A Neonate with Multiple Causes of Apparent Life-Threatening Event (ALTE): A Case Report

Document Type : Case Report


1 Department of Pediatrics, Division of Neonatology, Children’s Medical Center, Tehran University of Medical Sciences, Tehran, Iran

2 Tehran University of Medical Sciences, Tehran, Iran


Apparent life-threatening event (ALTE) is a major cause of neonatal emergency visits. In this paper, we presented the case of a three-day-old neonate with multiple indications of ALTE. The patient was referred to the emergency department due to a cyanotic attack before admission. The neonate woke a few hours after breastfeeding and turned blue while crying, which was resolved spontaneously within a few seconds. During ALTE, moderate hypotonia was observed in the neonate, while the physical examination was not remarkable. Primary sepsis workup and electrolyte measurement were performed, the results of which were mostly within the normal limits, with the exception of low levels of calcium, magnesium, and vitamin D. Moreover, the infant had primary hypothyroidism and received treatment with intravenous antibiotics initially accompanied by magnesium and calcium for a few days. Treatment continued with vitamin D and levothyroxine, and the neonate was discharged from the hospital in good overall condition without further ALTE episodes. All infants must be evaluated in terms of common indications of ALTE, such as electrolyte imbalance. In addition, other probable causes of ALTE should be investigated through obtaining a detailed medical history and proper physical examination. According to the literature, neonates are likely to present with more than one manifestation of ALTE.


  1. Brousseau T, Sharieff GQ. Newborn emergencies: the first 30 days of life. Pediatr Clin North Am. 2006; 53(1):69–84.
  2. McGovern MC, Smith MB. Causes of apparent life-threatening events in infants: a systematic review. Arch Dis Child. 2004; 89(11):1043–8.
  3. Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. 2005; 115(4):885-93.
  4. Davies F, Gupta R. Apparent life threatening events in infants presenting to an emergency department. Emerg Med J. 2002; 19(1):11-6.
  5. Kadivar M, Yaghmaie B, Allahverdi B, Shahbaznejad L, Razi N, Mosayebi Z. Apparent life-threatening events in neonatal period: clinical manifestations and diagnostic challenges in a pediatric referral center. Iran J Pediatr. 2013; 23(4):458-66.
  6. Romaneli MT, Morcillo AM, Fraga AM, Tresoldi AT, Baracat EC. Factors associated with infant death after apparent life-threatening event (ALTE). J Pediatr (Rio J). 2010; 86(6):515-9.
  7. Bonkowsky JL, Guenther E, Filloux FM, Srivastava R. Death, child abuse, and adverse neurological outcome of infants after an apparent life-threatening event. Pediatrics. 2008; 122(1):125-31.
  8. Choi HJ, Kim YH. Relationship between the clinical characteristics and intervention scores of infants with apparent life-threatening events. J Korean Med Sci. 2015; 30(6):763-9.
  9. Al Khushi N, Côté A. Apparent life-threatening events: assessment, risks, reality. Paediatr Respir Rev. 2011; 12(2):124-32.

10. Fu LY, Moon RY. Apparent life-threatening events: an update. Pediatr Rev. 2012; 33(8):361-8.

11. Waseem M, Soontharothai D, Pinkert H, Erickson E, Trotman M. An uncommon cause of apparent life­threatening event. Int J Case Rep Images. 2012; 3(11):17-20.

12. Mosalli R, Yasser E, Ali AM, Al Harbi S. Congenital vitamin D deficiency: a rare etiology of an acute life threatening event in early infancy. Saudi J Kidney Dis Transpl. 2010; 21(3):511-4.

13. Teran-Perez G, Arana-Lechuga Y, Gonzalez-Robles RO, Mandujano M, Santana-Miranda R, Esqueda-Leon E, et al. Polysomnographic features in infants with early diagnosis of congenital hypothyroidism. Brain Dev. 2010; 32(4):332–7.