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.

http://www.medpagetoday.com/Pediatrics/GeneralPediatrics/57532