The ALTE mysteries

I have previously shared my frustration regarding the bias against normal birth and the ability of women’s bodies to grow, carry, birth and feed their babies (Wickham 2016). As is often the case when one starts to pay attention to an area, I have been spotting further examples of this, and one took me back to an incident in my own practice a few years ago.

Helping Elsa

I was working on a postnatal ward when I was called by Karen, who had been breastfeeding her day-old baby. When I reached her, I saw that Karen’s baby was blue and appeared to be either asleep or unconscious and not breathing. Within moments I had scooped up the proffered baby, told Karen we were going to the next room (where there was a Resuscitaire) and asked a colleague to call a paediatrician, bring Karen and follow me. (This was in the days before it was decreed that babies could only be driven around hospitals in cots. I hereby acknowledge that such a sequence would probably not be considered good practice nowadays.)

When I reached the nursery, I put baby Elsa onto the Resuscitaire. She was conscious, breathing normally and in just that 10-second journey, her colour had improved. Neither I nor any of my midwifery or paediatric colleagues nor any of the tests that special care offered over the next 24 hours could find anything wrong. I think it likely that the short but brisk walk to the Resuscitaire may have stimulated Elsa into breathing normally again but, even though I know it is unlikely, I still wonder whether my eyes initially deceived me. The paediatricians’ best guess was that Elsa had begun to suffocate while breastfeeding. I was reluctant to embrace this conclusion, for Elsa was a healthy term baby who had removed herself from Karen’s breast several times that morning, and it didn’t seem very empowering to conclude that, in the absence of a better answer, Karen’s body must be the source of the problem.

The ALTE problem

Many practitioners would say that Elsa had an ALTE: an acute life-threatening event. I am by no means an expert on this topic, but I learned from a quick literature search that almost every paper on ALTEs in young babies describes these as a set of symptoms rather than a specific disease. The symptoms are alarming and of sudden onset and may include apnoea, change in colour, change in muscle tone (floppiness or stiffening), coughing and/or gagging. Commonly cited possible causes include infection, digestive problems and cardiac, metabolic or nervous system disorders, but ALTEs are mysterious in that no cause can be found in about half of cases. Most affected babies survive and thrive, but a few do not. Clearly, we need to better understand what’s going on in these situations, although it also seems important to appreciate that, because this is a symptom pattern rather than a specific disease, it is extremely unlikely that there is one answer. To me, this implies that we need to be very cautious while we are studying the area and not draw premature conclusions.

However, the abstract of the paper which made me think of Karen and Elsa began by noting that, ‘The benefits of early skin-to-skin contact and its role in the promotion of successful breastfeeding are widely known and well recognized.’ It then immediately added that,’One rare but potentially devastating consequence is an apparent life-threatening event, or ALTE’ (Thompson et al 2015: 209).

Blaming women again

This paper is not the only one to imply that ALTEs are associated with or a consequence of skin-to-skin cuddling or breastfeeding. I am concerned about this trend and about how such statements may affect knowledge, research and practice. Yes, ALTEs are a rare but serious problem, and we need to be vigilant. I have read case studies and heard stories describing situations where a baby was being breastfed or cuddled by its mother when an ALTE occurred, but there are wide gulfs between a) an occasional problem which occurs in an everyday situation, b) evidence of a causal link between ALTEs and skin-to-skin cuddling or breastfeeding, and c) a claim that skin-to-skin cuddling and breastfeeding are intrinsically dangerous. It’s clearly vital to investigate ALTEs, but surely it would be best to do this in an open-minded way rather than prematurely deciding that women’s bodies must be the ‘fall-back’ causative factor? When we stop placing the blame for everything on women and their bodies, perhaps we will be able to better understand the complexities of such phenomena.

REFERENCES

Thompson K, Matyas M, Abate S et al (2015). ‘Discovering apparent life-threatening events in the first 24 hours of birth: a case study’. Jour Neon Nurs, 21(5): 209-212.

Wickham S (2016). ‘Whatever happened to the precautionary principle?’ TPM, 19(1): 40-41.