U.S. Hospitals Lack Standards for Treating Apparent Life-Threatening Symptoms in Newborns
It’s every new parent’s nightmare: Their baby suddenly turns blue, appears to stop breathing, chokes or gags, or seems to suffer from some kind of seizure.
It’s every new parent’s nightmare: Their baby suddenly turns blue, appears to stop breathing, chokes or gags, or seems to suffer from some kind of seizure. Though the frightening situation may appear to pass, what’s an alarmed parent to do? Apparently, the U.S. health care system is not sure, according to a new study published in the May 2008 issue of The Journal of Pediatrics.
The study found that “Apparent Life-Threatening Events” (ALTEs) in newborns 3 days to 5 months of age resulted in wide variation in hospital admissions and lengths of stay, diagnostic tests performed, costs of care incurred and diagnostic condition codes assigned, with no apparent systematized standards across different hospitals and treatment providers.
The study examined more than 12,000 patient records from 2000 to 2005 in the Pediatric Health Information System (PHIS), a large national administrative database developed by the Child Health Corporation of America. The PHIS includes information on hospital stays, diagnostic data and admission and discharge codes for 17 of the 20 major metropolitan areas and 70% of the freestanding children’s hospitals in the United States.
An ALTE is defined by the National Institutes of Health as an episode in the first year of life that appears potentially life threatening to the observer, and is characterized by some combination of color change, apnea, alteration in muscle tone, choking or gagging. Applying the diagnostic code for ALTE depends upon subjective provider and institutional interpretation of a wide variety of symptoms that may not have an identifiable cause.
The records studied showed that in response to an ALTE, some hospitals tested extensively, some ordered a few tests, and others sent children home with no testing. Some hospitals admitted these children, some did not. Length of stay and costs ranged widely. The average age of children in the study was just under one month old, with average length of hospital stay just over four days, and average costs incurred slightly under $16,000.
The most frequently reported underlying possible causes for the ALTEs were gastroesphageal reflux (GER), seizures, and lower respiratory tract infections, according to the study. Less common causes included pertussis, cardiac arrhythmias, nonaccidental trauma and bacterial infections. Upon admission to hospitals, wide variations in diagnostic testing for many children included complete blood and urine workups, chest X-rays, cranial ultrasound, cranial computed tomography (CT), magnetic resonance imaging (MRI), electrocardiography (EKG), sleep studies and upper gastrointestinal tract testing. Treatments offered included antibiotics and GER medication. Many children were also sent home with no hospitalization, testing or treatment.
Previously called “Near SIDS” events, these episodes frequently remain medical mysteries and don’t result in any clear diagnosis. Generally the infant’s parent or primary care giver witnesses the event and brings the infant to seek diagnosis or care. In most cases, the children are no longer symptomatic when examined, since ALTEs frequently appear to be isolated incidents.
“The inconsistencies in diagnosis and management of these symptoms raises concerns over patient care quality,” said Joel S. Tieder, MD, MPH, principal investigator from Seattle Children’s Hospital Research Institute and the University of Washington School of Medicine’s Department of Pediatrics. “These findings point to an area of much-needed quality improvement in pediatric care. This is a wake-up call: we need standards for addressing apparent life-threatening events across all clinics, emergency departments and hospitals. Further research on the true risks of morbidity and mortality is needed so that providers can use scientific evidence to drive medical decision-making. Parents need to know that when their child exhibits such frightening symptoms the medical community will provide safe and consistent care.”
In addition to Tieder, the research team from Seattle Children’s Hospital Research Institute and the University of Washington School of Medicine Department of Pediatrics included Charles A. Cowan, MD, Michelle M. Garrison, PhD, and Dimitri A. Christakis, MD, MPH.
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