How is a brief resolved unexplained event (BRUE) (apparent life-threatening event) (ALTE) treated?

Updated: Feb 28, 2019
  • Author: Patrick L Carolan, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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In-hospital observation has traditionally been suggested for most infants following a brief resolved unexplained event (BRUE). The initial evaluation of some infants reveals active ongoing symptoms or examination findings clearly suggesting the need for hospitalization for purposes of further evaluation and treatment (eg, sepsis). However, ALTEs that are the result of a self-resolving episode of choking or gagging associated with feedings in well-appearing infants may be observed in an outpatient setting. [46]

Claudius and Keens (2007) noted that infants younger than 1 month or those who had a history of multiple apparent life-threatening events at the time of presentation were at higher risk for additional events or eventual diagnoses that required further in-hospital evaluation. [16] This study suggests that well-appearing infants older than 30 days who have experienced a single ALTE and who have normal initial screening findings may be safely discharged from the hospital with proper outpatient follow-up.

Doshi et al (2012) report a series of 300 infants admitted following an ALTE. [19] Forty-six percent of these infants were diagnosed with gastroesophageal reflux as the cause of the event. Of the infants diagnosed with gastroesophageal reflux disease, only 6% experienced additional events while in the hospital. Most of these infants were younger than age 30 days or had histories of premature birth.

Mittal et al (2012) report a prospective cohort series of infants admitted following an ED diagnosis of ALTE. [20] Following admission, 12% of infants required significant intervention. Logistic regression identified prematurity, abnormal result in the physical examination, color change to cyanosis, absence of symptoms of upper respiratory tract infection, and absence of choking as predictors for significant intervention. These variables were used to create a clinical decision rule, based on which, 184 infants (64%) could be discharged home safely from the ED, reducing the hospitalization rate to 102 (36%). The model yielded a negative predictive value of 96.2% (range, 92-98.3%).

In a multicenter study of 832 ALTE patients presenting to ED, [21] 16.5% met criteria mandating admission (eg, need for supplemental oxygen or antibiotics). Regression-tree analysis identified 2 additional historical factors predicting need for admission: significant medical history and more than 1 ALTE within 24 hours of presentation. For these 2 factors, sensitivity was 89% (95% confidence interval, 83.5-92.9%) and specificity was 61.9% (95% confidence interval, 58-65.7%).

Based on these studies, approximately 10-15% of ALTE patients seen in ED benefit from admission, owing to the risk for further deterioration or identification of a significant underlying diagnosis. Study data suggest that infants younger than age 1 month, preterm infants, infants with a significant medical history, infants experiencing multiple events, or infants with episodes not associated with choking are at higher risk for additional events or significant diagnoses warranting hospitalization. Additional low-risk infants and their families may benefit from the reassurance provided by an observational stay.

Documenting cardiorespiratory monitors should be reserved for preterm infants who are at high risk for recurrent apnea or bradycardia and for infants who depend on technology because they have specific disorders of cardiorespiratory control. [22]

A study by Ueda et al reported that symptoms of respiratory tract infection were more frequent in patients who experienced a brief resolved unexplained event recurrence (44% vs 14%). [45]

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