We read with great interest the article by Altman et al1 regarding the association of abusive head injury and apparent life-threatening events (ALTEs). The authors should be commended on heightening awareness that nonaccidental trauma can initially appear to be an ALTE.
The study impetus was the finding of 5 patients with ALTEs ultimately diagnosed with abusive head injury. In these patients, "the initial history and physical examination revealed no apparent cause, but the discovery of retinal hemorrhages in 4 of the infants and the development of focal seizures in the fifth patient prompted further evaluation that led to the diagnosis of child abuse."1(p1013) These cases represent the most challenging of all ALTEs—those infants who have a significant event by history yet lack obvious examination findings that would readily explain such an event.