Unifying Concepts

Definition and Causes of Apparent Life-Threatening Events (ALTE)

Definition of ALTE

By definition, an ALTE refers to a sudden event, often characterized by apnea or other abrupt changes in the child’s behavior. Symptoms of an ALTE include one or more of the following: apnea, change in color or muscle tone, coughing, or gagging.

Diagnoses Made in Children with an Apparent Life-Threatening Event

* Idiopathic (approximately 50 percent)

* Gastrointestinal – GI (most common, up to 50 percent of diagnosed cases)

  • Gastroesophageal reflux

  • Gastric volvulus

  • Intussusception

  • Swallowing abnormalities

  • Other GI abnormalities

* Neurologic (approximately 30 percent)

  • Seizure disorder

  • Febrile seizure

  • CNS bleeding

  • Neurologic conditions affecting respiration (Budd-Chiari syndrome, hindbrain malformation, brainstem malformation)

  • Vasovagal reflexes

  • Hydrocephalus

  • CNS infection

  • Ventriculoperitoneal shunt malfunction

  • Malignancy

* Respiratory (approximately 20 percent)

  • Respiratory compromise from infection, respiratory syncytial virus, pertussis, mycoplasma, croup, other pneumonias

  • Obstructive sleep apnea

  • Breath-holding spells

  • Conditions affecting respiratory control (prematurity, central hypoventilation)

  • Vocal cord abnormalities, adenoid vegetations

  • Laryngotracheomalacia

  • Airway obstruction resulting from congenital abnormalities

  • Foreign-body aspiration

* Cardiac (up to 5 percent)

  • Arrhythmia

  • Long QT syndrome

  • Wolff-Parkinson-White syndrome

  • Congenital heart disease

  • Myocarditis

  • Cardiomyopathy

* Metabolic abnormalities (less than 5 percent)

  • Inborn errors of metabolism

  • Endocrine, electrolyte disorders

  • Other infections

  • Urinary tract infection

  • Sepsis

* Child abuse (less than 5 percent)

  • Munchausen syndrome by proxy (suffocation, intentional salt poisoning, medication overdose, physical abuse, head injury)

  • Smothering (unintentional or intentional)

* Other

  • Food allergy (uncommon)

  • Anaphylaxis

  • Medication (prescription, over the counter, herbal remedies)




  1. McGovern MC, Smith MB. Causes of apparent life threatening events in infants: a systematic review. Arch Dis Child. 2004 Nov;89(11):1043-8. [Medline]

  2. Hall KL, Zalman B. Evaluation and management of apparent life-threatening events in children. Am Fam Physician. 2005 Jun 15;71(12):2301-8. [Medline]

Created: January 24, 2006

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