Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Apparent life-threatening event in infants

Michael J Corwin, MD
Section Editors
George B Mallory, MD
Stephen J Teach, MD, MPH
Teresa K Duryea, MD
Deputy Editor
Alison G Hoppin, MD


An apparent life-threatening event (ALTE) describes an acute, unexpected change in an infant’s breathing, appearance, or behavior that is frightening to the parent or caretaker. It is not a specific diagnosis, but rather a “chief complaint” that brings an infant to medical attention. The term ALTE and its definition were established at a consensus conference in 1986. ALTE replaced misleading terms, such as "near-miss SIDS" or "aborted crib deaths", which incorrectly implied a direct association between these symptoms and SIDS [1].

Infants with ALTE represent a heterogeneous group of patients of varying ages with diverse pathophysiology. The clinical challenge is to identify the infants with medically significant ALTE, and diagnose any underlying disease when possible, while avoiding unnecessary testing for the many infants with medically insignificant ALTE. As a result, appropriate evaluation and management should be individualized. This topic review outlines the primary diagnostic considerations, and a stepwise plan for evaluating infants presenting with this chief complaint.  


An apparent life-threatening event (ALTE) is not a specific diagnosis but a description of an acute, unexpected episode that is frightening to the caretaker and that includes one or more of the following features [1]:

Apnea – usually no respiratory effort (central) or sometimes effort with difficulty (obstructive)

Color change – usually cyanotic or pallid but occasionally erythematous or plethoric


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Jun 2016. | This topic last updated: Jan 17, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring, Sept 29 to Oct 1, 1986. Pediatrics 1987; 79:292.
  2. Polberger S, Svenningsen NW. Early neonatal sudden infant death and near death of fullterm infants in maternity wards. Acta Paediatr Scand 1985; 74:861.
  3. Davis N, Sweeney LB. Apnea of infancy--a clinical problem. West J Med 1986; 144:429.
  4. Wennergren G, Milerad J, Lagercrantz H, et al. The epidemiology of sudden infant death syndrome and attacks of lifelessness in Sweden. Acta Paediatr Scand 1987; 76:898.
  5. Sunkaran K, McKenna A, O'Donnell M, et al. Apparent life-threatening prolonged infant apnea in Saskatchewan. West J Med 1989; 150:293.
  6. Kiechl-Kohlendorfer U, Hof D, Peglow UP, et al. Epidemiology of apparent life threatening events. Arch Dis Child 2005; 90:297.
  7. Semmekrot BA, van Sleuwen BE, Engelberts AC, et al. Surveillance study of apparent life-threatening events (ALTE) in the Netherlands. Eur J Pediatr 2010; 169:229.
  8. Fu LY, Moon RY. Apparent life-threatening events: an update. Pediatr Rev 2012; 33:361.
  9. Esani N, Hodgman JE, Ehsani N, Hoppenbrouwers T. Apparent life-threatening events and sudden infant death syndrome: comparison of risk factors. J Pediatr 2008; 152:365.
  10. Hoffman HJ, Damus K, Hillman L, Krongrad E. Risk factors for SIDS. Results of the National Institute of Child Health and Human Development SIDS Cooperative Epidemiological Study. Ann N Y Acad Sci 1988; 533:13.
  11. Steinschneider A. Prolonged apnea and the sudden infant death syndrome: clinical and laboratory observations. Pediatrics 1972; 50:646.
  12. Task Force on Sudden Infant Death Syndrome, Moon RY. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment. Pediatrics 2011; 128:e1341.
  13. Fleming, P, Blair, P, Bacon, C, et al. Sudden unexpected deaths in infancy: the CESDI SUDI studies 1993-1996. Stationery Office 2000.
  14. Kahn A, Groswasser J, Rebuffat E, et al. Sleep and cardiorespiratory characteristics of infant victims of sudden death: a prospective case-control study. Sleep 1992; 15:287.
  15. Hoppenbrouwers T, Hodgman JE, Ramanathan A, Dorey F. Extreme and conventional cardiorespiratory events and epidemiologic risk factors for SIDS. J Pediatr 2008; 152:636.
  16. Krongrad E. Infants at high risk for sudden infant death syndrome??? Have they been identified???--A commentary. Pediatrics 1991; 88:1274.
  17. Krongrad E, O'Neill L. Near miss sudden infant death syndrome episodes? A clinical and electrocardiographic correlation. Pediatrics 1986; 77:811.
  18. Nathanson I, O'Donnell J, Commins MF. Cardiorespiratory patterns during alarms in infants using apnea/bradycardia monitors. Am J Dis Child 1989; 143:476.
  19. Steinschneider A, Santos V. Parental reports of apnea and bradycardia: temporal characteristics and accuracy. Pediatrics 1991; 88:1100.
  20. Weese-Mayer DE, Silvestri JM. Documented monitoring: an alarming turn of events. Clin Perinatol 1992; 19:891.
  21. Côté A, Hum C, Brouillette RT, Themens M. Frequency and timing of recurrent events in infants using home cardiorespiratory monitors. J Pediatr 1998; 132:783.
  22. Kahn, A, Rebuffat, E, Franco, P, et al. Apparent life-threatening events and apnea of infancy. In: Respiratory control disorders in infants and children. Berckerman, RC, Brouillette, RT, Hunt, CE (Eds), Williams and Wilkins, New York 1992. p.178.
  23. McGovern MC, Smith MB. Causes of apparent life threatening events in infants: a systematic review. Arch Dis Child 2004; 89:1043.
  24. Rudolph CD, Mazur LJ, Liptak GS, et al. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr 2001; 32 Suppl 2:S1.
  25. Di Fiore JM, Arko M, Whitehouse M, et al. Apnea is not prolonged by acid gastroesophageal reflux in preterm infants. Pediatrics 2005; 116:1059.
  26. Mousa H, Woodley FW, Metheney M, Hayes J. Testing the association between gastroesophageal reflux and apnea in infants. J Pediatr Gastroenterol Nutr 2005; 41:169.
  27. Orenstein SR. An overview of reflux-associated disorders in infants: apnea, laryngospasm, and aspiration. Am J Med 2001; 111 Suppl 8A:60S.
  28. Sherman PM, Hassall E, Fagundes-Neto U, et al. A global, evidence-based consensus on the definition of gastroesophageal reflux disease in the pediatric population. Am J Gastroenterol 2009; 104:1278.
  29. Mittal MK, Donda K, Baren JM. Role of pneumography and esophageal pH monitoring in the evaluation of infants with apparent life-threatening event: a prospective observational study. Clin Pediatr (Phila) 2013; 52:338.
  30. Gray C, Davies F, Molyneux E. Apparent life-threatening events presenting to a pediatric emergency department. Pediatr Emerg Care 1999; 15:195.
  31. Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics 2005; 115:885.
  32. Davies F, Gupta R. Apparent life threatening events in infants presenting to an emergency department. Emerg Med J 2002; 19:11.
  33. Kant S, Fisher JD, Nelson DG, Khan S. Mortality after discharge in clinically stable infants admitted with a first-time apparent life-threatening event. Am J Emerg Med 2013; 31:730.
  34. Genizi J, Pillar G, Ravid S, Shahar E. Apparent life-threatening events: neurological correlates and the mandatory work-up. J Child Neurol 2008; 23:1305.
  35. Bonkowsky JL, Guenther E, Srivastava R, Filloux FM. Seizures in children following an apparent life-threatening event. J Child Neurol 2009; 24:709.
  36. 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; 157:1011.
  37. Guenther E, Powers A, Srivastava R, Bonkowsky JL. Abusive head trauma in children presenting with an apparent life-threatening event. J Pediatr 2010; 157:821.
  38. Tieder JS, Altman RL, Bonkowsky JL, et al. Management of apparent life-threatening events in infants: a systematic review. J Pediatr 2013; 163:94.
  39. Pitetti RD, Maffei F, Chang K, et al. Prevalence of retinal hemorrhages and child abuse in children who present with an apparent life-threatening event. Pediatrics 2002; 110:557.
  40. Bonkowsky JL, Guenther E, Filloux FM, Srivastava R. Death, child abuse, and adverse neurological outcome of infants after an apparent life-threatening event. Pediatrics 2008; 122:125.
  41. Parker K, Pitetti R. Mortality and child abuse in children presenting with apparent life-threatening events. Pediatr Emerg Care 2011; 27:591.
  42. Meadow R. Munchausen syndrome by proxy. The hinterland of child abuse. Lancet 1977; 2:343.
  43. Southall DP, Stebbens VA, Rees SV, et al. Apnoeic episodes induced by smothering: two cases identified by covert video surveillance. Br Med J (Clin Res Ed) 1987; 294:1637.
  44. Samuels MP, McClaughlin W, Jacobson RR, et al. Fourteen cases of imposed upper airway obstruction. Arch Dis Child 1992; 67:162.
  45. Meadow R. Suffocation, recurrent apnea, and sudden infant death. J Pediatr 1990; 117:351.
  46. Southall DP, Plunkett MC, Banks MW, et al. Covert video recordings of life-threatening child abuse: lessons for child protection. Pediatrics 1997; 100:735.
  47. Curcoy AI, Trenchs V, Morales M, et al. Retinal hemorrhages and apparent life-threatening events. Pediatr Emerg Care 2010; 26:118.
  48. Pitetti RD, Whitman E, Zaylor A. Accidental and nonaccidental poisonings as a cause of apparent life-threatening events in infants. Pediatrics 2008; 122:e359.
  49. McCormick T, Levine M, Knox O, Claudius I. Ethanol ingestion in two infants under 2 months old: a previously unreported cause of ALTE. Pediatrics 2013; 131:e604.
  50. Hoki R, Bonkowsky JL, Minich LL, et al. Cardiac testing and outcomes in infants after an apparent life-threatening event. Arch Dis Child 2012; 97:1034.
  51. Zuckerbraun NS, Zomorrodi A, Pitetti RD. Occurrence of serious bacterial infection in infants aged 60 days or younger with an apparent life-threatening event. Pediatr Emerg Care 2009; 25:19.
  52. Kahn A, European Society for the Study and Prevention of Infant Death. 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; 163:108.
  53. Guilleminault C, Pelayo R, Leger D, Philip P. Apparent life-threatening events, facial dysmorphia and sleep-disordered breathing. Eur J Pediatr 2000; 159:444.
  54. Wilson AC, Moore DJ, Moore MH, et al. Late presentation of upper airway obstruction in Pierre Robin sequence. Arch Dis Child 2000; 83:435.
  55. De Piero AD, Teach SJ, Chamberlain JM. ED evaluation of infants after an apparent life-threatening event. Am J Emerg Med 2004; 22:83.
  56. Putnam-Hornstein E, Schneiderman JU, Cleves MA, et al. A prospective study of sudden unexpected infant death after reported maltreatment. J Pediatr 2014; 164:142.
  57. Wise MS, Nichols CD, Grigg-Damberger MM, et al. Executive summary of respiratory indications for polysomnography in children: an evidence-based review. Sleep 2011; 34:389.
  58. Hoppenbrouwers T, Hodgman JE, Rybine D, et al. Sleep architecture in term and preterm infants beyond the neonatal period: the influence of gestational age, steroids, and ventilatory support. Sleep 2005; 28:1428.
  59. Kelly DH, Shannon DC, O'Connell K. Care of infants with near-miss sudden infant death syndrome. Pediatrics 1978; 61:511.
  60. Kaji AH, Claudius I, Santillanes G, et al. Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med 2013; 61:379.
  61. Samuels MP, Poets CF, Noyes JP, et al. Diagnosis and management after life threatening events in infants and young children who received cardiopulmonary resuscitation. BMJ 1993; 306:489.
  62. Al-Kindy HA, Gélinas JF, Hatzakis G, Côté A. Risk factors for extreme events in infants hospitalized for apparent life-threatening events. J Pediatr 2009; 154:332.
  63. Santiago-Burruchaga M, Sánchez-Etxaniz J, Benito-Fernández J, et al. Assessment and management of infants with apparent life-threatening events in the paediatric emergency department. Eur J Emerg Med 2008; 15:203.
  64. Mittal MK, Sun G, Baren JM. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care 2012; 28:599.
  65. Ramanathan R, Corwin MJ, Hunt CE, et al. Cardiorespiratory events recorded on home monitors: Comparison of healthy infants with those at increased risk for SIDS. JAMA 2001; 285:2199.
  66. Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted? Pediatrics 2007; 119:679.
  67. Brooks JG. Apparent life-threatening events and apnea of infancy. Clin Perinatol 1992; 19:809.
  68. Kelly DH, Shannon DC. Sudden infant death syndrome and near sudden infant death syndrome: a review of the literature, 1964 to 1982. Pediatr Clin North Am 1982; 29:1241.
  69. Oren J, Kelly D, Shannon DC. Identification of a high-risk group for sudden infant death syndrome among infants who were resuscitated for sleep apnea. Pediatrics 1986; 77:495.