New AAP Guideline: Brief Unexplained Events in Infants

Marcia Frellick

April 25, 2016

The American Academy of Pediatrics (AAP) has released a new clinical practice guideline on brief resolved unexplained events (BRUE) in low-risk infants. BRUE refers to brief events in infants, such as when a baby stops breathing for a few seconds, that are unexplained and rarely associated with underlying medical problems.

The new term, BRUE, will replace "apparent life-threatening event" (ALTE).

The committee's new guidelines, by Joel S. Tieder, MD, MPH, chair of the committee, and colleagues, were published online April 25 in Pediatrics.

The authors define BRUE as an event observed in infants younger than 1 year when an observer reports a sudden, brief (less than a minute), but then resolved episode of at least one of these: cyanosis or pale complexion; absent, decreased, or irregular breathing; marked change in muscle tone (hyper- or hypotonia); or altered responsiveness.

This is the first AAP guideline that specifically addresses these events. The new guideline and change in terminology are based on a literature review of ALTEs from 1970 through 2014. The new term "better reflects the transient nature and lack of clear cause of such events, which are rarely life-threatening under the BRUE definition," according to a news release.

New guidance around the term is meant to help reduce costly and unnecessary interventions and better inform care.

What BRUE Does, Does Not Cover

Presence of respiratory symptoms or fever would rule out classification of an event as a BRUE. Likewise, the definition does not include choking or gagging associated with spitting up, because clinicians will want to pursue the cause of vomiting, the authors write.

One difference from ALTE is that a BRUE diagnosis is based on how the clinician characterizes the event, and not on a caregiver's perception that the event was life-threatening. BRUE also differs from ALTE in that it has an age limit of younger than 1 year.

BRUE also goes beyond "apnea" in describing qualifying breathing irregularities and includes absent and diminished breathing.

In evaluating skin tone, the clinician should determine whether the infant had an episode of cyanosis or pallor, "rather than just determining whether 'color change' occurred," the authors write. BRUE does not describe episodes of redness because those are common in healthy infants. A diagnosis of BRUE applies only when there is no other possible explanation for a qualifying event.

Physicians who determine a BRUE has occurred should conduct a careful history and physical exam, assess the risk it will happen again, and evaluate whether there is an underlying disorder to determine next steps.

This guideline focuses on care for infants with a low risk for recurrence or serious underlying disorder.

The authors note that until BRUE-specific diagnosis codes are available, clinicians should bill under International Classification of Diseases, 9th Revision, and International Classification of Diseases, 10th revision, ALTE codes.

Pediatrics. Published online April 25, 2016. Full text

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