Kaji et al. bring us “Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital”, which is pretty much what it sounds like. What did it leave us with? The study looked at 832 kids presenting w/ ALTE to four different sites and identified three variables (obvious need for admission, significant medical history, >1 apparent life-threatening event in 24 hours) that identified most (but not all!) infants with apparent life-threatening events necessitating admission. I’ll just put that here again, in case you missed it: one of the conclusions was that obvious need for admission was a variable that predicted need for admission. Huh.
That point aside (and really, it’s a more interesting conclusion than it sounds like — meaning, that the ALTE kids who look sick when they get there tend to go on to have bad outcomes (hypoxia, apnea, bradycardia that is not self-resolving, or serious bacterial infection) discovered while in-hospital or receive some sort of “significant intervention” during their hospitalization that, retrospectively, necessitated admission. To be fair, the variable “obvious need for admission” was defined in the paper as occurring “if the child needed supplemental oxygen for non–self-resolving hypoxia, intubation, ventilation, cardiopulmonary resuscitation (CPR), intravenous antibiotics for a confirmed serious bacterial infection, or antiepileptic drugs (for status epilepticus); had hemodynamic instability warranting continuous intravenous fluids or vasopressors; or had a positive test result for respiratory syncytial virus or pertussis in the setting of an apparent life-threatening event.”
It would be difficult to argue against admitting any patient in one of these contexts (with the possible exception of non-self-solving hypoxia, which in the bronchiolitic child who is otherwise well-appearing should probably not serve in isolation as a reason to admit), and I imagine that such events occurring in the context of an ALTE are even more clear-cut indications for continued observation and management. Still, this is a nice body of literature showing that even with 84% of patients appearing well at time of ED presentation, 23% go onto need serious interventions once hospitalized — which is to say, being well-appearing at presentation does not protect against the need for escalation of care or therapeutic interventions soon thereafter.