Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants

In this new clinical practice guideline, the American Academy of Pediatrics has recommended that the term “apparent life-threatening events” (ALTEs) be replaced with a new term, “brief resolved unexplained events” (BRUEs). ALTE, proposed in 1986 to replace the term near-SIDS (sudden infant death syndrome), has been defined as an episode that is frightening to the observer and characterized by some combination of apnea, color change, marked change in muscle tone, and/or choking or gagging. Many of these children undergo a comprehensive work-up in addition to the initial history and physical. Children may be admitted for observation, and the admission often includes further evaluation with cardiorespiratory monitoring, labs, and occasionally specialized studies. These tests are usually normal, and patients are discharged home, leaving families to continue to worry that there is an undetected underlying problem.

The ALTE definition is often vague in determination and dependent on a subjective report from caregivers and their perception of the severity of the event. The new term BRUE is based on more stringent, objective criteria. BRUE is defined as occurring in children less than 1 year of age, where an observer reports a sudden, brief now-resolved episode with one or more of the following:

• Cyanosis or pallor.

• Absent, decreased, or irregular breathing.

• A marked change in tone (hypertonia or hypotonia).

• An altered level of responsiveness.

• No explanation for a qualifying event after an appropriate history and physical are conducted.

The BRUE definition differs from that of an ALTE. First, the “life-threatening” qualifier has been removed from both the title and diagnostic criteria. This allows providers to approach the patient with more objectivity, and allows clinical decision making to stem from the evaluation of the child rather than the perceived severity of the event.

“Color change” has been more strictly defined to be only cyanosis or pallor. In the ALTE definition, redness or rubor was an acceptable criterion for diagnosis; however, this is a common finding in healthy newborns.

“Change in muscle tone” has been more specifically defined and must be characterized as hypertonia or hypotonia. Characterizing the change in tone assists providers in investigating specific underlying causes. “Altered level of responsiveness” is a new criterion.

There is a notable absence of “choking or gagging” from the BRUE definition. These are often signs of reflux and upper respiratory infections in the infant. By the very nature of the definition, if a child is diagnosed with an underlying illness, this excludes the diagnosis of BRUE.

Identifying risk factors for repeat events

In addition to using new criteria for diagnosis, providers are also able to characterize infants as higher risk and lower risk. If a child truly has a BRUE, he/she may be diagnosed as higher risk or lower risk for a recurrent episode or SIDS.

A lower-risk infant has the following characteristics:

• Over 60 days old.

• Gestational age greater than 32 weeks; postconception age over 45 weeks.

• First BRUE.

• Duration of event under 1 minute.

• No CPR required by a trained medical provider (not parents).

• No concerning history and physical findings.

Children who are identified as being at higher risk would benefit from further work-up beyond a thorough history and physical. Additional testing may reveal the underlying cause of the episode (congenital cardiac disease, underlying metabolic disorder, abuse), thereby excluding the diagnosis of BRUE. By further characterizing the diagnosis, the new definition allows providers to avoid unnecessary studies in otherwise healthy children.

Key action statements and recommendations

Action statements are recommended for the evaluation of children who are classified as lower risk with BRUE. While not all the action statements can be covered in this review, for lower-risk individuals, clinicians:

• Do not need to admit infants solely for cardiorespiratory monitoring.

• Should not start home cardiorespiratory monitoring, obtain an overnight polysomnogram, a chest radiograph, or an echocardiogram.

• Assess for risk factors in order to detect any possible child abuse.

• Should not obtain neuroimaging to detect neurologic disorders or child abuse, and should not perform an EEG to detect a neurologic disorder.

• Are strongly recommended to refrain from doing a WBC, blood culture, or lumbar puncture with cerebrospinal fluid studies to rule out an occult bacterial infection.

• Should avoid doing an extensive work-up for underlying gastroesophageal reflux (e.g., upper gastrointestinal tract series, endoscopy, pH probe, ultrasound).

• Are encouraged to educate parents and families about BRUEs, and offer resources for CPR training for families and caregivers.

Limitations

While there are many benefits to these new guidelines, there are challenges. ALTE is ingrained in clinical practice, and it may take time for a uniform acceptance of the change in terminology and criteria. Additional limitations come with the lack of evidence of outcomes and impact, as all studies available are based on ALTE criteria, and data will lag in evaluating the utility of conceptualizing events as BRUEs.

The bottom line

BRUE has been proposed to replace the term ALTE for an unexplained witnessed event as defined above. BRUEs differ from ALTEs in that the criteria are more strictly defined, and they allow providers to stratify children as lower risk or higher risk for a recurrent episode or SIDS. By identifying a child’s risk, providers are able to appropriately utilize resources to refrain from doing an extensive medical work-up in a child who is otherwise healthy and low risk for a serious event.

Reference

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Cavanaugh is a second-year resident in the Abington-Jefferson Family Medicine Residency Program.

In this new clinical practice guideline, the American Academy of Pediatrics has recommended that the term “apparent life-threatening events” (ALTEs) be replaced with a new term, “brief resolved unexplained events” (BRUEs). ALTE, proposed in 1986 to replace the term near-SIDS (sudden infant death syndrome), has been defined as an episode that is frightening to the observer and characterized by some combination of apnea, color change, marked change in muscle tone, and/or choking or gagging. Many of these children undergo a comprehensive work-up in addition to the initial history and physical. Children may be admitted for observation, and the admission often includes further evaluation with cardiorespiratory monitoring, labs, and occasionally specialized studies. These tests are usually normal, and patients are discharged home, leaving families to continue to worry that there is an undetected underlying problem.

The ALTE definition is often vague in determination and dependent on a subjective report from caregivers and their perception of the severity of the event. The new term BRUE is based on more stringent, objective criteria. BRUE is defined as occurring in children less than 1 year of age, where an observer reports a sudden, brief now-resolved episode with one or more of the following:

• Cyanosis or pallor.

• Absent, decreased, or irregular breathing.

• A marked change in tone (hypertonia or hypotonia).

• An altered level of responsiveness.

• No explanation for a qualifying event after an appropriate history and physical are conducted.

The BRUE definition differs from that of an ALTE. First, the “life-threatening” qualifier has been removed from both the title and diagnostic criteria. This allows providers to approach the patient with more objectivity, and allows clinical decision making to stem from the evaluation of the child rather than the perceived severity of the event.

“Color change” has been more strictly defined to be only cyanosis or pallor. In the ALTE definition, redness or rubor was an acceptable criterion for diagnosis; however, this is a common finding in healthy newborns.

“Change in muscle tone” has been more specifically defined and must be characterized as hypertonia or hypotonia. Characterizing the change in tone assists providers in investigating specific underlying causes. “Altered level of responsiveness” is a new criterion.

There is a notable absence of “choking or gagging” from the BRUE definition. These are often signs of reflux and upper respiratory infections in the infant. By the very nature of the definition, if a child is diagnosed with an underlying illness, this excludes the diagnosis of BRUE.

Identifying risk factors for repeat events

In addition to using new criteria for diagnosis, providers are also able to characterize infants as higher risk and lower risk. If a child truly has a BRUE, he/she may be diagnosed as higher risk or lower risk for a recurrent episode or SIDS.

A lower-risk infant has the following characteristics:

• Over 60 days old.

• Gestational age greater than 32 weeks; postconception age over 45 weeks.

• First BRUE.

• Duration of event under 1 minute.

• No CPR required by a trained medical provider (not parents).

• No concerning history and physical findings.

Children who are identified as being at higher risk would benefit from further work-up beyond a thorough history and physical. Additional testing may reveal the underlying cause of the episode (congenital cardiac disease, underlying metabolic disorder, abuse), thereby excluding the diagnosis of BRUE. By further characterizing the diagnosis, the new definition allows providers to avoid unnecessary studies in otherwise healthy children.

Key action statements and recommendations

Action statements are recommended for the evaluation of children who are classified as lower risk with BRUE. While not all the action statements can be covered in this review, for lower-risk individuals, clinicians:

• Do not need to admit infants solely for cardiorespiratory monitoring.

• Should not start home cardiorespiratory monitoring, obtain an overnight polysomnogram, a chest radiograph, or an echocardiogram.

• Assess for risk factors in order to detect any possible child abuse.

• Should not obtain neuroimaging to detect neurologic disorders or child abuse, and should not perform an EEG to detect a neurologic disorder.

• Are strongly recommended to refrain from doing a WBC, blood culture, or lumbar puncture with cerebrospinal fluid studies to rule out an occult bacterial infection.

• Should avoid doing an extensive work-up for underlying gastroesophageal reflux (e.g., upper gastrointestinal tract series, endoscopy, pH probe, ultrasound).

• Are encouraged to educate parents and families about BRUEs, and offer resources for CPR training for families and caregivers.

Limitations

While there are many benefits to these new guidelines, there are challenges. ALTE is ingrained in clinical practice, and it may take time for a uniform acceptance of the change in terminology and criteria. Additional limitations come with the lack of evidence of outcomes and impact, as all studies available are based on ALTE criteria, and data will lag in evaluating the utility of conceptualizing events as BRUEs.

The bottom line

BRUE has been proposed to replace the term ALTE for an unexplained witnessed event as defined above. BRUEs differ from ALTEs in that the criteria are more strictly defined, and they allow providers to stratify children as lower risk or higher risk for a recurrent episode or SIDS. By identifying a child’s risk, providers are able to appropriately utilize resources to refrain from doing an extensive medical work-up in a child who is otherwise healthy and low risk for a serious event.

Reference

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Cavanaugh is a second-year resident in the Abington-Jefferson Family Medicine Residency Program.

In this new clinical practice guideline, the American Academy of Pediatrics has recommended that the term “apparent life-threatening events” (ALTEs) be replaced with a new term, “brief resolved unexplained events” (BRUEs). ALTE, proposed in 1986 to replace the term near-SIDS (sudden infant death syndrome), has been defined as an episode that is frightening to the observer and characterized by some combination of apnea, color change, marked change in muscle tone, and/or choking or gagging. Many of these children undergo a comprehensive work-up in addition to the initial history and physical. Children may be admitted for observation, and the admission often includes further evaluation with cardiorespiratory monitoring, labs, and occasionally specialized studies. These tests are usually normal, and patients are discharged home, leaving families to continue to worry that there is an undetected underlying problem.

The ALTE definition is often vague in determination and dependent on a subjective report from caregivers and their perception of the severity of the event. The new term BRUE is based on more stringent, objective criteria. BRUE is defined as occurring in children less than 1 year of age, where an observer reports a sudden, brief now-resolved episode with one or more of the following:

• Cyanosis or pallor.

• Absent, decreased, or irregular breathing.

• A marked change in tone (hypertonia or hypotonia).

• An altered level of responsiveness.

• No explanation for a qualifying event after an appropriate history and physical are conducted.

The BRUE definition differs from that of an ALTE. First, the “life-threatening” qualifier has been removed from both the title and diagnostic criteria. This allows providers to approach the patient with more objectivity, and allows clinical decision making to stem from the evaluation of the child rather than the perceived severity of the event.

“Color change” has been more strictly defined to be only cyanosis or pallor. In the ALTE definition, redness or rubor was an acceptable criterion for diagnosis; however, this is a common finding in healthy newborns.

“Change in muscle tone” has been more specifically defined and must be characterized as hypertonia or hypotonia. Characterizing the change in tone assists providers in investigating specific underlying causes. “Altered level of responsiveness” is a new criterion.

There is a notable absence of “choking or gagging” from the BRUE definition. These are often signs of reflux and upper respiratory infections in the infant. By the very nature of the definition, if a child is diagnosed with an underlying illness, this excludes the diagnosis of BRUE.

Identifying risk factors for repeat events

In addition to using new criteria for diagnosis, providers are also able to characterize infants as higher risk and lower risk. If a child truly has a BRUE, he/she may be diagnosed as higher risk or lower risk for a recurrent episode or SIDS.

A lower-risk infant has the following characteristics:

• Over 60 days old.

• Gestational age greater than 32 weeks; postconception age over 45 weeks.

• First BRUE.

• Duration of event under 1 minute.

• No CPR required by a trained medical provider (not parents).

• No concerning history and physical findings.

Children who are identified as being at higher risk would benefit from further work-up beyond a thorough history and physical. Additional testing may reveal the underlying cause of the episode (congenital cardiac disease, underlying metabolic disorder, abuse), thereby excluding the diagnosis of BRUE. By further characterizing the diagnosis, the new definition allows providers to avoid unnecessary studies in otherwise healthy children.

Key action statements and recommendations

Action statements are recommended for the evaluation of children who are classified as lower risk with BRUE. While not all the action statements can be covered in this review, for lower-risk individuals, clinicians:

• Do not need to admit infants solely for cardiorespiratory monitoring.

• Should not start home cardiorespiratory monitoring, obtain an overnight polysomnogram, a chest radiograph, or an echocardiogram.

• Assess for risk factors in order to detect any possible child abuse.

• Should not obtain neuroimaging to detect neurologic disorders or child abuse, and should not perform an EEG to detect a neurologic disorder.

• Are strongly recommended to refrain from doing a WBC, blood culture, or lumbar puncture with cerebrospinal fluid studies to rule out an occult bacterial infection.

• Should avoid doing an extensive work-up for underlying gastroesophageal reflux (e.g., upper gastrointestinal tract series, endoscopy, pH probe, ultrasound).

• Are encouraged to educate parents and families about BRUEs, and offer resources for CPR training for families and caregivers.

Limitations

While there are many benefits to these new guidelines, there are challenges. ALTE is ingrained in clinical practice, and it may take time for a uniform acceptance of the change in terminology and criteria. Additional limitations come with the lack of evidence of outcomes and impact, as all studies available are based on ALTE criteria, and data will lag in evaluating the utility of conceptualizing events as BRUEs.

The bottom line

BRUE has been proposed to replace the term ALTE for an unexplained witnessed event as defined above. BRUEs differ from ALTEs in that the criteria are more strictly defined, and they allow providers to stratify children as lower risk or higher risk for a recurrent episode or SIDS. By identifying a child’s risk, providers are able to appropriately utilize resources to refrain from doing an extensive medical work-up in a child who is otherwise healthy and low risk for a serious event.

Reference

Dr. Skolnik is associate director of the family medicine residency program at Abington (Pa.) Memorial Hospital and professor of family and community medicine at Temple University, Philadelphia. Dr. Cavanaugh is a second-year resident in the Abington-Jefferson Family Medicine Residency Program.