AAP updates guidelines for random, resolved infant events

May 12, 2016

Article

Sometimes babies briefly stop breathing. Sometimes they can turn shades of blue. Sometimes, these things are not serious. The American Academy of Pediatrics (AAP) is recommending a new, less threatening label for such events, in hopes of reducing unnecessary treatment and stress.

Under the new guidelines, clinicians are advised to replace the term “apparent life-threatening event” (ALTE) with “brief resolved unexplained event” (BRUE) to better reflect the transient nature and lack of clear cause in these instances, says Joel Tieder, MD, MPH, a pediatric hospitalist at Seattle Children's Hospital in Washington and chair of the committee AAP’s Subcommittee on Apparent Life Threatening Events.

“Kids aren’t born with a manual. Sometimes infants do things that are normal for a baby, but parents don’t know about them (such as breath holding spells, periodic breathing of the newborn, and acrocyanosis),” says Tieder. “A lot of things that were once called an ALTE fall into this category. However, the BRUE definition is a diagnosis of exclusion to be applied after an evaluation by a pediatric provider. The guideline will help physicians manage patients who have events that cannot be explained.”

Apparent life-threatening events were first identified in the 1980s as a way to identify events that physicians thought may serve as a precursor to sudden infant death syndrome (SIDS). However Tieder says these events are not precursors to SIDS, and that ALTE was a poorly defined phrase that in many cases led to unnecessary hospitalization and testing that yielded no information other than confirmation of a healthy child.

Apparent life-threatening event was loosely defined as “an episode that is frightening to the observer and that is characterized by some combination of apnea (central or occasionally obstructive), color change (usually cyanotic or pallid but occasionally erythematous or plethoric), marked change in muscle tone (usually marked limpness), choking, or gagging. In some cases, the observer fears that the infant has died,” according to AAP. It was also often diagnosed based merely on parental reports, and a BRUE diagnoses will require a physical examination and medical history. The AAP is also working on an implementation tool kit including an algorithm, quality measures, a caregiver handout, and a key driver diagram.

While a broad range of disorders may fall under this spectrum, AAP notes that a majority of infants who have such an event and appear well afterwards generally have “extremely low” risk of having a serious underlying disorder.

A BRUE, on the other hand, is an event during which a child aged less than 1 year has a sudden, brief, resolved episode of 1 of the following: cyanosis or pallor; absent, decreased, or irregular breathing; a marked change in tone (hypertonia or hypotonia); or an altered level of responsiveness.

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A BRUE is diagnosed only when there is no explanation for the qualifying event. Physicians will determine, after examination, whether a child is in the low- or high-risk groups for BRUE, and those in the high-risk population may receive further examination and treatment, according to AAP, although the association is not making specific treatment recommendations.

“This clinical practice guideline is intended to foster a patient- and family-centered approach to care; reduce unnecessary and costly medical interventions; improve patient outcomes; support implementation; and provide direction for future research,” according to AAP.

The definition of BRUE needs to be precise enough to allow clinicians to distinguish between a normal, but concerning event, and a potentially serious medical issue. It could also prevent the overuse of medical interventions, and importantly removes the connotation to parents and caregivers that the event was ever life threatening-as it is not in most cases, according to AAP.

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The hallmark differences between ALTE and BRUE are the clear age limits, and the absence of any other medical explanation.

“Clinical symptoms such as fever, nasal congestion, and increased work of breathing may indicate temporary airway obstruction from viral infection. Events characterized as choking after vomiting may indicate a gastrointestinal cause, such as gastroesophageal reflux,” according to AAP.

Also, BRUE is diagnosed on a clinician’s assessment and not caregiver reporting. Physicians should also take care to identify whether children had a “color change” versus episodic cyanosis or pallor, as well as what types of respiratory or muscle tone symptoms were present.

The AAP also notes that while ALTE should not be used in describing a scenario, it will have to be on the books a while longer. Until BRUE-specific codes are available for billing and coding, AAP recommends physicians continue to apply the ALTE International Classification of Diseases, 9th Revision, and International Classification of Diseases, 10th revision, codes to patients determined to have experienced a BRUE.

Infants who experience a BRUE under the new guidelines will be categorized as either high or low risk based on a variety of factors. Infants with BRUE may be considered high risk if they are aged under 2 months, have a history of prematurity (particularly those born before 32 weeks gestation), or in cases of lengthier or multiple BRUE events.

Infants aged more than 2 months who were born at or after 32 weeks gestations are typically placed in the low risk categories. Low-risk infants will also not have had previous BRUE-or at least none occurring in clusters, a BRUE duration of less than one minute, no additional historical or physical examination findings such as abuse or trauma, and does not require cardiopulmonary resuscitation.

Tieder stresses that just because an infant is high risk in general, that does not necessarily mean they will be high risk when it comes to a BRUE.

“Research is needed to quantify this risk,” says Tieder. “It may be that most of these patients will not benefit from testing or observation.”

The categorization into high- and low-risk groups focuses less on the typical checklist of interventions, and more on what not to do, according to Tieder.

“The AAP is making recommendations against unnecessary tests and treatments for lower-risk infants,” Tieder says. “As much as this guideline aims to improve the health of infants by reducing their exposure to unnecessary tests and treatments, it will also improve the health of families by not subjecting them to additional fear and anxiety.”