Question

• What is the value of home monitors with apparent life-threatening events in infants under the age of 12 months?

Clinical Bottom Lines

1. An infant with an ALTE (apparent life-threatening event) as defined by the 1986 NIH consensus panel should be admitted to the hospital for further evaluation.⁵
2. If evaluation as dictated by the consensus panel remains negative, the patient should be discharged home with an event monitor.^3,4,5
3. Study demonstrates that event recording, which is comparatively cheap and does not require prolonged hospitalization, is useful in the initial diagnostic evaluation of ALTE's.⁶

Summary of Key Evidence

1. Prospective study of 94 infants with a history of 2 or more ALTE's of unknown etiology who were studied with event recordings of tcO2, SaO2, breathing movements, HR, and EKG.
2. In mean duration of 1.3 months monitored, 52 events recorder in 32 patients.
3. Seven events excluded because of poor signals. Of the remaining 45 events in 30 patients, a specific mechanism for the ALTE was found in 23 cases (19 pts).
4. Six events (5 pts) had patterns suggestive of hypoxemia induced by epileptic seizure.
5. Four events (4pts) had patterns suggestive of hypoxemia induced by suffocation by a parent.
6. Seven events (6 pts) had patterns suggestive of parental fabrication of events (Muchausen by proxy).
7. Twenty two events (12 pts) had hypoxemia that had unexplained etiology (true apnea of infancy).
8. Event monitors were able to identify potentially preventable mechanisms in 63% of ALTE's.
9. Study not designed to determine the specificity and sensitivity of event recording in identifying underlying mechanisms of ALTE's.

Additional Comments

• No good EBM studies available for utility of home monitoring in preventing
  death in infants with ALTE's.
• However, per the current consensus policies, all infants with ALTE should be
  discharged home with home monitors.3,4,5
• Steinschneider et al showed that event recording resulted in a significant cost savings
  by decreasing the duration of monitoring and by reducing the number of unnecessary diagnostic studies.7
• Daniels et al showed abnormal polysomnagraphy predicted ALTE's in 58% of patients
  who were discharged with home monitors.2
• Cote et al showed that events during the initial investigation period predicted the likelihood of events occurring at home. They also showed that most events occurred during the first month of monitoring.1

Citation

1. Cote A, Hum C, Brouillette RT, Themens M. Frequency and timing of recurrent events in infants using home cardiorespiratory monitors. Journal of  Pediatrics, 1998; 312:783-98.
2. Daniels H, Naulaers G, Devlieger H. Polysomnography and home documented monitoring of cardiorespiratory pattern. Archives of Disease in Childhood, 1999; 81:434-436.
3. McIntosh NA, Roloff DW. Protocols for the Diagnosis & Management of Apnea in Infants and Children. University of Michigan Apnea Program. 1993.
4. Michigan Association of Apnea Professionals Consensus Statement of Infantile Apnea and Home Monitoring Fourth Edition. 1998.
5. National Institute of Health. Consensus statement on infantile apnea and home monitoring. Pediatrics, 1987; 79:292-9.
6. Poets CF, Samuels MP, Noyes JP, Hewertson J, Hartman H, Holder A, Southall DP. Home event recordings of oxygenation, breathing movements, and heart rate and rhythm in infants with recurrent life-threatening events. Journal of  Pediatrics, 1993; 123:693-701.
7. Steinschneider A, Santos V, Freed G. Cost implications of event recording in Apnea/bradycardia home monitoring: A theoretical analysis. Pediatrics, 1995; 93:378-380.

CAT Author: Kristin Bencik Boudreau, DO

CAT Appraisers: John G. Frohna, MD

Date appraised: July 31, 2000