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Tieder JS, Bonkowsky JL, Subcommittee on Apparent Life-Threatening Events, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: executive summary. Pediatrics. 2016;137(5):e20160591.
In 1986, the term ALTE was proposed by the National Institutes of Health Consensus Conference on Infantile Apnea and Home Monitoring to replace the term near-miss sudden infant death syndrome. Due to its broad nature, the term ALTE has raised significant challenges for clinicians and families in the management of these patients. The term BRUE was proposed to replace ALTE in an effort to reduce unnecessary medical interventions and improve patient care.
Definition of a Brief Resolved Unexplained Event
A BRUE is defined as “an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥ 1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness.” The diagnosis of a BRUE is intended to be applied only to well-appearing patients and is a diagnosis of exclusion, when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. If a patient has abnormal vital signs or additional symptoms (eg, cough, respiratory difficulties, or fever), he/she would not meet the criteria for a BRUE and should be evaluated for the presenting signs and symptoms.
Once a diagnosis of a BRUE is made, the patient can be risk stratified and managed accordingly. A thorough history and physical examination should be conducted. If there are any concerning findings (eg, social factors, feeding or respiratory problems, family history of sudden cardiac death), the patient is no longer considered “lower risk” or to have experienced a BRUE and should be managed based on clinician judgment. If the patient does not have any concerning risk factors on history or physical examination, then the patient can be further risk stratified based on additional factors: patient age > 60 days, born ≥ 32 weeks’ gestation and corrected gestational age ≥ 45 weeks, no cardiopulmonary resuscitation (CPR) performed by a trained medical provider, event lasting < 1 minute, and no prior history of a BRUE. If the patient fits all of these criteria, he/she is considered to be a lower-risk patient and can be managed as described in the guideline.
Concerning History and Physical Examination Findings
This guideline summary paper cites 2 comprehensive tables that are available via a link within the full guideline. These tables provide guidance on important history and physical examination elements to consider when a patient presents with a suspected BRUE. The historical features cited include those concerning for possible child abuse (inconsistent history, unexplained bruising, and inappropriate caregiver expectations), the details of the event, the child’s state prior to and during the event (eg, breathing, consciousness, etc), recent illnesses or injuries, medical and developmental history, family and social history, and recent exposures (eg, tobacco smoke, illnesses, drugs). In addition to basic examination features, other important physical examination features include craniofacial anomalies, age-appropriate response to the environment, growth variables (eg, weight), evidence of bruising, bleeding from the nose or mouth, and retinal or conjunctival hemorrhage. Clinician judgment is integral to determining whether the findings are concerning.
Management of Lower-Risk Patients
In patients who are identified as being at lower risk, educating the family is recommended, including providing resources for CPR training and engaging the family in shared decision-making. Clinicians may consider ordering pertussis testing and an electrocardiogram (ECG), and briefly monitoring patients with pulse oximetry and serial examinations. Clinicians do not need to obtain further laboratory testing, such as viral respiratory tests, urinalysis, blood glucose, serum bicarbonate, serum lactic acid, or neuroimaging, to attempt to ascertain an etiology. Patients do not need to be admitted for cardiorespiratory monitoring.
For lower-risk BRUE patients, the guidelines recommend against obtaining white blood cell counts, blood cultures, cerebrospinal fluid analysis or culture, a basic metabolic panel, calcium level, ammonia level, blood gases, urine organic acids, plasma amino acids or acylcarnitines, chest radiographs, echocardiography, electroencephalography, gastroesophageal reflux studies, or laboratory evaluations for anemia. In addition, they recommend against initiating home cardiorespiratory monitoring and prescribing acid-suppression therapy or antiepileptic medications.
This article provides a well-argued rationale for why ALTE should be replaced by BRUE. Additionally, this clinical guideline offers a clear algorithm for approaching lower-risk patients presenting with a BRUE, which is difficult given the nonspecific, undifferentiated nature of the diagnosis. This guideline clearly represents a huge step toward minimizing over-evaluation and hospitalization of patients who are highly unlikely to benefit from these interventions. This management algorithm tool is intended for use only if there are no concerning history or physical examination findings and the patient is, otherwise, at lower risk. For patients who do not fall into the lower-risk category, there is no recommendation offered. Given that many BRUE patients are aged < 2 months, that leaves equipoise in the management of “higher-risk” BRUE patients.
Due to the nature of this being a clinical practice guideline and not a meta-analysis, this summary article provides a general overview of the evaluation and management recommendations but does not provide any details on the research behind those recommendations. For example, Table 1, which excellently summarizes the quality of evidence behind the recommendations, does not cite specific literature. There is a full version of the guideline available that summarizes the literature behind each recommendation for readers interested in a more substantial overview of the evidence. The full version is available at: http://pediatrics.aappublications.org/content/137/5/e20160590.long.
For a detailed review on the updated BRUE guideline and its applicability to the emergency department setting, see the special report titled, “Brief Resolved Unexplained Events: What the Emergency Clinician Needs to Know.”
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Synopsis
This clinical practice guideline defines a new term, brief resolved unexplained event (BRUE), and recommends that this should replace the term apparent life-threatening event (ALTE). The guideline details and recommends a risk-based approach for evaluation and management of BRUEs. The article provided here for review is a summary of the guidelines. The full guideline is available at: http://pediatrics.aappublications.org/content/137/5/e20160590.long.
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