What are the guidelines for the evaluation and disposition of unexplained event (BRUE) (apparent life-threatening event) (ALTE)?

Updated: Feb 28, 2019
  • Author: Patrick L Carolan, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Updated BRUE guidelines for evaluation and disposition are now focused on risk stratification.  Low risk infants meet the following: age greater than 60 days; gestational age greater than 32 weeks and post-conceptual age greater than 45 weeks, a negative history and normal physical examination; a single BRUE without a "BRUE cluster"; event duration less than one minute; no CPR by a trained provider. Infants meeting these criteria do not need to undergo laboratory testing or imaging studies.

A meta-analysis of the risk of death following BRUE/ALTE revealed no higher risk for death than the baseline rate of mortality for infants under one year of age. This meta-analysis supports the return-home approach advocated in the recently published clinical practice guideline for BRUE patients who have been evaluated in the emergency department and determined to be at lower risk. [51]

In discussing the updated BRUE guidelines with parents, care providers should anticipate the likelihood of parental concern regarding management plans which include an option for discharge to home.  Brand et al conducted structured interviews of parents of infants diagnosed with BRUE. [48]   Interview transcripts revealed a near-universal fear about the child's well-being, ambivalence about the best course of action following the evaluation in the emergency department, and the need for reassurance about the unlikelihood of a recurrence. Parental attitudes toward the "return-home scenario" ranged from unthinkable to extreme relief. Two-thirds of parents expressed at least some reservations about the idea of returning home.

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