Brief resolved unexplained event - BRUE (< 12 months) - Curbside

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Evidence
Total Notes: 7
Evidence

1 ALTE

The historical term ALTE (now replaced with "BRUE")  was defined by a consensus conference in 1986 as:

"An episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic of pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer fears that the infant has died. Previously used terminology such as "aborted crib death" or "near-miss SIDS should be abandoned because it implies a possibly misleadingly close association between this type of spell and SIDS."

In the literature, ALTE has been defined in different manners giving an estimated to be 0.05 to 1 percent incidence. Most of these episodes occur before 2 months of age (especially before 10 weeks of age). Risk factors for having an ALTE are prior episodes, respiratory illness, young age, materal smoking, prematurity, post-mature infants and first-born infants.

BRUE was defined in the 2016 AAP clinical practice guideline as:

Clinicians should use the term BRUE to describe an event occurring in an infant <1 year of age when the observer  reports a sudden, brief, and now resolved 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

Moreover, clinicians should diagnose a BRUE only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination



References:
  1. National Institutes of Health Consensus Development Conference on Infantile Apnea and Home Monitoring, Sept 29 to Oct 1, 1986.
    Consensus Conference
    Pediatrics. 1987;79(2):292.79(2):292.
  2. Early neonatal sudden infant death and near death of fullterm infants in maternity wards.
    Polberger S, Svenningsen NW
    Acta Paediatr Scand. 1985;74(6):861.
  3. Apnea of infancy--a clinical problem.
    Davis N, Sweeney LB
    West J Med. 1986;144(4):429.
  4. The epidemiology of sudden infant death syndrome and attacks of lifelessness in Sweden.
    Wennergren G, Milerad J, Lagercrantz H, Karlberg P, Svenningsen NW, Sedin G, Andersson D, Grögaard J, Bjure J
    Acta Paediatr Scand. 1987;76(6):898.
  5. Apparent life-threatening prolonged infant apnea in Saskatchewan.
    Sunkaran K, McKenna A, O'Donnell M, Ninan A, Kasian G, Skwarchuk J, Bingham WT
    West J Med. 1989;150(3):293.
  6. Epidemiology of apparent life threatening events.
    Kiechl-Kohlendorfer U, Hof D, Peglow UP, Traweger-Ravanelli B, Kiechl S
    Arch Dis Child. 2005;90(3):297.
  7. Surveillance study of apparent life-threatening events (ALTE) in the Netherlands.
    Semmekrot BA, van Sleuwen BE, Engelberts AC, Joosten KF, Mulder JC, Liem KD, Rodrigues Pereira R, Bijlmer RP, L'Hoir MP
    Eur J Pediatr. 2010 Feb;169(2):229-36.
  8. Apparent life-threatening events: an update.
    Fu LY, Moon RY
    Pediatr Rev. 2012 Aug;33(8):361-8;
  9. Apparent life-threatening events and sudden infant death syndrome: comparison of risk factors.
    Esani N, Hodgman JE, Ehsani N, Hoppenbrouwers T
    J Pediatr. 2008;152(3):365.

2 SIDS

In the past BRUE/ALTE was thought to be an "early-warning" sign for Sudden Infant Death Syndrome (SIDS). However, recent studies have shown no causal relationship between ALTE and SIDS. Although some patients with SIDS have had a prior ALTE (~5 percent), the vast majority have not. Furthermore, interventions that have markedly decreased the incidence of SIDS (prone sleeping) have not decreased the incidence of ALTE. The primary age of SIDS patients (2 - 4 months) is different than that of ALTE (< 2 months). Also, ALTE primarily occurs during daylight hours (8a - 8p) while SIDS occurs overnight (12a - 6a).

Put together, this evidence suggests that SIDS and BRUE are independent entities and the workup and management of BRUE should focus on the identification of a specific historical or physical exam finding associated with a known disease entity.



References:
  1. Risk factors for SIDS. Results of the National Institute of Child Health and Human Development SIDS Cooperative Epidemiological Study.
    Hoffman HJ, Damus K, Hillman L, Krongrad E
    Ann N Y Acad Sci. 1988;533:13.
  2. SIDS and other sleep-related infant deaths: expansion of recommendations for a safe infant sleeping environment.
    Task Force on Sudden Infant Death Syndrome, Moon RY
    Pediatrics. 2011;128(5):e1341.
  3. Epidemiology of SIDS and explained sudden infant deaths. CESDI SUDI Research Group.
    Leach CE, Blair PS, Fleming PJ, Smith IJ, Platt MW, Berry PJ, Golding J.
    Pediatrics. 1999 Oct;104(4):e43.
  4. Sudden Unexpected Death in Infancy: place and time of death
    Glasgow J, Thompson AJ, Ingram PJ
    Ulster Med J. Jan 2006; 75(1): 65–71.
  5. Sleep and cardiorespiratory characteristics of infant victims of sudden death: a prospective case-control study.
    Kahn A, Groswasser J, Rebuffat E, Sottiaux M, Blum D, Foerster M, Franco P, Bochner A, Alexander M, Bachy A
    Sleep. 1992;15(4):287.
  6. Apparent life-threatening events and sudden infant death syndrome: comparison of risk factors.
    Esani N, Hodgman JE, Ehsani N, Hoppenbrouwers T
    J Pediatr. 2008;152(3):365.
  7. Epidemiology of apparent life threatening events.
    Kiechl-Kohlendorfer U, Hof D, Peglow UP, Traweger-Ravanelli B, Kiechl S
    Arch Dis Child. 2005;90(3):297.
  8. Extreme and conventional cardiorespiratory events and epidemiologic risk factors for SIDS.
    Hoppenbrouwers T, Hodgman JE, Ramanathan A, Dorey F
    J Pediatr. 2008;152(5):636.

3 Etiology

BRUEs are caused by a large, diffuse array of etiologies. Over 50 percent are identifiable for history and physical with confirmatory testing. However, the remaining 1/2 of cases may never have specific etiology identified. Common etiologies include:

  • 30% - Gastroesophageal reflux (although normal infants in this age group may have GERD as well)
  • 20% - Upper respiratory tract infection (RSV ~ 10%, Pertussis 6 - 9%)
  • 10 - 20% - Seizure / central nervous system disorder
  • 0.4 - 11% - Child abuse

Lower percentages (0.5 to 3 percent) of poisoning, anaphylaxis, serious bacterial infections, cardiac disease, upper airway obstruction, metabolic disorders and other rare disorders make up the additional etiologies.

 



References:
  1. Causes of apparent life threatening events in infants: a systematic review.
    McGovern MC, Smith MB
    Arch Dis Child. 2004;89(11):1043.
  2. Apparent life-threatening events presenting to a pediatric emergency department.
    Gray C, Davies F, Molyneux E
    Pediatr Emerg Care. 1999;15(3):195.
  3. Yield of diagnostic testing in infants who have had an apparent life-threatening event.
    Brand DA, Altman RL, Purtill K, Edwards KS
    Pediatrics. 2005;115(4):885.
  4. Apparent life threatening events in infants presenting to an emergency department.
    Davies F, Gupta R
    Emerg Med J. 2002;19(1):11.
  5. Mortality after discharge in clinically stable infants admitted with a first-time apparent life-threatening event.
    Kant S, Fisher JD, Nelson DG, Khan S
    Am J Emerg Med. 2013 Apr;31(4):730-3.
  6. Apparent life-threatening events: neurological correlates and the mandatory work-up.
    Genizi J, Pillar G, Ravid S, Shahar E
    J Child Neurol. 2008;23(11):1305.
  7. Seizures in children following an apparent life-threatening event.
    Bonkowsky JL, Guenther E, Srivastava R, Filloux FM
    J Child Neurol. 2009 Jun;24(6):709-13.
  8. Abusive head injury as a cause of apparent life-threatening events in infancy.
    Altman RL, Brand DA, Forman S, Kutscher ML, Lowenthal DB, Franke KA, Mercado VV
    Arch Pediatr Adolesc Med. 2003;157(10):1011.
  9. Abusive head trauma in children presenting with an apparent life-threatening event.
    Guenther E, Powers A, Srivastava R, Bonkowsky JL
    J Pediatr. 2010;157(5):821.
  10. Management of apparent life-threatening events in infants: a systematic review.
    Tieder JS, Altman RL, Bonkowsky JL, Brand DA, Claudius I, Cunningham DJ, Dewolfe C, Percelay JM, Pitetti RD, Smith MB
    J Pediatr. 2013;163(1):94.
  11. Prevalence of retinal hemorrhages and child abuse in children who present with an apparent life-threatening event.
    Pitetti RD, Maffei F, Chang K, Hickey R, Berger R, Pierce MC
    Pediatrics. 2002;110(3):557.
  12. Death, child abuse, and adverse neurological outcome of infants after an apparent life-threatening event.
    Bonkowsky JL, Guenther E, Filloux FM, Srivastava R
    Pediatrics. 2008 Jul;122(1):125-31.
  13. Mortality and child abuse in children presenting with apparent life-threatening events.
    Parker K, Pitetti R
    Pediatr Emerg Care. 2011;27(7):591.
  14. Accidental and nonaccidental poisonings as a cause of apparent life-threatening events in infants.
    Pitetti RD, Whitman E, Zaylor A
    Pediatrics. 2008;122(2):e359.
  15. Cardiac testing and outcomes in infants after an apparent life-threatening event.
    Hoki R, Bonkowsky JL, Minich LL, Srivastava R, Pinto NM
    Arch Dis Child. 2012 Dec;97(12):1034-8.
  16. Occurrence of serious bacterial infection in infants aged 60 days or younger with an apparent life-threatening event.
    Zuckerbraun NS, Zomorrodi A, Pitetti RD
    Pediatr Emerg Care. 2009 Jan;25(1):19-25.

4 History

The patient's history is often the most helpful resource in identifying potential sources for an BRUE episode. In addition to the episode itself a complete past medical history, family history, and social/environmental history should be performed to identify high risk features and etiologies. Special emphasis should be placed on social concerns for abuse as these are often overlooked in the initial presentations of these infants. A detailed listing of all medications and other substances in the household should be reviewed for possible toxic or environmental exposures.



References:
  1. Frequency and timing of recurrent events in infants using home cardiorespiratory monitors.
    CôtéA, Hum C, Brouillette RT, Themens M
    J Pediatr. 1998;132(5):783.
  2. Accidental and nonaccidental poisonings as a cause of apparent life-threatening events in infants.
    Pitetti RD, Whitman E, Zaylor A
    Pediatrics. 2008;122(2):e359.
  3. Apparent life threatening events in infants presenting to an emergency department
    Davies F, Gupta R
    Emerg Med J. Jan 2002;19(1): 11–16.

5 Physical exam

A detailed physical exam is necessary in all patients with BRUE. Special attention should be paid to: vital signs (especially oxygen saturation), subtle signs of trauma (bruising, lack of extremity use, bulging fontanel), growth (height, weight, head circumference), appropriate developmental status/reflexes for age, distress (respiratory difficulty/obstruction, sweating with feeds) or any signs of congenital abnormalities (dysmorphism, tone).



References:
  1. Recommended clinical evaluation of infants with an apparent life-threatening event. Consensus document of the European Society for the Study and Prevention of Infant Death, 2003.
    Kahn A, European Society for the Study and Prevention of Infant Death
    Eur J Pediatr. 2004;163(2):108.
  2. Apparent life-threatening events, facial dysmorphia and sleep-disordered breathing.
    Guilleminault C, Pelayo R, Leger D, Philip P
    Eur J Pediatr. 2000;159(6):444.
  3. Late presentation of upper airway obstruction in Pierre Robin sequence.
    Wilson AC, Moore DJ, Moore MH, Martin AJ, Staugas RE, Kennedy JD
    Arch Dis Child. 2000;83(5):435.
  4. Apparent life threatening events in infants presenting to an emergency department
    Davies F, Gupta R
    Emerg Med J. Jan 2002;19(1): 11–16.

6 Risk factors

If the history and physical do not suggest a probable etiology (idiopathic BRUE), then the description of the event and concerning risk factors should be considered in order to determine further investigation of the infant. A systemic review concluded that for well-appearing infants where the H&P did not suggest a specific diagnosis or that the event was life-threatening; routine laboratory testing OR testing for gastroesophageal reflux is unlikely to assist in diagnosis or management. However, if the event appeared to be life-threatening or the patient has high risk factors, further laboratory workup and admission may be beneficial.

H&P alone establishes a diagnosis in 21 percent of cases, with diagnosis confirmed in an additional 49 percent with testing. However, of all tests ordered only 18 percent were positive with 6 percent contributing to the diagnosis.



References:
  1. Management of apparent life-threatening events in infants: a systematic review.
    Tieder JS, Altman RL, Bonkowsky JL, Brand DA, Claudius I, Cunningham DJ, Dewolfe C, Percelay JM, Pitetti RD, Smith MB
    J Pediatr. 2013;163(1):94.
  2. Yield of diagnostic testing in infants who have had an apparent life-threatening event.
    Brand DA, Altman RL, Purtill K, Edwards KS
    Pediatrics. 2005;115(4):885.

7 Admission

Hospital admission of infants with signs of physiologic compromise or high risk factors may be useful as further events may be identified through monitoring in the hospital. This is not necessary for a majority of infants with BRUE who have shown not concerns on history, physical and laboratory testing. A clinical decision rule found 3 variables (obvious need for admission, significant medical history,>1 apparent life-threatening event in 24 hours) that identified most but not all infants with apparent life-threatening events necessitating admission.

In addition home monitoring has not shown to benefit patients with benign H&Ps and initial workup.



References:
  1. Apparent life-threatening events: an update.
    Fu LY, Moon RY
    Pediatr Rev. 2012 Aug;33(8):361-8
  2. Apparent life-threatening event: multicenter prospective cohort study to develop a clinical decision rule for admission to the hospital.
    Kaji AH, Claudius I, Santillanes G, Mittal MK, Hayes K, Lee J, Gausche-Hill M
    Ann Emerg Med. 2013 Apr;61(4):379-387.
  3. Causes of apparent life threatening events in infants: a systematic review.
    McGovern MC, Smith MB
    Arch Dis Child. 2004;89(11):1043.