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