ALTEr your definitions and brush up on BRUEs

The Amercian Academy of Pediatrics has just released an update guideline on the definition, assessment and management of the condition formerly known as Acute Life Threatening Event (ALTE). With this, they introduce the new name: Brief Resolved Unexplained Event (BRUE).

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Definitions

A 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... when there is no explanation for a qualifying event after conducting an appropriate history and physical examination

The symptoms to look for in the history (given that it would have resolved already to meet definition) are ≥1 of the following:

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

This guideline defines low-risk patients, and offers advice on their management. Any patient who does not meet low-risk criteria are, obviously, high-risk, and require inpatient paediatric admission and investigation. Low risk patient must meet all of the criteria:

  1. Age >60 days
  2. Gestational age ≥32 weeks and postconceptional age ≥45 weeks
  3. Occurrence of only 1 BRUE (no prior BRUE ever and not occurring in clusters)
  4. Duration of BRUE <1 minute
  5. No cardiopulmonary resuscitation by trained medical provider required

Recommendations

Recommendations are of limited strength, either weak or moderate (levels B & C). The key points are:

  • Limit unnecessary investigations
    • Consider pertussis testing, 12-lead electrocardiogram, and a brief period of continuous pulse oximetry monitoring with serial observations
    • Don't do other testing or monitoring for cardiopulmonary, child abuse (although explore the social setting), neurologic, infectious disease, gastrointestinal, inborn errors of metabolism, or anaemia evaluation, including home cardiorespiratory monitoring, sleep testing or admission solely for cardiorespiratory monitoring
  • Do not prescribe acid suppression therapy or antiepileptic medications
  • Use shared decision-making with the family
  • Educate the caregivers/parents about BRUEs and offer resources for CPR training

The Bottom Line

If your young BRUE patient is low risk, then focus on a thorough history and examination, reassure the parents, and consider using the opportunity to direct parents and caregivers to learn CPR skills.

 

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