• Joel S Tieder, Robin L Altman, Joshua L Bonkowsky, Donald A Brand, Ilene Claudius, Diana J Cunningham, Craig DeWolfe, Jack M Percelay, Raymond D Pitetti, and Michael B H Smith.
• Department of Pediatrics, Division of Hospital Medicine, Seattle Children's Hospital and the University of Washington, Seattle, WA 98105, USA. joel.tieder@seattlechildrens.org
• J. Pediatr. 2013 Jul 1; 163 (1): 94-9.e1-6.

ObjectiveTo determine in patients who are well-appearing and without a clear etiology after an apparent life-threatening event (ALTE): (1) What historical and physical examination features suggest that a child is at risk for a future adverse event and/or serious underlying diagnosis and would, therefore, benefit from testing or hospitalization? and (2) What testing is indicated on presentation and during hospitalization?Study DesignSystematic review of clinical studies, excluding case reports, published from 1970 through 2011 identified using key words for ALTE.ResultsThe final analysis was based on 37 studies; 18 prospective observational, 19 retrospective observational. None of the studies provided sufficient evidence to fully address the clinical questions. Risk factors identified from historical and physical examination features included a history of prematurity, multiple ALTEs, and suspected child maltreatment. Routine screening tests for gastroesophageal reflux, meningitis, bacteremia, and seizures are low yield in infants without historical risk factors or suggestive physical examination findings.ConclusionSome historical and physical examination features can be used to identify risk in infants who are well-appearing and without a clear etiology at presentation, and testing tailored to these risks may be of value. The true risk of a subsequent event or underlying disorder cannot be ascertained. A more precise definition of an ALTE is needed and further research is warranted.Copyright © 2013 Mosby, Inc. All rights reserved.

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