Investigating and managing neonates presenting to the emergency department with an apparent life threatening event
Aims
Apparent Life-Threatening Events (ALTEs) are concerning for caregivers and medical professionals. There is little consensus on how best to investigate and manage neonates presenting with ALTE, especially when the patient appears well on examination. Both over and under-investigation can lead to significant anxiety in the context of balancing risks and benefits of invasive testing or missing an underlying pathology. Recent guidelines from the American Academy of Paediatrics have suggested a pathway in children over 2 months old with the re-named Brief Resolved Unexplained Event (BRUE), but this does not apply to younger infants. This survey aimed to examine how an ALTE presentation in this vulnerable group might be managed in a local emergency department setting.
Methods
A survey available both online and on paper was undertaken in a UK district general hospital with 6000 live-born infants per year. The emergency department (ED) is a mixed adult and paediatric environment. It was available for a 4-week period to all paediatric department and ED doctors and nurse practitioners likely to be involved in early assessment and management of these patients. Respondents were screened initially to determine who had an awareness or knowledge of an ALTE presentation in children; these then answered further questions about investigating and managing a neonate (up to 28 days old) presenting with ALTE who appeared well on examination using a typical scenario.
Results
33/83 practitioners responded to the survey (40% response rate). Three were excluded due to incomplete responses, leaving a total of 30. 21/30 (70%) were aware of ALTE as a presentation and so completed the remainder of the survey. The available investigations in the scenario were selected as follows: oxygen saturation monitoring (20/21, 95%), blood glucose (19/21, 90%), urinalysis (16/21, 76%), blood gas (14/21, 67%), electrocardiogram (14/21, 67%), metabolic screen (8/21, 38%), chest x-ray (7/21, 33%), fundoscopy (6/21, 29%), septic screen (5/21, 24%), urine toxicology (3/21, 14%), nasopharyngeal aspirate (2/21, 10%) and CT head and skeletal survey (1/21, 5%). One respondent (5%) would not perform any investigations. Everyone else would perform multiple investigations per patient (median 6, interquartile range 4).
12/21 (57%) chose to admit the patient, 7 (33%) chose to observe for 4 hours, one (5%) chose to discharge to community care and one (5%) did not know. 16/21 (76%) respondents supported the provision of basic life support to parents before discharge.
Discussion
This is a small local study, but the respondents are representative of those at the front line in many units in the UK. The results show variation in approach to both investigations and management of ALTE in those under a month old. The variation and the investigations and management chosen broadly correlate with recommendations and evidence of practice in the literature, despite there being an overall low yield of positive results from investigations.These variable responses highlight the complexity of managing these nebulous presentations and the need for consistent education and senior supervision.
Conclusion
Further larger studies would be helpful in clarifying and standardising the appropriate response to these presentations.
