Evaluation of the Hypothesis That Choking/ALTE May Mimic Abusive Head Trauma.

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DOI: 10.1016/j.acap.2016.10.002


Objective: Apparent life-threatening events (ALTEs), often accompanied by choking, have been hypothesized to cause subdural hemorrhages (SDH), retinal hemorrhages, and brain injury. If the choking/ALTE hypothesis were true, children who present with ALTE and SDH would have fewer extracranial injuries suspicious for abuse than those with SDH and no ALTE. We aimed to compare the prevalence of suspicious extracranial injuries in children who have ALTE-associated SDH to those with non-ALTE SDH.

Methods: We performed a 5-year retrospective case-control study of childrenchildren's hospital. Subjects were classified as ALTE-associated SDH and non-ALTE SDH on the basis of ALTE definitions as proposed by the authors of the choking/ALTE hypothesis. The 2 groups were compared for the prevalence of suspicious extracranial injuries.

Results: Of 170 study subjects, 64 had an ALTE-associated SDH and 106 had non-ALTE SDH. ALTE-associated SDH subjects were nearly 5 times more likely to have at least one suspicious extracranial injury (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.9-12.1) and were more likely to have individual types of suspicious extracranial injuries, including retinoschisis (OR 4.1, 95% CI 1.6-10.2), high-specificity bruising (OR 2.6, 95% CI 1.3-4.9), and internal abdominal injury (3.5, 95% CI 1.2-9.9). Subjects with ALTE-associated SDH were also significantly more likely to die or have persistent neurologic impairment. All 10 subjects with a dysphagic-choking type ALTE had at least 1 suspicious extracranial injury.

Conclusions: ALTEs are not supported as causative mechanisms for findings concerning abusive head trauma.

Journal Title

Acad Pediatr





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MeSH Keywords

Abdominal Injuries; Airway Obstruction; Brain Injuries; Case-Control Studies; Child Abuse; Child, Preschool; Contusions; Craniocerebral Trauma; Diagnosis, Differential; Female; Hematoma, Subdural; Humans; Infant; Infant, Newborn; Male; Mortality; Odds Ratio; Retinal Hemorrhage; Retinoschisis; Retrospective Studies


abusive head trauma; child abuse; child maltreatment; physical abuse; shaken baby syndrome

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