Evaluation and Management of Apparent Life-Threatening Events in Infants

Apparent life-threatening events (ALTE) represent sudden episodes in infants characterised by pauses in breathing, changes in skin colour and alterations in muscle tone, often accompanied by choking or gagging. Although the majority of infants recover fully, these events prompt intensive investigation owing to the potential for underlying pathologies such as gastro-oesophageal reflux, seizure disorders, cardiac arrhythmias or respiratory infections. In recent years the terminology has evolved to include brief resolved unexplained events (BRUE), denoting lower-risk presentations that resolve without clear explanation. Evaluation begins with a meticulous history and physical examination to identify warning features—prematurity, recurrent events or family history of sudden death. First-line investigations typically include continuous cardiorespiratory monitoring, electrocardiography to exclude arrhythmia and pulse oximetry. Second-line tests are guided by clinical suspicion and may comprise multichannel intraluminal impedance-pH monitoring for reflux assessment, neuroimaging for suspected central causes and metabolic or genetic assays when indicated. Risk stratification tools have been developed to distinguish infants requiring inpatient observation from those suitable for outpatient follow-up. Management is aetiology-driven: antireflux measures and pharmacotherapy for gastro-oesophageal reflux disease, anti-epileptic drugs for seizure disorders and targeted antibiotic therapy for infections. Where no cause is identified, supportive care and family education—including safe-sleep advice and training in basic life support—remain central. Emerging telemonitoring platforms and standardised care pathways aim to reduce unnecessary hospital transfers and optimise resource utilisation, while multidisciplinary collaboration enhances diagnostic accuracy and long-term outcomes.

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Evaluation and Management of Apparent Life-Threatening Events in Infants publication trend

The graph below shows the total number of articles in evaluation and management of apparent life-threatening events in infants across all publications each year (not limited to Nature Index journals).

Technical terms

Apparent Life-Threatening Event (ALTE): a sudden episode in an infant involving apnoea, colour change and altered muscle tone, often alarming to caregivers and requiring urgent assessment.

Brief Resolved Unexplained Event (BRUE): a subcategory of ALTE defined by transient, unexplained symptoms in low-risk infants that resolve completely before medical evaluation.

Cardiorespiratory Monitoring: continuous recording of heart rate, respiratory rate and oxygen saturation to detect and quantify apnoea, bradycardia and desaturation events.

Multichannel Intraluminal Impedance-pH Monitoring: a diagnostic method measuring both acid and non-acid reflux episodes by detecting changes in electrical impedance and pH within the oesophagus.

References

1. Inter-hospital cardiorespiratory telemonitoring of newborns and infants: a wellworking example of a hub and spoke network. Italian Journal of Pediatrics (2023).
2. Management of Infants with Brief Resolved Unexplained Events (BRUE) and Apparent Life-Threatening Events (ALTE): A RAND/UCLA Appropriateness Approach. Life (2021).
3. Brief resolved unexplained event: Severity-associated factors at admission in the pediatric emergency ward. Archives de Pédiatrie (2023).