Brief resolved unexplained events in lower-risk infants: a clinical practice guideline

The AAP has proposed renaming apparent life-threatening events as brief resolved unexplained events.
The AAP has proposed renaming apparent life-threatening events as brief resolved unexplained events.

The American Academy of Pediatrics (AAP) has released a clinical practice guideline for the evaluation and management of brief resolved unexplained events (formerly known as apparent life-threatening events) in lower-risk infants. The guideline is published in the May issue of Pediatrics.

The clinical practice guideline has 3 main objectives:

  1. Recommending the replacement of the term apparent life-threatening event (ALTE) with the new term, brief resolved unexplained event (BRUE)
  2. Providing an approach to evaluating patients based on the risk of the infant having a repeat event or serious underlying disorder
  3. Providing management recommendations for lower-risk infants

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The AAP defines the term BRUE 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.”

Infants who present with a BRUE can either be classified as lower- or higher-risk, based on history and physical examination. The AAP's guidelines only apply to lower-risk patients who have the following characteristics:

  • Older than 60 days
  • Gestational age of ≥32 weeks and postconceptional age of ≥45 weeks
  • Occurrence of only 1 BRUE
  • Duration of the BRUE is less than 1 minute
  • No CPR required by trained medical provider
  • No concerning history features
  • No concerning physical examination findings

The current data on higher-risk infants who have experienced a BRUE is not strong enough to inform evidence-based recommendations, so the AAP's guideline does not provide recommendations for higher-risk infants at this time.

The guideline was developed by a multidisciplinary panel based on evidence from a systemic review of studies published from 1970 to 2014. The following table summarizes the key action statements that the panel generated using evidence from that review.

TABLE 1. Summary of key action statements for lower-risk BRUEs1

When managing an infant aged >60 d and <1 y and who, on the basis of a thorough history and physical examination, meets criteria for having experienced a lower-risk BRUE, clinicians: Evidence Quality; Strength of Recommendation

1. Cardiopulmonary evaluation

1A. Need not admit infants to the hospital solely for cardiorespiratory monitoring.

B; Weak

1B. May briefl y monitor patients with continuous pulse oximetry and serial observations.

D; Weak

1C. Should not obtain a chest radiograph.

B; Moderate

1D. Should not obtain a measurement of venous or arterial blood gas.

B; Moderate

1E. Should not obtain an overnight polysomnograph.

B; Moderate

1F. May obtain a 12-lead electrocardiogram.

C; Weak

1G. Should not obtain an echocardiogram.

C; Moderate

1H. Should not initiate home cardiorespiratory monitoring.

B; Moderate

2. Child abuse evaluation

2A. Need not obtain neuroimaging (CT, MRI, or ultrasonography) to detect child abuse.

C; Weak

2B. Should obtain an assessment of social risk factors to detect child abuse.

C; Moderate

3. Neurologic evaluation

3A. Should not obtain neuroimaging (CT, MRI, or ultrasonography) to detect neurologic disorders.

C; Moderate

3B. Should not obtain an EEG to detect neurologic disorders.

C; Moderate

3C. Should not prescribe antiepileptic medications for potential neurologic disorders.

C; Moderate

4. Infectious disease evaluation

4A. Should not obtain a WBC count, blood culture, or cerebrospinal fl uid analysis or culture to detect an occult bacterial infection.

B; Strong

4B. Need not obtain a urinalysis (bag or catheter).

C; Weak

4C. Should not obtain chest radiograph to assess for pulmonary infection.

B; Moderate

4D. Need not obtain respiratory viral testing if rapid testing is available.

C; Weak

4E. May obtain testing for pertussis.

B; Weak

5. Gastrointestinal evaluation

5A. Should not obtain investigations for GER (eg, upper gastrointestinal tract series, pH probe, endoscopy, barium contrast study, nuclear scintigraphy, and ultrasonography).

C; Moderate

5B. Should not prescribe acid suppression therapy.

C; Moderate

6. IEM evaluation

6A. Need not obtain measurement of serum lactic acid or serum bicarbonate.

C; Weak

6B. Should not obtain a measurement of serum sodium, potassium, chloride, blood urea nitrogen, creatinine, calcium, or ammonia.

C; Moderate

6C. Should not obtain a measurement of venous or arterial blood gases.

C; Moderate

6D. Need not obtain a measurement of blood glucose.

C; Weak

6E. Should not obtain a measurement of urine organic acids, plasma amino acids, or plasma acylcarnitines.

C; Moderate

7. Anemia evaluation

7A. Should not obtain laboratory evaluation for anemia.

C; Moderate

8. Patient- and family-centered care

8A. Should offer resources for CPR training to caregiver.

C; Moderate

8B. Should educate caregivers about BRUEs.

C; Moderate

8C. Should use shared decision-making.

C; Moderate


Notably, the recommendations focus on what not do to for lower-risk infants. According to researcher Joel S. Tieder, MD, MPH, FAAP, “We're actually making recommendations against doing things for lower-risk infants — doing less is more for these children.”

Reference

  1. 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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