ALTE has been deprecated and replaced with BRUE. Apparent Life-Threatening Events scared parents and led physicians to unnecessary testing. The American Academy of Pediatrics has issued the following guideline.
BRUE
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STEP 1: Meets DEFINITION of BRUE
- BRIEF: less than 1 minute episode
- RESOLVED: back to baseline/normal
- UNEXPLAINED: no other etiology (no URI, vomiting, etc)
- EVENT:
- cyanosis or pallor (not erythema)
- absent, decreased or irregular breathing
- marked change in tone
- altered level of responsiveness
- in a normal child, less than 1 year old
STEP 2: Stratify as LOW risk
- more than 60 days old
- full term (gestational age more than 32w)
- 1st event and not in clusters
- less than 1 minute
- no CPR by *trained medical provider*
- no concerning features on H&P
STEP 3: Consider TREATMENT options for LOW risk
- SHOULD DO: educate care giver, shared medical decision making regarding can-do items, CPR training for parents
- CAN DO: pertussis testing, ekg, serial observation, pulse oximetry
- DONT HAVE TO DO: admit, viral PCR, glucose, HCO3, lactate, Hgb, CT head (unless judgement says differently), UA
- SHOULD NOT DO: WBC, CSF, Cx, BMP, urine organic acids, CXR, echo, EEG, GERD tests, H2 blockers, anti-epileptics, no home monitoring
HIGH risk patients consider
- abuse
- cardiac arrhythmias (family history of sudden death)
- infection (URI Sx)
- others guided by context
- Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL 2nd, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MB; SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016 May;137(5). https://www.ncbi.nlm.nih.gov/pubmed/27244836
my peripheral brain 