Abusive head trauma in children presenting with an apparent life-threatening event

Diagnostic testing for and detection of physical abuse in infants with brief resolved unexplained events

BACKGROUND

A Brief Resolved Unexplained Event (BRUE) can be a sign of occult physical abuse.

OBJECTIVES

To identify rates of diagnostic testing able to detect physical abuse (head imaging, skeletal survey, and liver transaminases) at BRUE presentation. The secondary objective was to estimate the rate of physical abuse diagnosed at initial BRUE presentation through 1 year of age.

PARTICIPANTS AND SETTING

Infants who presented with a BRUE at one of 15 academic or community hospitals were followed from initial BRUE presentation until 1 year of age for BRUE recurrence or revisits.

METHODS

This study was part of the BRUE Research and Quality Improvement Network, a multicenter retrospective cohort examining infants with BRUE. Generalized estimating equations assessed associations with performance of diagnostic testing (adjusted odds ratio (aOR)).

RESULTS

Of the 2036 infants presenting with a BRUE, 6.2 % underwent head imaging, 7.0 % skeletal survey, and 12.1 % liver transaminases. Infants were more likely to undergo skeletal survey if there were physical examination findings concerning for trauma (aOR 8.23, 95 % CI [1.92, 35.24], p < 0.005) or concerning social history (aOR 1.89, 95 % CI [1.13, 3.16], p = 0.015). There were 7 (0.3 %) infants diagnosed with physical abuse: one at BRUE presentation, one <3 days after BRUE presentation, and five >30 days after BRUE presentation.

CONCLUSION

There were low rates of diagnostic testing and physical abuse identified in infants presenting with BRUE. Further study including standardized testing protocols is warranted to identify physical abuse in infants presenting with a BRUE.

Injuries Suggestive of Physical Abuse in Young Children With Subconjunctival Hemorrhages

OBJECTIVE

The aim of this study was to compare the demographic characteristics, clinical presentations, medical evaluation, and injuries identified in a cohort of children with and without subconjunctival hemorrhage who were evaluated by a child abuse specialist.

METHODS

This was a case-control study that used data from the ExSTRA (Examining Siblings to Recognize Abuse) research network. Subjects with a subconjunctival hemorrhage(s) were designated as cases. Four controls matched for age and participating center were included for each case. Descriptive statistics were used to compare cases and controls.

RESULTS

Fifty of the 2890 subjects in the parent study had a subconjunctival hemorrhage(s) and were designated as cases. The cases had a median (interquartile range) age of 5.0 months (2.0-23.6 months). Two hundred controls were matched to the cases. There was no difference in the demographics, clinical characteristics, medical evaluation, or rate of occult injuries identified in cases and controls. Almost one-quarter of children with subconjunctival hemorrhages had no other external sign of trauma but had the same rate of occult injuries as children with bruises.

CONCLUSIONS

These data suggest that subconjunctival hemorrhages are relatively rare among children undergoing evaluation by a child abuse specialist, but that they are often an indicator of occult injury. Even in the absence of other external signs of trauma, the presence of subconjunctival hemorrhages should prompt an age-appropriate evaluation for physical abuse.

Characteristics That Distinguish Abusive From Nonabusive Causes of Sudden Unexpected Infant Deaths

BACKGROUND

Fatal child abuse can be mistaken for sudden unexpected infant death (SUID) in the emergency department setting. It is unknown if there are characteristics that distinguish abusive from nonabusive causes of SUIDs in the emergency department.

METHODS

Using a matched case-control design, we reviewed the medical examiner records of deaths of infants younger than 12 months who were found unresponsive at a residence, required cardiopulmonary resuscitation, and had a complete forensic autopsy between 2009 and 2015. Infants with a manner of death as homicide were cases; controls were those with the manner of death as accident, natural, or undetermined. Each case was matched with 5 controls based on age (months). Differences between cases and controls were evaluated with respect to demographic, parental, and household characteristics and clinical outcomes.

RESULTS

We identified 12 cases (homicides) and 169 controls (nonhomicides), of which 60 were selected for the matched analysis. We found no significant differences between cases and controls with respect to age, race, sex, maternal substance use, Child Protective Services involvement prior to death, presence of male head of household, surviving siblings, or emergency medical services transport. Cases were more likely to have Child Protective Services involvement at the time of death (83% vs 38%; P = 0.01), sentinel injuries (odds ratio, 9.67; 95% confidence interval, 1.30-122.43), and return of spontaneous circulation (odds ratio, 29.99; 95% confidence interval, 3.70-241.30).

CONCLUSIONS

Child Protective Services agency involvement at time of death, sentinel injury, and return of spontaneous circulation were more often associated with abusive causes of SUID. Further study is needed to confirm these findings.

Brief Resolved Unexplained Event: Not Just a New Name for Apparent Life-Threatening Event

OBJECTIVES

This study aimed to evaluate patients who presented to the pediatric emergency department with an apparent life-threatening event (ALTE) to (1) determine if these patients would meet the criteria for brief resolved unexplained event (BRUE), a new term coined by the American Academy of Pediatrics in May, 2016; (2) risk stratify these patients to determine if they meet the BRUE low-risk criteria; and (3) evaluate outcomes of patients meeting the criteria for BRUE.

METHODS

We conducted a retrospective chart review of patients who presented to a large urban academic center pediatric emergency department with an ALTE from January 2013 to May 2015 (before the publication of the BRUE guideline). Children ≤12 months of age were identified by the International Classification of Diseases, Ninth/Tenth Revision. Two physician reviews were performed to determine if patients met the ALTE diagnostic criteria. Data were then extracted from these charts to complete objectives.

RESULTS

Seventy-eight patients met the diagnostic criteria for ALTE. Only 1 of those patients met the diagnostic criteria for BRUE, but not for low-risk BRUE. This patient underwent an extensive inpatient evaluation and was eventually discharged after monitoring with a benign diagnosis. Most patients did not meet the criteria for BRUE because the event was not unexplained.

CONCLUSIONS

Only 1 patient who presented to the ED with ALTE met the criteria for BRUE, and this patient did not meet the low-risk criteria. This study corroborates previous research on BRUE and continues to highlight the importance of conducting a thorough history and physical examination on all patients presenting to the ED with concerning events.

Brief resolved unexplained events vs. child maltreatment: a review of clinical overlap and evaluation

Within their first year, a number of infants present for medical evaluation because of unexplained changes in color, tone, breathing, or level of responsiveness. This broad collection of symptoms has an accordingly large differential diagnosis that includes both brief resolved unexplained event (BRUE) and child maltreatment. The overlap between clinical presentation for BRUE and maltreatment can present a diagnostic challenge - especially given the significant consequences for infants and families for diagnostic error at that juncture. In this review, we provide overviews of the presenting features and findings in cases of BRUE and child maltreatment with a focus on areas of overlap and differentiation.

The Use of Experts to Evaluate a Child Abuse Guideline in Community Emergency Departments

OBJECTIVE

Guidelines and pathways exist to help frontline providers evaluate injured children for suspected child abuse. Little, however, is known about whether the decision-making resulting from these interventions is correct. Therefore, in the absence of an available gold-standard test, we used experts' judgments to examine the appropriateness of these clinical decisions. We evaluated community emergency department (ED) providers' adherence to a guideline recommending a child protection team (CPT) consultation for infants with injuries associated with abuse. We then compared providers' decision-making to experts' recommendations before and after guideline implementation.

METHODS

Two experts conducted a blinded, retrospective review of injured infants from 3 community EDs (N = 175). Experts rated the likelihood that an injury was abusive, indeterminate, or accidental, and made recommendations that were compared with skeletal survey (SS) testing and child protective services (CPS) reporting by providers before and after guideline implementation.

RESULTS

Postguideline implementation, there was a significant increase in CPT consultations in indeterminate cases (14.3% vs 72.2%, P < .001) and in SS testing when experts recommended SS (20.6% vs 56.8%, P = .002). In contrast, a higher percentage of cases for whom the experts did not recommend reporting were reported to CPS (1.8% vs 14.6%, P = .02).

CONCLUSIONS

Providers consulted the CPT most often for indeterminate cases. SS testing was in line with expert recommendations, but CPS reporting diverged from expert recommendations. Interventions linking community ED providers with a CPT may improve the evaluation of infants with injuries concerning for abuse.

Dissemination of child abuse clinical decision support: Moving beyond a single electronic health record

BACKGROUND

Child maltreatment is a leading cause of pediatric morbidity and mortality. We previously reported on development and implementation of a child abuse clinical decision support system (CA-CDSS) in the Cerner electronic health record (EHR). Our objective was to develop a CA-CDSS in two different EHRs.

METHODS

Using the CA-CDSS in Cerner as a template, CA-CDSSs were developed for use in four hospitals in the Northwell Health system who use Allscripts and two hospitals in the University of Wisconsin health system who use Epic. Each system had a combination of triggers, alerts and child abuse-specific order sets. Usability evaluation was done prior to launch of the CA-CDSS.

RESULTS

Over an 18-month period, a CA-CDSS was embedded into Epic and Allscripts at two hospital systems. The CA-CDSSs vary significantly from each other in terms of the type of triggers which were able to be used, the type of alert, the ability of the alert to link directly to child abuse-specific order sets and the order sets themselves.

CONCLUSIONS

Dissemination of CA-CDSS from one EHR into the EHR in other health care systems is possible but time-consuming and needs to be adapted to the strengths and limitations of the specific EHR. Site-specific usability evaluation, buy-in of multiple stakeholder groups and significant information technology support are needed. These barriers limit scalability and widespread dissemination of CA-CDSS.

Documentation of Child Maltreatment by Emergency Medical Services in a National Database

BACKGROUND

Child abuse and neglect (CAN) has an estimated annual incidence of 1.46% among those ≤3 years old. Prehospital providers (PHPs) report difficulties identifying CAN and the frequency in which PHPs document CAN during prehospital encounters of young children is not known.

OBJECTIVE

To report the percentage of CAN documentation by PHPs during encounters among children ≤3 years in a national dataset and describe the characteristics of this population.

METHODS

This is an analysis of concurrent cases in the 2017-18 National Emergency Medical Services Information System database. We identified children ≤3 years old with ICD-10-CM codes specific for CAN including codes for physical and sexual abuse as well as neglect. We examined patient demographics including race, gender, Emergency Medical Services (EMS) primary and secondary impression, associated symptoms, anatomic location of chief complaint, and cause of injury. Our primary outcome is the percentage of CAN reported as an EMS primary or secondary impression; secondary outcomes include proportion of children with each subtype of abuse, the description of patients by demographic information, anatomic location of injury, and associated symptoms.

RESULTS

There were 498,555 for children ≤3 years old, of which 522 had an impression of CAN (0.10%). Within our cohort, 43% were <1 year of age, 51% were male. The most common anatomic location of injury was general/global (29.7%), followed by head (23.5%) and extremity (14%). The most common symptoms reported by PHPs are those associated with injury including codes for injury, burn, fracture, cutaneous findings, hemorrhage, or pain (n = 244, 63%). Pain is the most commonly reported symptom (n = 110, 21%). Few encounters specified vomiting, seizure, or disordered breathing as symptoms (1%, 1%, and 5.4%, respectively). Interestingly, 28.2% (27/124) of cases in our cohort were related to sexual abuse.

CONCLUSIONS

The percentage of PHP documentation of CAN among children ≤3 years of age is very low. Among those with an EMS primary impression of CAN, documentation is primarily associated with findings of injury whereas documentation of nonspecific symptoms such as vomiting and seizure is infrequent. These findings suggest that recognition of abuse primarily occurs in young patients with overt signs of trauma.

Integration of physical abuse clinical decision support into the electronic health record at a Tertiary Care Children's Hospital

Objective

To evaluate the effect of a previously validated electronic health record-based child abuse trigger system on physician compliance with clinical guidelines for evaluation of physical abuse.

Methods

A randomized controlled trial (RCT) with comparison to a preintervention group was performed. RCT-experimental subjects' providers received alerts with a direct link to a physical abuse-specific order set. RCT-control subjects' providers had no alerts, but could manually search for the order set. Preintervention subjects' providers had neither alerts nor access to the order set. Compliance with clinical guidelines was calculated.

Results

Ninety-nine preintervention subjects and 130 RCT subjects (73 RCT-experimental and 57 RCT-control) met criteria to undergo a physical abuse evaluation. Full compliance with clinical guidelines was 84% pre-intervention, 86% in RCT-control group, and 89% in RCT-experimental group. The physical abuse order set was used 43 times during the 7-month RCT. When the abuse order set was used, full compliance was 100%. The proportion of cases in which there was partial compliance decreased from 10% to 3% once the order set became available (P = .04). Male gender, having >10 years of experience and completion of a pediatric emergency medicine fellowship were associated with increased compliance.

Discussion/Conclusion

A child abuse clinical decision support system comprised of a trigger system, alerts and a physical abuse order set was quickly accepted into clinical practice. Use of the physical abuse order set always resulted in full compliance with clinical guidelines. Given the high baseline compliance at our site, evaluation of this alert system in hospitals with lower baseline compliance rates will be more valuable in assessing the efficacy in adherence to clinical guidelines for the evaluation of suspected child abuse.

Integration of physical abuse clinical decision support at 2 general emergency departments

OBJECTIVE

The study sought to develop and evaluate an electronic health record-based child abuse clinical decision support system in 2 general emergency departments.

MATERIALS AND METHODS

A combination of a child abuse screen, natural language processing, physician orders, and discharge diagnoses were used to identify children <2 years of age with injuries suspicious for physical abuse. Providers received an alert and were referred to a physical abuse order set whenever a child triggered the system. Physician compliance with clinical guidelines was compared before and during the intervention.

RESULTS

A total of 242 children triggered the system, 86 during the preintervention and 156 during the intervention. The number of children identified with suspicious injuries increased 4-fold during the intervention (P < .001). Compliance was 70% (7 of 10) in the preintervention period vs 50% (22 of 44) in the intervention, a change that was not statistically different (P = .55). Fifty-two percent of providers said that receiving the alert changed their clinical decision making. There was no relationship between compliance and provider or patient demographics.

CONCLUSIONS

A multifaceted child abuse clinical decision support system resulted in a marked increase in the number of young children identified as having injuries suspicious for physical abuse in 2 general emergency departments. Compliance with published guidelines did not change; we hypothesize that this is related to the increased number of children identified with suspicious, but less serious injuries. These injuries were likely missed preintervention. Tracking compliance with guidelines over time will be important to assess whether compliance increases as physician comfort with evaluation of suspected physical abuse in young children improves.

A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event

In 2016, the American Academy of Pediatrics published a clinical practice guideline that more specifically defined apparent life-threatening events as brief resolved unexplained events (BRUEs) and provided evidence-based recommendations for the evaluation of infants who meet lower-risk criteria for a subsequent event or serious underlying disorder. The clinical practice guideline did not provide recommendations for infants meeting higher-risk criteria, an important and common population of patients. Therefore, we propose a tiered approach for clinical evaluation and management of higher-risk infants who have experienced a BRUE. Because of a vast array of potential causes, the initial evaluation prioritizes the diagnosis of time-sensitive conditions for which delayed diagnosis or treatment could impact outcomes, such as child maltreatment, feeding problems, cardiac arrhythmias, infections, and congenital abnormalities. The secondary evaluation addresses problems that are less sensitive to delayed diagnosis or treatment, such as dysphagia, intermittent partial airway obstruction, and epilepsy. The authors recommend a tailored, family-centered, multidisciplinary approach to evaluation and management of all higher-risk infants with a BRUE, whether accomplished during hospital admission or through coordinated outpatient care. The proposed framework was developed by using available evidence and expert consensus.

Development of an electronic medical record-based child physical abuse alert system

Objective

Physical abuse is a leading cause of pediatric morbidity and mortality. Physicians do not consistently screen for abuse, even in high-risk situations. Alerts in the electronic medical record may help improve screening rates, resulting in early identification and improved outcomes.

Methods

Triggers to identify children < 2 years old at risk for physical abuse were coded into the electronic medical record at a freestanding pediatric hospital with a level 1 trauma center. The system was run in "silent mode"; physicians were unaware of the system, but study personnel received data on children who triggered the alert system. Sensitivity, specificity, and negative and positive predictive values of the child abuse alert system for identifying physical abuse were calculated.

Results

Thirty age-specific triggers were embedded into the electronic medical record. From October 21, 2014, through April 6, 2015, the system was in silent mode. All 226 children who triggered the alert system were considered subjects. Mean (SD) age was 9.1 (6.5) months. All triggers were activated at least once. Sensitivity was 96.8% (95% CI, 92.4-100.0%), specificity was 98.5% (95% CI, 98.3.5-98.7), and positive and negative predictive values were 26.5% (95% CI, 21.2-32.8%) and 99.9% (95% CI, 99.9-100.0%), respectively, for identifying children < 2 years old with possible, probable, or definite physical abuse.

Discussion/Conclusion

Triggers embedded into the electronic medical record can identify young children with who need to be evaluated for physical abuse with high sensitivity and specificity.

The Utility of Head Computed Tomography in the Evaluation of Apparent Life-Threatening Event

OBJECTIVE

This study aimed to evaluate the diagnostic utility of empiric head computed tomography (CT) in apparent life threatening event (ALTE).

METHODS

This was a retrospective chart review of children younger than 12 months presenting to an urban pediatric hospital and its suburban satellite for an ALTE from October 2009 to December 2012. The ALTE cases were identified as having had a diagnosis of ALTE (International Classification of Diseases, 9th Revision 799.82) or as having had a constellation of studies performed consistent with our institutional protocol for ALTE evaluation. Exclusion criteria were known trauma and cases lacking an identifiable ALTE feature on review.

RESULTS

There were 631 cases identified, of which 617 met inclusion and exclusion criteria. Of those, 537 had a head CT performed. Five patients were identified with clinically important head CT findings: a case of congenital toxoplasmosis, a case of intraventricular hemorrhage, and 3 cases of nonaccidental trauma (NAT). One of the NAT patients had a bruise on his forehead; the other patients had no historical, physical examination, and other laboratory or radiologic findings to raise concern for significant finding on head CT. The rate of clinically significant findings and occult clinically significant findings was 5/537 (0.93%) (95% confidence interval, 0.30%-2.16%; number needed to treat = 108) and 4/537 (0.75%) (95% confidence interval, 0.20%-1.90%; number needed to treat = 135), respectively.

CONCLUSIONS

The rate of clinically important head CT findings in ALTE evaluation was relatively rare, at 0.93%. Given the severe consequences of missing these cases, these data establish a role for empiric head CT in the evaluation of ALTE.

Potential Opportunities for Prevention or Earlier Diagnosis of Child Physical Abuse in the Inpatient Setting

OBJECTIVES

To compare rates of previous inpatient visits among children hospitalized with child physical abuse (CPA) with controls as well as between individual abuse types.

METHODS

In this study, we used the Pediatric Health Information System administrative database of 44 children's hospitals. Children <6 years of age hospitalized with CPA between January 1, 2011, and September 30, 2015, were identified by discharge codes and propensity matched to accidental injury controls. Rates for previous visit types were calculated per 10 000 months of life. χ2 and Poisson regression were used to compare proportions and rates.

RESULTS

There were 5425 children hospitalized for CPA. Of abuse and accident cases, 13.1% and 13.2% had a previous inpatient visit, respectively. At previous visits, abused children had higher rates of fractures (rate ratio [RR] = 3.0 times; P = .018), head injuries (RR = 3.5 times; P = .005), symptoms concerning for occult abusive head trauma (AHT) (eg, isolated vomiting, seizures, brief resolved unexplained events) (RR = 1.4 times; P = .054), and perinatal conditions (eg, prematurity) (RR = 1.3 times; P = .014) compared with controls. Head injuries and symptoms concerning for occult AHT also more frequently preceded cases of AHT compared with other types of abuse (both P < .001).

CONCLUSIONS

Infants hospitalized with perinatal-related conditions, symptoms concerning for occult AHT, and injuries are inpatient populations who may benefit from abuse prevention efforts and/or risk assessments. Head injuries and symptoms concerning for occult AHT (eg, isolated vomiting, seizures, and brief resolved unexplained events) may represent missed opportunities to diagnose AHT in the inpatient setting; however, this requires further study.

Apparent Life-Threatening Events (ALTE): Italian guidelines

Five years after the first edition, we have revised and updated the guidelines, re-examining the queries and relative recommendations, expanding the issues addressed with the introduction of a new entity, recently proposed by the American Academy of Pediatrics: BRUE, an acronym for Brief Resolved Unexplained Events. In this manuscript we will use the term BRUE only to refer to mild, idiopathic cases rather than simply replace the acronym ALTE per se.In our guidelines the acronym ALTE is used for severe cases that are unexplainable after the first and second level examinations.Although the term ALTE can be used to describe the common symptoms at the onset, whenever the aetiology is ascertained, the final diagnosis may be better specified as seizures, gastroesophageal reflux, infection, arrhythmia, etc. Lastly, we have addressed the emerging problem of the so-called Sudden Unexpected Postnatal Collapse (SUPC), that might be considered as a severe ALTE occurring in the first week of life.

Missed Fractures in Infants Presenting to the Emergency Department With Fussiness

OBJECTIVES

The aim of this study was to evaluate incidence of prior fussy emergency visits in infants with subsequently diagnosed fractures suggestive of abuse.

METHODS

This was a retrospective chart review of infants younger than 6 months who presented to the pediatric emergency department (ED) between January 1, 2006, and December 31, 2011. Inclusion criteria included age 0 to 6 months, discharge diagnosis including "fracture," "broken" (or break), or "trauma" or any child abuse diagnosis or chief complaint of "fussy" or "crying" as documented in the electronic medical record by the triage nurse.

RESULTS

Three thousand seven hundred thirty-two charts were reviewed, and 279 infants with fractures were identified. Eighteen (6.5%) of 279 infants had a prior ED visit for fussiness without an obvious source. Of these, 2 had a witnessed event causing their fracture, and therefore the fracture was not considered concerning for abuse. The remaining 16 had fractures concerning for abuse. Mean age was 2.5 (SD, 1.2) months. Fifteen (83%) of 18 infants were 3 months or younger at the time of the fussy visit. The mean interval between the first and second ED visits was 27 days (median, 20 days). Thirty-nine percent were evaluated by a pediatric emergency medicine-trained physician during their initial fussy visit, whereas 78% were evaluated by pediatric emergency medicine-trained physician during their subsequent visit. Most common injuries were multiple types of fractures followed by extremity and rib fractures.

CONCLUSIONS

Fractures concerning for child abuse are an important cause of unexplained fussiness in infants presenting to the pediatric ED. A high index of suspicion is essential for prompt diagnosis and likely prevention of other abuse.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.

Management of apparent life-threatening events in infants: a systematic review

OBJECTIVE

To determine in patients who are well-appearing and without a clear etiology after an apparent life-threatening event (ALTE): (1) What historical and physical examination features suggest that a child is at risk for a future adverse event and/or serious underlying diagnosis and would, therefore, benefit from testing or hospitalization? and (2) What testing is indicated on presentation and during hospitalization?

STUDY DESIGN

Systematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE.

RESULTS

The final analysis was based on 37 studies; 18 prospective observational, 19 retrospective observational. None of the studies provided sufficient evidence to fully address the clinical questions. Risk factors identified from historical and physical examination features included a history of prematurity, multiple ALTEs, and suspected child maltreatment. Routine screening tests for gastroesophageal reflux, meningitis, bacteremia, and seizures are low yield in infants without historical risk factors or suggestive physical examination findings.

CONCLUSION

Some historical and physical examination features can be used to identify risk in infants who are well-appearing and without a clear etiology at presentation, and testing tailored to these risks may be of value. The true risk of a subsequent event or underlying disorder cannot be ascertained. A more precise definition of an ALTE is needed and further research is warranted.

Ethanol ingestion in two infants under 2 months old: a previously unreported cause of ALTE

The differential diagnosis for the infant presenting with an apparent life-threatening event (ALTE) is broad. Toxic ingestions are a relatively uncommon cause of an ALTE, although several over-the-counter, prescription, and illicit drugs have been implicated. We present 2 cases of ethanol intoxication in infants as a previously unreported cause of an ALTE. Additionally, serial ethanol levels for these patients offer novel insight into the pharmacokinetics of ethanol metabolism in infants. Ethanol ingestion may be an underrecognized cause of an ALTE and should be considered if the history or physical examination is suggestive.

Evento com aparente risco de morte: uma revisão

OBJETIVO: Realizar uma revisão crítica reunindo informações disponíveis a respeito dos eventos com aparente risco de morte. FONTES DE DADOS: Revisão bibliográfica dos artigos (em português, inglês e espanhol) obtidos dos bancos de dados eletrônicos Medline, Lilacs e SciELO, utilizando as palavras-chave: eventos com aparente risco de morte, evento com aparente risco de vida infantil, lactente, apneia, monitorização e cianose. SÍNTESE DOS DADOS: Os eventos com aparente risco de mortesão súbitos e caracterizados por uma combinação de apneia, alteração na coloração da pele e tônus muscular, com inúmeras causas subjacentes. Sua incidência verdadeira é desconhecida e a faixa etária mais acometida é de 11 a 12 semanas. Não há correlação entre o evento com aparente risco de morte e a síndrome da morte súbita do lactente, embora já tenham sido consideradas manifestações da mesma doença. Muitas vezes, o lactente tem aparência saudável ao ser avaliado pelo pediatra após apresentar eventos com aparente risco de morte, porém, isso não afasta a possibilidade de existir uma doença grave associada ao evento, que deve ser investigada e tratada. Quando não são encontradas as causas, o evento é idiopático, geralmente com boa evolução. CONCLUSÕES: É necessário investigar os lactentes levados ao pronto-socorro após apresentarem eventos com aparente risco de morte, devido ao risco de sequelas e mortalidade. Não há uma padronização das condutas a serem realizadas diante de um lactente com aparência saudável que tenha evento com aparente risco de morte, mas recomenda-se que o paciente seja internado e a causa do evento, investigada. A observação e o monitoramento em ambiente hospitalar devem ocorrer no mínimo 24 horas após o evento.

Adverse outcomes associated with gastroesophageal reflux disease are rare following an apparent life-threatening event

OBJECTIVE

To evaluate for adverse outcomes associated with gastroesophageal reflux disease (GERD) following an apparent life-threatening event (ALTE) and potential risk factors of these outcomes.

STUDY DESIGN

Retrospective cohort study of well-appearing infants (<12 months) admitted for ALTE. Patients were followed for adverse outcomes associated with GERD (including aspiration pneumonia, failure-to-thrive, or anti-reflux surgery), second ALTE, or death. Risk factors evaluated included: age, prematurity, gender, previous event, diagnosis of GERD, gastrointestinal (GI) testing positive for gastroesophageal reflux, length of stay (LOS), and neurologic impairment diagnosed in follow-up.

RESULTS

Four hundred sixty-nine patients met inclusion criteria, mean age was 45 days, 110 (22%) were premature. Patients were followed for an average of 7.8 years; 3.8% of all patients had an adverse outcome associated with GERD. The only significant risk factors were a longer LOS, and development of neurological impairment. A diagnosis of GERD and positive reflux testing during the initial hospitalization were not associated with adverse outcomes associated with GERD.

CONCLUSIONS

Adverse outcomes associated with GERD are rare following an ALTE. Patients who developed neurological impairment and a longer initial LOS were at higher risk for developing these outcomes. Positive testing for gastroesophageal reflux during hospitalization for ALTE did not predict adverse outcomes associated with GERD.

Cerebrospinal fluid levels of high-mobility group box 1 and cytochrome C predict outcome after pediatric traumatic brain injury

High-mobility group box 1 (HMGB1) is a ubiquitous nuclear protein that is passively released from damaged and necrotic cells, and actively released from immune cells. In contrast, cytochrome c is released from mitochondria in apoptotic cells, and is considered a reliable biomarker of apoptosis. Thus, HMGB1 and cytochrome c may in part reflect the degree of necrosis and apoptosis present after traumatic brain injury (TBI), where both are felt to contribute to cell death and neurological morbidity. Ventricular cerebrospinal fluid (CSF) was obtained from children admitted to the intensive care unit (ICU) after TBI (n=37). CSF levels of HMGB1 and cytochrome c were determined at four time intervals (0-24 h, 25-48 h, 49-72 h, and>72 h after injury) using enzyme-linked immunosorbent assay (ELISA). Lumbar CSF from children without TBI served as controls (n=12). CSF HMGB1 levels were: control=1.78±0.29, 0-24 h=5.73±1.45, 25-48 h=5.16±1.73, 49-72 h=4.13±0.75,>72 h=3.80±0.90 ng/mL (mean±SEM). Peak HMGB1 levels were inversely and independently associated with favorable Glasgow Outcome Scale (GOS) scores at 6 mo (0.49 [0.24-0.97]; OR [5-95% CI]). CSF cytochrome c levels were: control=0.37±0.10, 0-24 h=0.69±0.15, 25-48 h=0.82±0.48, 49-72 h=1.52±1.08,>72 h=1.38±1.02 ng/mL (mean±SEM). Peak cytochrome c levels were independently associated with abusive head trauma (AHT; 24.29 [1.77-334.03]) and inversely and independently associated with favorable GOS scores (0.42 [0.18-0.99]). In conclusion, increased CSF levels of HMGB1 and cytochrome c were associated with poor outcome after TBI in infants and children. These data are also consistent with the designation of HMGB1 as a "danger signal." Distinctly increased CSF cytochrome c levels in infants and children with AHT and poor outcome suggests that apoptosis may play an important role in this unique patient population.