PEDIATRICS Vol. 122 No. 1 July 2008, pp. 125-131 (doi:10.1542/peds.2007-3376)
ARTICLE |
Death, Child Abuse, and Adverse Neurological Outcome of Infants After an Apparent Life-Threatening Event
Divisions of a Pediatric Neurology
b Pediatric Emergency Medicine
c Hospital Medicine, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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OBJECTIVES. Apparent life-threatening events in infants constitute a significant challenge for health care providers. Apparent life-threatening event evaluation and management are poorly defined, and outcomes have not been clearly determined. Our objectives were to characterize short- and long-term risks for death, child abuse, and abnormal neurological outcomes of infants after an apparent life-threatening event and to identify clinical features that are predictive of these outcomes.
METHODS. We collected data from infants ages birth to 12 months of age who were hospitalized after an apparent life-threatening event during a 5-year time period. Patients were evaluated for subsequent death, child abuse, or adverse neurological outcome (chronic epilepsy or developmental delay).
RESULTS. A total of 471 patients met inclusion criteria and were followed an average of 5.1 years. Two patients died after developing chronic epilepsy and severe developmental delay. Fifty-four (11%) patients were diagnosed as being a victim of child abuse, but only 2 were identified at initial presentation. There were 23 (4.9%) patients with adverse neurological outcomes, including 17 (3.6%) with chronic epilepsy and 14 (3.0%) with developmental delay. Of those who developed chronic epilepsy, 71% returned within 1 month of the initial apparent life-threatening event with a second event. Neurological evaluation at the time of the apparent life-threatening event had low yield for predicting those who would develop chronic epilepsy.
CONCLUSIONS. Infants who suffer an apparent life-threatening event are at risk for subsequent child abuse and adverse neurological outcomes. Deaths were uncommon and only occurred in the setting of severe developmental delay and seizure disorders. Neurological evaluation during hospitalization for a first apparent life-threatening event is of low yield, but close follow-up is essential.
Key Words: ALTE • EEG • MRI • CT • seizures • SIDS • child abuse
Abbreviations: ALTE—apparent life-threatening event • SIDS—sudden infant death syndrome • CNS—central nervous system • GERD—gastroesophageal reflux disease • ICD-9-CM—International Classification of Diseases, Ninth Revision, Clinical Modification • EDW—Enterprise Data Warehouse • EEG—electroencephalogram • OR—odds ratio • PPV—positive predictive value • NPV—negative predictive value • CI—confidence interval • CT—computed tomography
Apparent life-threatening events (ALTEs) in infants less than 1 year of age pose a significant challenge for evaluation and management. An ALTE is defined as "an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid), marked change in muscle tone, choking, or gagging. In some cases, the observer fears that the infant has died."1 The incidence of ALTEs has been estimated at between 0.6 and 9.4 in 1000 of live-born infants, and they account for 0.6% to 0.8% of emergency department visits for children <1 year of age.2,3 Near–sudden infant death syndrome (SIDS), seizures, central nervous system (CNS) abnormalities, cardiac problems, and child abuse are major concerns when an infant presents with an ALTE.2,4,5
There is no consensus on what diagnostic evaluation is necessary or indicated for the child who presents with an ALTE,2,6–8 in part because of the lack of outcomes data. Although the most common discharge diagnoses for ALTEs have been reported (gastroesophageal reflux [GERD], unknown causes, seizures, and lower respiratory tract infections),2 no long-term follow-up studies in patients with an ALTE have been performed.
The purpose of our study was to determine the immediate and long-term risks for death, child abuse, or adverse neurological outcome (defined as chronic epilepsy or developmental delay) after an ALTE. In addition, we sought to identify clinical characteristics that are predictive of these outcomes.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Study Design
We reviewed the medical charts of all infants <12 months of age who had been admitted for an ALTE between January 1, 1999, through December 31, 2003. The study was performed at a children's hospital that serves as the sole tertiary pediatric center for an estimated pediatric population of >1 million children,9 as well as the primary children's hospital in an urban area with >270000 children.10 The hospital is operated by a large vertically integrated not-for-profit health care system (Intermountain Healthcare). The study was approved by the institutional review boards of the University of Utah and the Utah Department of Human Services.
We attempted to identify all patients who presented with an ALTE over the 5-year time period. Because ALTE is not a codeable diagnosis, we searched records of children <12 months of age by using a computer-based screen from 3 sources: key words from emergency department chief complaint diagnoses, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes from pediatric neurology consultation, and hospital discharge diagnoses. The key words and diagnoses were ALTE, altered mental status, apnea, breath-holding spell, choking, GERD, hypotonia, lethargy, other convulsions, other neurology diagnosis, other respiratory diagnosis, pallor, seizures, sleep apnea, stiff, syncope, and unresponsiveness (ICD-9-CM codes were 327.23, 530.81, 719.5, 770.81, 780.01, 780.09, 780.2, 780.39, 780.57, 780.79, 780.99, 781.3, 782.5, 782.61, 782.62, 784.9, 786.03, 786.9, 933.1). Discharge diagnoses were obtained from the diagnosis assigned to the patient by the medical housestaff or attending physician. A total of 1148 possible patients were identified; 7 charts could not be located (Fig 1). We reviewed all 1141 charts to determine if a patient met the inclusion and exclusion criteria (see below). If a patient was admitted more than once for an ALTE, only the first admission was included for analysis.
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Patients were included if they were
12 months of age and had a clinical history of an ALTE. An ALTE was defined as a sudden event consisting of 1 or more of the following that was concerning to the caregiver: (1) breathing irregularity (including apnea, choking, gagging); (2) color change (including cyanosis and pallor); (3) altered muscle tone (including hypotonia, hypertonia); (4) abnormal movements (including clonus); or (5) altered mental status (including unresponsiveness). Patients were excluded from the study for 2 categories of reasons: (1) if they had a known past medical history that could explain their ALTE (such as a seizure disorder) or (2) if at their presentation to the emergency department or admitting hospital doctor there was an apparent diagnosis that could explain their ALTE (such as bronchiolitis). The complete exclusion criteria (listed in Table 4, which is published as supporting information at www.pediatrics.org/content/full/122/1/125) consisted of at least 1 of the following: preexisting disorder; bronchiolitis; unstable vital signs; seizure disorder; CNS pathology; treated with an antiepileptic drug; febrile seizure; medication misdose or overdose; trauma; and child abuse.
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Data Collection
Clinical data were abstracted from the charts. Data abstracted from Intermountain Healthcare's computerized database (Enterprise Data Warehouse [EDW]) included age, total hospitalization cost and charges, and length of stay.11,12 Hospital cost incurred was adjusted to 2003 US dollars by applying a yearly consumer price index for hospital services.13
Outcomes
All patients in the ALTE cohort were followed for outcomes of death, child abuse, or adverse neurological outcome. The time for follow-up included the original enrollment period (January 1, 1999, through December 31, 2003), as well as 2.5 years of additional follow-up (January 1, 2004, through August 31, 2006).
Deaths were identified through both the EDW and state health death records (Utah State vital records) by cross-matching patients using a unique electronic patient identification number.
Child abuse was identified by using the EDW and also by cross-referencing the ALTE cohort to the Utah Division of Child and Family Services records on the basis of name and date of birth. Child abuse is defined by the State of Utah Division of Child and Family Services as "actual or threatened nonaccidental physical or mental harm, negligent treatment, sexual exploitation, or sexual abuse."14 All cases included in the analysis had been substantiated through a standardized and formal process.14
Adverse neurological outcome was defined as developmental delay or chronic epilepsy. Developmental delay was defined if a patient was diagnosed with developmental delay, static encephalopathy, or language delay in the records of the study center pediatric neurology clinic by a pediatric neurologist. Chronic epilepsy was defined as any seizure disorder persisting for >2 years and requiring continued treatment with an antiepileptic drug. Adverse neurological outcomes were determined by evaluating charts from computer records for other hospital admissions and diagnoses (both at the children's hospital and for any other admissions or emergency department visits in the 20-hospital Intermountain Healthcare system), by review of pediatric neurology clinic charts, and by review of electroencephalogram (EEG) results. A positive outcome for a pediatric neurology consult was defined for the outcome of developing chronic epilepsy by whether an antiepileptic drug was started and/or follow-up in a neurology clinic was arranged.
Statistical Analyses
Descriptive statistics were used to characterize the study cohort. Univariate analyses were performed to compare predictor variables with the dichotomous outcome variables of death, child abuse, or adverse neurological outcome. Wilcoxon rank-sum tests were performed for nonnormal continuous predictors such as age. 
2 tests were performed for dichotomous predictors (eg, family history of seizure) and to calculate odds ratios (ORs). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and exact binomial 95% confidence intervals (CIs) were calculated for each of the clinical tests (obtaining a neurology consult, EEG, or CNS imaging or starting the patient on an antiepileptic drug) against the outcome of chronic epilepsy. SAS 9.1.3 (SAS Institute, Inc, Cary, NC) was used for analyses.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Baseline Characteristics and Follow-up
The identification of the study population is shown in Fig 1. From a total of 187903 patients, we identified 1148 patients with an ALTE, of whom 471 patients met our inclusion criteria.
Demographics of the 471 patients are displayed in Table 1. Average age at presentation was 66 days (range: 1–364 days). The average length of hospitalization was 2.4 days. Average length of follow-up for the study cohort was 5.1 years (range: 2.6–7.6 years). Discharge diagnoses are shown in Table 5, which is published as supporting information at www.pediatrics.org/content/full/122/1/125).
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Study Outcomes
The results regarding death, child abuse, and adverse neurological outcomes are summarized in Table 2.
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Two patients died. Both deaths were related to chronic respiratory problems and bulbar insufficiency associated with their underlying seizure disorders and severe developmental delay. Death occurred 18 months and 5.5 years, respectively, after the initial ALTE hospitalization in these children. Their ALTE discharge diagnoses were "bronchiolitis" and "abnormal movement." Neither infant had been started on an antiepileptic drug at their initial ALTE presentation. In our ALTE cohort, there were no cases of SIDS.
Fifty-four (11%) of the 471 patients were ultimately found to be victims of child abuse, including 4 (0.9%) patients who were physically abused and 6 (1.3%) who were sexually abused. The remaining 44 patients had other types of abuse including domestic violence exposure, child endangerment or improper supervision, drug exposure, sibling with child abuse, emotional maltreatment, and Munchausen by proxy. Seventeen (3.6%) patients were diagnosed as having been victim of abuse within 1 year of their ALTE hospitalization. For 2 patients the diagnosis of physical abuse was made during the first admission.
Adverse neurological problems developed in 23 (4.9%) patients, including 17 patients with chronic epilepsy and 14 with developmental delay (8 patients had both).
Clinical Predictors of Outcomes
Figure 2 presents the associations between the clinical characteristics at presentation and child abuse, adverse neurological outcome, or chronic epilepsy.
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For child abuse within 1 year of the ALTE, there were no clinical features that were predictive. Significant predictors of adverse neurological outcome (developmental delay and/or chronic epilepsy) were a family history of seizures and male gender (ORs: 4.5 [95% CI: 1.9–11.1] and 2.4 [95% CI: 1.1–5.3], respectively). The only significant predictor of chronic epilepsy was a family history of seizures (OR: 4.5 [95% CI: 1.6–12.2]).
In-Hospital Management
The primary findings and outcomes of the inpatient neurological evaluation of the ALTE cohort are shown in Table 3.
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Of the 471 patients, 137 (29%) had a neurology consultation. Twelve of these patients went on to develop chronic epilepsy. Obtaining a consultation had a sensitivity of 71% (95% CI: 44%–90%) for predicting those who would develop chronic epilepsy, but the PPV was low (8.8% [95% CI: 4.6%–15%]). The outcome of the neurology consult was less sensitive and specific than the actual request for the consult.
One hundred fifty-six (33%) patients had an EEG, of which 6 (1.3%) showed abnormal results. Two of the patients with an abnormal EEG result developed chronic epilepsy, but 11 of the patients who developed chronic epilepsy had normal EEG results. This yielded a sensitivity of 15% (95% CI: 2%–45%) and PPV of 33% (95% CI: 4.3%–48%) of an EEG.
CNS imaging studies, including head computed tomography (CT), brain MRI, and head ultrasound tests, were performed on 199 (42%) patients. CNS imaging results were abnormal for 4 patients, including 2 patients for whom child abuse (nonaccidental trauma) was diagnosed and 1 patient who developed chronic epilepsy. The sensitivity and PPV of abnormal CNS imaging for predicting chronic epilepsy was 6.7% (95% CI: 0.2%–32%) and 25% (95% CI: 0.6%–81%), respectively.
In no case did an MRI reveal a previously undetected abnormality. Although the MRI, in some cases, did clarify the underlying CNS pathology (eg, cortical dysplasia), MRI did not have any additional sensitivity (compared with CT) for detecting novel pathology.
Twenty-three (4.9%) patients were started on an antiepileptic drug, 5 of whom developed chronic epilepsy. Prescription of an antiepileptic drug at the first ALTE had low sensitivity (30% [95% CI: 10%–56%]) and PPV (22% [95% CI: 7.5%–44%]) for predicting the development of chronic epilepsy. Of the patients who developed chronic epilepsy, 5 had been placed on an antiepileptic drug during their first hospitalization. Overall, 71% were diagnosed within 1 month of their first presentation because they returned with a second event and were placed on an antiepileptic drug (unpublished data).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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This study had 4 major findings. First, for patients with an ALTE who appear well when they present, 1 in 9 will subsequently suffer from child abuse and 1 in 20 will develop an adverse neurological outcome. Second, inpatient neurological evaluation has a low yield for predicting adverse neurological outcome. Third, a majority of patients who develop chronic epilepsy will present again within 1 month of their initial ALTE. Fourth, an ALTE did not seem to be a risk factor for SIDS. To our knowledge, this study presents the single largest ALTE cohort with the most extensive follow-up after hospital discharge to date.
In our study, 11% of the patients went on to have substantiated child abuse, including 0.9% with physical abuse. The risk for physical abuse is markedly above the published background rate (0.02%) of physical child abuse15 and is similar to other published results on ALTEs.4,16 Similarly, rates of adverse neurological outcome, including chronic epilepsy and developmental delay, are significantly elevated above reported background rates.17,18 Other ALTE studies have shown similarly elevated rates of adverse neurological outcomes.19–22
These elevated rates of abuse and adverse neurological outcome occurred in our study despite the exclusion of patients with a known preexisting explanatory diagnosis (such as a known seizure disorder) and patients in whom a diagnosis was apparent at presentation (including sepsis, electrolyte abnormalities, or otherwise unstable patients). For these patients, there is minimal diagnostic dilemma, and their management is significantly directed by past history or obvious clinical findings. Instead, our ALTE cohort consisted of well-appearing infants with no apparent clinical abnormalities at presentation. Our study demonstrates that there are still significant short- and long-term risks for those well-appearing patients.
The optimal approach for inpatient ALTE management with regards to abuse requires additional study. Although we are not able to determine causality between an ALTE and abuse, our data suggest that patients who present with ALTE are "at risk." Head CT scans, dilated fundoscopic examinations, or the use of a hospital-based child protection team offer possible management options for patients after an ALTE.4,23,24
The inpatient neurological evaluation of patients with an ALTE is of low sensitivity and low yield at the first presentation. The only clinical predictor for adverse neurological outcome and chronic epilepsy was a family history of seizures. However, the association between obtaining a neurology consultation and the subsequent development of chronic epilepsy suggests that subtle clinical factors are present, which lead to the request for a consult. It is interesting to note that the consult recommendations had low sensitivity and predictive value for the likelihood to develop chronic epilepsy. Because most patients with an ALTE who develop chronic epilepsy have a second event within 1 month of their initial presentation, delaying antiepileptic drug initiation would avoid potential morbidities associated with unnecessary exposure to these medications.
Death was an infrequent outcome in our ALTE cohort and only occurred in patients who developed chronic epilepsy and static encephalopathy. There were no cases of SIDS, which is in concordance with results of other recent studies.3,25,26
Strengths of this study include the large cohort size and the extended follow-up (>5 years). Also, we had the ability to comprehensively track and identify patients for subsequent outcomes, because a significant majority of pediatric patients in Utah are cared for by the same health care system, which maintains records (including admissions, emergency department visits, clinic visits to pediatric neurology, EEG results, and radiology results) in an electronic chart format for its 20 hospitals. In addition, the study hospital is the sole tertiary care pediatric hospital in Utah and receives referrals from Wyoming, Idaho, Montana, and parts of Nevada, Colorado, and Arizona. We were also able to track patients by their referrals to the pediatric neurology clinic (there is only 1 other pediatric neurologist in Utah). Finally, we were able to link our cohort to the Utah state health department databases to evaluate for death and child abuse.
There are several limitations to this study. First, the data were collected retrospectively. Second, because ALTE is not a codeable diagnosis, we used proxy key words and diagnoses to identify patients and potentially missed cases. Third, our follow-up was limited to patients who presented again to the same health care system or to the pediatric neurology clinic. Patients may have been lost to follow-up if they moved to a different state or if they presented to a different health care system. Fourth, it was difficult to generate a meaningful control group for comparison of outcomes (such as child abuse), given the strict inclusion criteria for the ALTE cohort.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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We found that patients with an ALTE are at increased risk for child abuse and adverse neurological outcomes but are at minimal risk of death, and only as related to their development of chronic epilepsy and severe developmental delay. Our study suggests that for ALTE management, a high level of suspicion for the possibility of abuse should be maintained, and screening tests should be considered. Inpatient neurological evaluation for a first ALTE, including pediatric neurology consultation, an EEG test, and CNS imaging, is of low yield. We recommend close communication with the primary care provider regarding the risks for child abuse or adverse neurological outcome.
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ACKNOWLEDGMENTS |
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Drs Guenther and Srivastava were supported by National Institutes of Health grants K23 HD43145 and K23 HD052553 from the National Institutes of Child Health and Human Development. This research was supported in part by the Children's Health Research Center (University of Utah).
We are indebted to N. Forsythe and the Utah Department of Human Services for assistance with collecting data on children with child abuse; P. Gesteland for assistance with database searches; C. Newberry for assistance with chart analyses; and H. Cornelli, M. Dean, R. Holubkov, and P. Young for critical review.
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FOOTNOTES |
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Accepted Dec 14, 2007.
Address correspondence to Joshua L. Bonkowsky, MD, PhD, University of Utah Health Sciences Center, Division of Pediatric Neurology, Department of Pediatrics, 295 Chipeta Way/Williams Building, Salt Lake City, UT 84108. E-mail: joshua.bonkowsky{at}hsc.utah.edu
The authors have indicated they have no financial relationships relevant to this article to disclose.
Portions of this study were presented at the Pediatric Academic Societies' meeting (May 2–5, 2007; Toronto, ON Canada); the Pediatric Hospital Medicine Conference (August 2–5, 2007; Salt Lake City, UT); and the Child Neurology Society Meeting (October 10–13, 2007; Quebec City, QC Canada).
| What's Known on This Subject ALTEs are thought to be a risk factor for SIDS, child abuse, and adverse neurological outcomes, but there are minimal data to support these possibilities.
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| What This Study Adds This study is a comprehensive evaluation of short- and long-term outcomes of infants after an ALTE.
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REFERENCES |
|---|
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
|---|
- National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring, Sept 29 to Oct 1, 1986.
Pediatrics.1987; 79
(2):292
–299
[Abstract/Free Full Text] - McGovern MC, Smith MB. Causes of apparent life threatening events in infants: a systematic review.
Arch Dis Child.2004; 89
(11):1043
–1048
[Abstract/Free Full Text] - Mitchell EA, Thompson JM. Parental reported apnoea, admissions to hospital and sudden infant death syndrome. Acta Paediatr.2001; 90 (4):417 –422[Web of Science][Medline]
- Pitetti RD, Maffei F, Chang K, Hickey R, Berger R, Pierce MC. Prevalence of retinal hemorrhages and child abuse in children who present with an apparent life-threatening event.
Pediatrics.2002; 110
(3):557
–562
[Abstract/Free Full Text] - Dewolfe CC. Apparent life-threatening event: a review. Pediatr Clin North Am.2005; 52 (4):1127 –1146[CrossRef][Web of Science][Medline]
- Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event [published correction appears in Pediatrics. 2005;116(3):802–803].
Pediatrics.2005; 115
(4):885
–893
[Abstract/Free Full Text] - Kahn A. Recommended clinical evaluation of infants with an apparent life-threatening event: consensus document of the European Society for the Study and Prevention of Infant Death, 2003. Eur J Pediatr.2004; 163 (2):108 –115[CrossRef][Web of Science][Medline]
- Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted [published correction appears in Pediatrics. 2007;119(6):1270]?
Pediatrics.2007; 119
(4):679
–683
[Abstract/Free Full Text] - Norlin C, Osborn LM. Organizational responses to managed care: issues for academic health centers and implications for pediatric programs.
Pediatrics.1998; 101
(4 pt 2):805
–811
[Abstract/Free Full Text] - Governor's Office of Planning and Budget. Age distribution in Utah. Available at: http://governor.utah.gov/dea/Publications/05%20Census%20Briefs/2%20Age%20Distribution.pdf. Accessed September 27, 2007
- Classen DC, Pestotnik SL, Evans RS, Lloyd JF, Burke JP. Adverse drug events in hospitalized patients: excess length of stay, extra costs, and attributable mortality.
JAMA.1997; 277
(4):301
–306
[Abstract/Free Full Text] - Harbarth S, Burke JP, Lloyd JF, Evans RS, Pestotnik SL, Samore MH. Clinical and economic outcomes of conventional amphotericin B-associated nephrotoxicity. Clin Infect Dis.2002; 35 (12):e120 –e127[CrossRef][Web of Science][Medline]
- Drummond M, Stoddart G, Labelle R, Cushman R. Health economics: an introduction for clinicians.
Ann Intern Med.1987; 107
(1):88
–92
[Abstract/Free Full Text] - Utah Department of Human Services. DCFS Practice Guidelines. Available at: www.hspolicy.utah.gov/dcfs. Accessed September 27, 2006
- Barlow KM, Minns RA. Annual incidence of shaken impact syndrome in young children. Lancet.2000; 356 (9241):1571 –1572[CrossRef][Web of Science][Medline]
- Altman RL, Brand DA, Forman S, et al. Abusive head injury as a cause of apparent life-threatening events in infancy.
Arch Pediatr Adolesc Med.2003; 157
(10):1011
–1015
[Abstract/Free Full Text] - Camfield CS, Camfield PR, Gordon K, Wirrell E, Dooley JM. Incidence of epilepsy in childhood and adolescence: a population-based study in Nova Scotia from 1977 to 1985. Epilepsia.1996; 37 (1):19 –23[CrossRef][Web of Science][Medline]
- Aicardi J. The etiology of developmental delay. Semin Pediatr Neurol.1998; 5 (1):15 –20[CrossRef][Medline]
- Okada K, Miyako M, Honma S, Wakabayashi Y, Sugihara S, Osawa M. Discharge diagnoses in infants with apparent life-threatening event. Pediatr Int.2003; 45 (5):560 –563[CrossRef][Web of Science][Medline]
- Gray C, Davies F, Molyneux E. Apparent life-threatening events presenting to a pediatric emergency department. Pediatr Emerg Care.1999; 15 (3):195 –199[Web of Science][Medline]
- Davies F, Gupta R. Apparent life threatening events in infants presenting to an emergency department.
Emerg Med J.2002; 19
(1):11
–16
[Abstract/Free Full Text] - Samuels MP, Poets CF, Noyes JP, Hartmann H, Hewertson J, Southall DP. Diagnosis and management after life threatening events in infants and young children who received cardiopulmonary resuscitation.
BMJ.1993; 306
(6876):489
–492
[Abstract/Free Full Text] - Tien I, Bauchner H, Reece RM. What is the system of care for abused and neglected children in children's institutions?
Pediatrics.2002; 110
(6):1226
–1231
[Abstract/Free Full Text] - Campbell KA, Berger RP, Ettaro L, Roberts MS. Cost-effectiveness of head computed tomography in infants with possible inflicted traumatic brain injury.
Pediatrics.2007; 120
(2):295
–304
[Abstract/Free Full Text] - Kiechl-Kohlendorfer U, Hof D, Peglow UP, Traweger-Ravanelli B, Kiechl S. Epidemiology of apparent life threatening events.
Arch Dis Child.2005; 90
(3):297
–300
[Abstract/Free Full Text] - Alm B, Norvenius SG, Wennergren G, et al. Changes in the epidemiology of sudden infant death syndrome in Sweden 1973–1996.
Arch Dis Child.2001; 84
(1):24
–30
[Abstract/Free Full Text] - US Census Bureau. Census 2000 data for the state of Utah. Available at: www.census.gov/census2000/states/ut.html. Accessed October 15, 2007
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