Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

Abstract

This is the fi rst clinical practice guideline from the American Academy of Pediatrics that specifi cally 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 defi ned 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 defi nition 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 benefi t-harm relationship, and the strength of recommendation.

Unexpected episodes of cyanosis in late preterm and term neonates prompted admission to a neonatal care unit

“…We wonder if the crises of cyanosis of unknown origin that we observed in our patients might actually represent episodes of SUPC [7, 14] that were precociously and casually detected before the development of more severe symptoms requiring need of resuscitation, or if they represent a low risk condition that may be referred to as a brief resolved unexplained event (BRUE) requiring simple interventions such as positional changes, brief stimulation, or procedures to resolve airway obstruction [15]. We are not able to answer this question but we can report that, to the best of our knowledge, none of our patients developed subsequent episodes of cyanosis or more severe life-threatening events after their discharge from hospital.…”

Pediatric tracheomalacia and the perioperative anesthetic management of thoracoscopic posterior tracheopexy

“…Tracheomalacia has been implicated as a cause of acute life‐threatening events (ALTEs) . The American Academy of Pediatrics has recently replaced the term “ALTE” with “BRUE,” or brief resolved unexplained event . Although similar in nature, BRUE describes “an event occurring in an infant <1 year of age when the observer reports a sudden, brief, and now resolved episode of more than one of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone; or altered level of responsiveness.” This is slightly different than the definition of ALTE in that it includes an age limitation and removes “life‐threatening” from the definition …”

Unexpected, unexplained and life‐threatening events in infants are age‐dependent descriptive syndromes with different risk and management

“…A recent clinical practice guideline from the American Academy of Pediatrics recommends replacing the term ALTE with BRUE , but only when ALTE events remain unexplained after an appropriate thorough structured history and physical examination. Moreover, BRUE does not apply to infants with additional symptoms or abnormal vital signs, such as a cough, respiratory findings or fever.…”

“…Thus, the suggested BRUE definition is broader than the original ALTE definition . These new clinical practice guidelines provide an approach to patient evaluation based on the risk that the infant will have a repeat event or has a serious underlying disorder and categorises infants with BRUE into high‐ or low ‐ risk infants . It also provides structured management recommendations, or key action statements, but only for low ‐ risk infants who are more than 60 days old.…”

“…It is important to distinguish between an ALTE occurring during the first postnatal week, a possible SUPC event and events in older infant. We also need further age stratification of infants between seven and 60 days old – which has been characterised as a high‐risk group – and those exhibiting ALTE without comorbidities between two and 12 months, BRUE . This age stratification, together with new guidelines will help guide our understanding and improve the quality of care we provide for these common conditions.…”