Clinical Practice Guideline: BRUE and Evaluation of Lower-Risk Infants

The American Academy of Pediatrics recently released a clinical practice guideline that updates the terminology and evaluation approach for lower-risk infants who were previously referred to as having “apparent life-threatening event” (ALTE) with “brief resolved unexplained event” (BRUE). The new term corresponds to an event that occurs in an infant younger than 1 year of age who has had a sudden, brief, resolved episode of one or more 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 or responsiveness. In addition, clinicians should diagnose a BRUE only when there is no other explanation for the event after conducting an appropriate history and physical examination.

The subcommittee recommended replacing the term ALTE with BRUE to address the challenges created by the clinical application of the ALTE classification for clinicians and parents caring for these infants. ALTE describes a broad range of observed, subjective, and nonspecific symptoms that compel clinicians to perform tests that could subject the patient to unnecessary risk and are unlikely to lead to a treatable diagnosis. The term BRUE focuses on a more accurate description that is designed to provide a patient- and family-centered approach to care, to reduce unnecessary and costly medical interventions, and to improve patient outcomes.

The recommendations in the guideline only apply to lower-risk patients, identified on the basis of history and physical examination and for whom evidence-based guidelines for evaluation and management are offered. These lower risk patients are defined by 1) age > 60 days; 2) gestational age > 32 weeks and postconceptional age > 45 weeks; 3) occurrence of only 1 BRUE, and no prior BRUE; 4) duration of BRUE < 1 minute; 5) no cardiopulmonary resuscitation by trained medical provider is required; 6) no concerning historical features; and 7) no concerning physical examination findings.

“This guideline really was developed with the practicing clinician in mind to identify low-risk children who do not require extensive, unnecessary testing and gives evidence-based guidance to facilitate care,” says Ann M. Dietrich, MD, FAAP, FACEP, editor or Pediatric Emergency Medicine Reports. “Remember to complete a careful and thorough history and physical exam and to mentally consider is there any suspicion for nonaccidental trauma before making the diagnosis of BRUE.”

The full clinical practice guideline can be found at the following link.

http://pediatrics.aappublications.org/content/pediatrics/early/2016/04/21/peds.2016-0590.full.pdf

In the coming months, a full article will be published in Pediatric Emergency Medicine Reports about the new guideline.