1. Where did the event take place?
2. How long did it last?
3. If present, did a home monitor go off?
4. Was the infant awake or asleep previously?
5. Was the infant breathing?
6. Was there a color change, and if so, what?
7. Was there a change in tone?
8. What resuscitation efforts were made?
9. When was the last feeding?
10. Did the infant vomit?

When investigating the infant’s history, these questions should be included:

1. Was the infant’s birth premature, and if so, what is the infant’s corrected age?
2. Are there any predisposing medical conditions?
3. Does he suffer from gastroesoph ageal reflux disease (GERD), and if so, how was it diagnosed?
4. Were there previous similar events?
5. Are there any current illnesses?

The history should also include a detailed assessment of risk factors for SIDS:

1. What was the room temperature?
2. What position was the baby in during the event?
3. How firm is the mattress?
4. Is there any bedsharing with others?
5. Were there soft blankets, pillows, or stuffed toy animals in bed?
6. Did the mother smoke during pregnancy or after?
7. Does the infant use a pacifier?
8. What is the infant’s access to toxins or medications?

Lastly, one should address family history that could be related to SIDS:

1. Did any of the infant’s siblings die an unexplained death in the first year of life?
2. Were there any other deaths in the family at a young age?
3. Are there any metabolic, neurologic, or cardiac conditions that family members suffer from?
4. Is there a risk for nonaccidental injury or Munchausen’s syndrome by proxy?

After completing the history, clinicians in most cases already may have a good idea of the severity of the event. When the history is suggestive of an infant who was physiologically compromised (i.e., significant apnea has occurred), admission for monitoring is warranted.

Physical Examination

A child who presents to the emergency department with a significant physical finding would not pose a great disposition dilemma. However, in most patients the physical exam will be unremarkable.1 Clues for an underlying condition masquerading as apnea should be considered on examination. These include:

1. Dysmorphic features.
2. Maxillofacial anomalies.
3. Signs of viral or bacterial infection.
4. Respiratory distress suggesting lung or metabolic conditions.
5. Cardiovascular assessment to reveal heart failure, shock, or cardiac anomalies.
6. Neurological impairment suggestive of neurological or electrolyte imbalance.

Investigations

Much debate surrounds the extent of investigations to be performed for a child with ALTE and whether there should be a standard work-up. Some patients may not require any investigations because of the low probability of a life-threatening condition, as suggested by a good history and physical exam.²