Sunday, July 10, 2016


Image: Flickr
Author: Danielle Goodrich, MD PGY-3
Stanford/Kaiser Emergency Medicine

In May, the American Academy of Pediatrics published new clinical guidelines to replace ALTE (Apparent Life-Threatening Events) with BRUE, Brief Resolved Unexplained Event. The new guidelines, in addition to defining BRUE, offer an approach to evaluation based on risk of repeat event or serious underlying disorder. The goal of the clinical guidelines is to better inform care while reducing costly and unnecessary interventions. The guidelines were devised from a comprehensive literature review of articles related to ALTEs from 1970 to 2014.

BRUE describes an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, now resolved episode with one or more of the following: (1) cyanosis or pallor, (2) absent, decreased or irregular breathing, (3) marked change in tone, and (4) altered level of responsiveness. The diagnosis is made when there is no explanation for a qualifying event after a thorough history and physical exam. BRUE and ALTE definitions differ as BRUE characterizes the event based on physician not caregiver observations and includes an age limit.

For lower risk patients who meet criteria for having experienced a BRUE, evidence based guidelines are provided for evaluation and workup. Lower risk patients are defined by (1) age >60 days, (2) gestational age >32 weeks and post-conceptional age >45 weeks, (3) occurrence of only 1 BRUE (no prior BRUE ever and not occurring in clusters), (4) duration of BRUE <1 minute, (5) no cardiopulmonary resuscitation by a trained medical provider required, (6) no concerning historical features, and (7) no concerning physical examination findings.

Much of the article discusses key action statements on evaluation and management for lower risk infants, recommendations are not offered for higher risk infants. For example, under infectious diseases, there is a strong recommendation to avoid CBC, Blood culture, and CSF studies to detect occult bacterial infections in infants with BRUE. This is one of the many classes of recommendations including child abuse evaluation, neurologic, gastrointestinal, inborn errors of metabolism, anemia, and patient and family centered care.

For the complete guidelines as well as clinically useful graphs and charts, check out the May 2016 edition of Pediatrics.

Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life Threatening Events) and Evaluation of Lower- Risk Infants. Pediatrics. 2016;137(5):e20160590

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