[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2005 by the American Academy of Pediatrics

Related articles in Pediatrics:

Yield of Diagnostic Testing in Infants Who Have Had an Apparent Life-Threatening Event
Mary C. McGovern and Michael B.H. Smith
Pediatrics 2005 116: 1599-1600. [Extract] [Full Text]  




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