What causes unexplained dips in a 1-year-old and how are they managed?

Causes and Management of Dips in 1-Year-Old Children

Brief resolved unexplained events (BRUEs) are the most likely explanation for unexplained "dips" in a 1-year-old child and should be evaluated based on risk stratification to determine appropriate management. 1

Understanding "Dips" in 1-Year-Olds

"Dips" in a 1-year-old typically refer to brief episodes characterized by one or more of the following:

• Cyanosis or pallor
• Absent, decreased, or irregular breathing
• Marked change in muscle tone (hyper- or hypotonia)
• Altered level of responsiveness

These episodes were previously called "apparent life-threatening events" (ALTEs) but are now classified as "brief resolved unexplained events" (BRUEs) when they occur in infants under 1 year of age and resolve without explanation after appropriate history and physical examination. 1

Common Causes of "Dips" in 1-Year-Olds

1. Physiological Causes

• Gastroesophageal reflux disease (GERD)

  • Common in infants, with regurgitation affecting 70-85% of infants in the first 2 months 2
  • Can cause choking, gagging, or coughing with feedings
  • May present with irritability and back arching (non-verbal equivalent of heartburn)

• Hypoglycemia

  • Can cause altered consciousness, pallor, and poor tone
  • More common in children with diabetes or metabolic disorders 3
  • Symptoms include tremors, sweating, lightheadedness, irritability, confusion, and drowsiness

2. Neurological Causes

• Seizures
  • Can present as brief episodes of altered consciousness or tone
  • May be accompanied by abnormal movements or eye deviation

3. Gastrointestinal Causes

• Food impaction or choking

  • Can cause sudden respiratory distress 4
  • May be associated with underlying conditions like eosinophilic esophagitis

• Dysphagia

  • Difficulty swallowing can lead to aspiration and respiratory symptoms 5
  • May present as feeding difficulties or respiratory problems

4. Respiratory Causes

• Laryngomalacia or other airway abnormalities
  • Can cause intermittent airway obstruction
  • Often worse during feeding or when supine

5. Cardiac Causes

• Arrhythmias
  • Can cause sudden pallor, altered consciousness
  • May be associated with family history of cardiac disease

Risk Stratification

According to the American Academy of Pediatrics guidelines, risk stratification is essential for appropriate management 1:

Lower-Risk BRUE Criteria:

• Age >60 days
• Gestational age ≥32 weeks and postconceptional age ≥45 weeks
• No CPR required by trained medical provider
• Episode duration <1 minute
• First BRUE episode
• No concerning historical features or physical examination findings

Higher-Risk BRUE:

• Does not meet all lower-risk criteria
• Requires more extensive evaluation

Management Approach

For Lower-Risk BRUEs:

1. Reassurance and education

   • Explain the nature of the event and its typically benign course
   • Discuss warning signs that would warrant return to medical care

2. Limited testing

   • Extensive diagnostic testing is NOT recommended for lower-risk BRUEs 1
   • The following tests are specifically NOT recommended:
     • Blood glucose measurement 1
     • Serum bicarbonate, blood lactate, or serum sodium 1
     • Neuroimaging
     • Extensive metabolic workup

3. Brief observation

   • Consider brief (<4 hours) observation in a medical setting
   • Monitor vital signs and general appearance

For Higher-Risk BRUEs or Concerning Features:

1. More extensive evaluation based on suspected etiology:

   • If hypoglycemia is suspected:

     • Check blood glucose levels
     • Provide oral carbohydrates (15-20g) if conscious and able to swallow 3
     • For unconscious patients, administer IV glucose 3

   • If GERD is suspected:

     • Consider trial of feeding modifications
     • Positioning changes (elevating head during and after feeds)
     • Smaller, more frequent feedings 2

   • If seizure is suspected:

     • Consider EEG and neurological consultation
     • Observe for additional episodes

2. Consider hospitalization for:

   • Recurrent episodes
   • Episodes requiring resuscitation
   • Abnormal findings on initial evaluation
   • Significant parental anxiety

Special Considerations for 1-Year-Olds

Toddlers (1-3 years) present unique challenges in distinguishing normal developmental behaviors from pathological events 1:

• Normal temper tantrums may be confused with hypoglycemic episodes
• Parents should measure blood glucose before dismissing a tantrum as behavioral 1
• Toddlers may have difficulty communicating symptoms
• Developmental changes in feeding and activity patterns may influence symptom presentation

Warning Signs Requiring Immediate Medical Attention

Parents should seek immediate medical care if their child experiences:

• Episodes lasting longer than 1 minute
• Multiple episodes
• Episodes associated with feeding difficulties
• Color changes (blue or pale)
• Difficulty breathing
• Altered consciousness
• Unusual body movements or posturing

Prevention Strategies

1. For suspected GERD:

   • Careful spacing of oral feeds and fluid intake
   • Consider smaller, more frequent meals
   • Avoid feeding immediately before bedtime

2. For suspected hypoglycemia:

   • Regular meal timing
   • Bedtime snack if pre-sleep glucose is low 3
   • Carrying fast-acting carbohydrates

3. For all children:

   • Proper positioning during and after feeding
   • Appropriate supervision during meals
   • Age-appropriate food choices to prevent choking

When to Refer to Specialists

Consider referral to specialists when:

• Episodes recur despite initial management
• Specific underlying conditions are identified
• Growth or development is affected
• Feeding difficulties persist
• Respiratory symptoms are prominent

Conclusion

Most "dips" in 1-year-olds are benign and self-limiting, but careful evaluation is necessary to identify those requiring intervention. Risk stratification helps determine the extent of evaluation needed, with lower-risk events generally requiring minimal testing and primarily reassurance.