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.
Recommendations for treating infants vary depending on the type of the event. A full description of the types of events covered by the definition of a BRUE, and their ensuing treatment recommendations, can be found on the AAP site.
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.
Tieder told MedPage Today that the AAP committee sought to examine common questions clinicians face when dealing with a BRUE, which often include whether a child needs certain diagnostic tests; if these tests are helpful; and whether admission to the hospital is helpful following the event. This was part of the reason to divide infants into higher and lower risk groups.
"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.
All AAP clinical practice guidelines automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.
Tieder and co-authors disclosed no relevant relationships with industry.
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