Tuesday, April 26, 2016

ALTEs become BRUEs

The American Academy of Pediatrics (AAP) has issued its first clinical practice guideline for infants less than a year old who have experienced a "brief resolved unexplained event (BRUE)."

Formerly called "apparent life-threatening events (ALTE)," a BRUE includes respiratory changes, such as when an infant stops breathing, or an altered level of consciousness. Infants should be evaluated based on level of risk that this event will recur or is based on an underlying condition, according to Joel S. Tieder, MD, chair of the AAP Subcommittee on BRUE, and colleagues.

"This clinical practice guideline is intended to foster a patient-and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research," the authors wrote in Pediatrics.

The authors went on to explain that they chose the term BRUE "to better reflect the transient nature and lack of clear cause and removes the 'life-threatening' label." They recommend that ALTE no longer be used by clinicians to describe an event or as a diagnosis...

In the new guideline, BRUE is defined as a sudden episode of ≥1 of the following:

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

These definitions are relatively similar to ALTE, except for the addition of altered level of responsiveness. Not included in the definition of a BRUE are choking or gagging, because there would be an explanation for these events, and by definition, a BRUE has no explanation for the qualifying event, the authors explained.

Unlike ALTE, which could be both a complaint and a diagnosis, a BRUE is a diagnosis offered only after a history of the infant is taken and a physical examination is performed. Following the examination, the clinician determines if the infant falls into a higher or lower risk category.

"For lower risk group, these tests were not going to be helpful," Tieder said. "The interesting thing about these guidelines is it's really what not to do for a particular group of infants because most of the time these events are not life-threatening, but merely normal behavior seen in newborns."

Infants would be classified as lower risk by meeting the following criteria:

Age >60 days
Gestational age ≥32 weeks and post-conceptional age ≥45 weeks
No previous BRUE
Duration of event <1 minute
No concerning historical features
No concerning physical examination findings

In fact, Tieder said that these BRUE in infants are actually fairly common, and are not considered a precursor to sudden infant death syndrome (SIDS), which can be a worry among most parents.

"It's a little hard to understand the epidemiology, but typically developing infants normally have periods of cyclical breathing with pauses, so a lot of parents will note these pauses, but that's normal, particularly during sleep. Infants can have irregular respiration in REM sleep, and that's present in all ages including adulthood," he said. "Oxygen desaturation is quite common in infants during sleep, so just because there's brief desaturation doesn't mean that's linked to an abnormality or underlying condition."

However, infants would be classified as higher risk if the following criteria were met:

Age <60 days
History of prematurity
Duration of event >1 minute
More than one event

Tieder added that concerning factors on a physical exam, such as a family member with a history of SIDS or unexplained bruising, might also place an infant in the higher risk group.

"Some studies show that child abuse in these populations to be fairly high, so physicians should be well aware that [unexplained bruising] could be a presenting sign of child abuse," he said.


1 comment:

  1. Joel S. Tieder, Joshua L. Bonkowsky, Ruth A. Etzel, Wayne H. Franklin, David A. Gremse, Bruce Herman, Eliot S. Katz, Leonard R. Krilov, J. Lawrence Merritt II, Chuck Norlin, Jack Percelay, Robert E. SapiƩn, Richard N. Shiffman, Michael B.H. Smith, for the SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics May 2016


    This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE). This clinical practice guideline has 3 objectives. First, it recommends the replacement of the term ALTE with a new term, brief resolved unexplained event (BRUE). Second, it provides an approach to patient evaluation that is based on the risk that the infant will have a repeat event or has a serious underlying disorder. Finally, it provides management recommendations, or key action statements, for lower-risk infants. The term 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. A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination. By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized either as (1) a lower-risk patient on the basis of history and physical examination for whom evidence-based recommendations for evaluation and management are offered or (2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are not offered. This clinical practice guideline is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient outcomes, support implementation, and provide direction for future research. Each key action statement indicates a level of evidence, the benefit-harm relationship, and the strength of recommendation.