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PA Boards 84: New Updated AAP Guideline – BRUE

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BRUE stands for brief resolved unexplained events – this new terminology will replace the old term ALTE (apparent life-threatening events). This is the first clinical practice guideline from the American Academy of Pediatrics that specifically applies to patients who have experienced an apparent life-threatening event (ALTE).

The AAP defines BRUE as an event occurring in an infant younger than 1 year when the observer (usually the parent) reports a sudden, brief, and now resolved episode of ≥1 of the following:

1. cyanosis or pallor (not just color change – rubor/redness is normal)
2. absent, decreased, or irregular breathing (not just apnea anymore)
3. marked change in tone (hyper- or hypotonia)
4. altered level of responsiveness (new criteria)

There cannot be any explanation for the event after a history and physical has been performed. The patient is then categorized as being low risk or high risk. It’s important to note that this new diagnosis is based on how the clinician categorizes the event – no the caregivers perception of it being life threatening.

The problem with ALTE was that these events are rarely a manifestation of a more serious illness. But, the fear that something more serious might occur leads to excessive testing and/or admission to the hospital for observation.

This increases anxiety in the parents, costs money, and places the child at risk – all the while never reaching a treatable diagnosis.

This new term aims at removing the “life threatening” label.

The guidelines states that fever and respiratory symptoms in the child would prevent the diagnosis of BRUE from occurring. Also, choking or gagging associated with spitting up is not included in the BRUE definition, because clinicians will want to pursue the cause of vomiting, which may be related to GER, infection, or central nervous system (CNS) disease.

Historical Features To Be Considered in the Evaluation of a Potential BRUE

Considerations for possible child abuse:

 Multiple or changing versions of the history/circumstances

 History/circumstances inconsistent with child’s developmental stage

 History of unexplained bruising

 Incongruence between caregiver expectations and child’s developmental stage, including assigning negative attributes to the child

History of the event

 General description

 Who reported the event?

 Witness of the event? Parent(s), other children, other adults? Reliability of historian(s)?

 State immediately before the event

  Where did it occur (home/elsewhere, room, crib/floor, etc)?

  Awake or asleep?

  Position: supine, prone, upright, sitting, moving?

  Feeding? Anything in the mouth? Availability of item to choke on? Vomiting or spitting       up?

  Objects nearby that could smother or choke?

 State during the event

  Choking or gagging noise?

  Active/moving or quiet/flaccid?

  Conscious? Able to see you or respond to voice?

  Muscle tone increased or decreased?

  Repetitive movements?

  Appeared distressed or alarmed?

  Breathing: yes/no, struggling to breathe?

  Skin color: normal, pale, red, or blue?

  Bleeding from nose or mouth?

  Color of lips: normal, pale, or blue?

 End of event

  Approximate duration of the event?

  How did it stop: with no intervention, picking up, positioning, rubbing or clapping back, mouth-to-mouth, chest compressions, etc?

  End abruptly or gradually?

  Treatment provided by parent/caregiver (eg, glucose-containing drink or food)?

  911 called by caregiver?

 State after event

  Back to normal immediately/gradually/still not there?

  Before back to normal, was quiet, dazed, fussy, irritable, crying?

Recent history

 Illness in preceding day(s)?

  If yes, detail signs/symptoms (fussiness, decreased activity, fever, congestion, rhinorrhea, cough, vomiting, diarrhea, decreased intake, poor sleep)

 Injuries, falls, previous unexplained bruising?

Past medical history

 Pre-/perinatal history

 Gestational age

 Newborn screen normal (for IEMs, congenital heart disease)?

 Previous episodes/BRUE?

 Reflux? If yes, obtain details, including management

 Breathing problems? Noisy ever? Snoring?

 Growth patterns normal?

 Development normal? Assess a few major milestones across categories, any concerns about development or behavior?

 Illnesses, injuries, emergencies?

 Previous hospitalization, surgery?

 Recent immunization?

 Use of over-the-counter medications?

Family history

 Sudden unexplained death (including unexplained car accident or drowning) in first- or second-degree family members before age 35, and particularly as an infant?

 Apparent life-threatening event in sibling?

 Long QT syndrome?

 Arrhythmia?

 Inborn error of metabolism or genetic disease?

 Developmental delay?

Environmental history

 Housing: general, water damage, or mold problems?

 Exposure to tobacco smoke, toxic substances, drugs?

Social history

 Family structure, individuals living in home?

 Housing: general, mold?

 Recent changes, stressors, or strife?

 Exposure to smoke, toxic substances, drugs?

 Recent exposure to infectious illness, particularly upper respiratory illness, paroxysmal cough, pertussis?

 Support system(s)/access to needed resources?

 Current level of concern/anxiety; how family manages adverse situations?

 Potential impact of event/admission on work/family?

 Previous child protective services or law enforcement involvement (eg, domestic violence, animal abuse), alerts/reports for this child or others in the family (when available)?

 Exposure of child to adults with history of mental illness or substance abuse?

Physical Examination Features To Be Considered in the Evaluation of a Potential BRUE

General appearance

 Craniofacial abnormalities (mandible, maxilla, nasal)

 Age-appropriate responsiveness to environment

Growth variables

 Length, weight, occipitofrontal circumference

Vital signs

 Temperature, pulse, respiratory rate, blood pressure, oxygen saturation

Skin

 Color, perfusion, evidence of injury (eg, bruising or erythema)

Head

 Shape, fontanelles, bruising or other injury

Eyes

 General, extraocular movement, pupillary response

 Conjunctival hemorrhage

 Retinal examination, if indicated by other findings

Ears

 Tympanic membranes

Nose and mouth

 Congestion/coryza

 Blood in nares or oropharynx

 Evidence of trauma or obstruction

 Torn frenulum

Neck

 Mobility

Chest

 Auscultation, palpation for rib tenderness, crepitus, irregularities

Heart

 Rhythm, rate, auscultation

Abdomen

 Organomegaly, masses, distention

 Tenderness

Genitalia

 Any abnormalities

Extremities

 Muscle tone, injuries, limb deformities consistent with fracture

Neurologic

 Alertness, responsiveness

 Response to sound and visual stimuli

 General tone

 Pupillary constriction in response to light

 Presence of symmetrical reflexes

 Symmetry of movement/tone/strength

These guidelines are for the management of the low risk patient. Low risk meaning the patient is unlikely to have a recognizable disease. The management of high risk patients isn’t clear. The following characteristics are evidence of a high risk patient:

1. infants <2 months of age
2. those with a history of prematurity
3. those with more than 1 event

Also, possible child abuse may be considered when the event history is reported inconsistently or is incompatible with the child’s developmental age, or when, on physical examination, there is unexplained bruising or a torn labial or lingual frenulum.

A cardiac arrhythmia may be considered if there is a family history of sudden, unexplained death in first-degree relatives

Infection may be considered if there is fever or persistent respiratory symptoms.

To be classified as low risk the following must be present:

Age >60 days
Born ≥32 weeks gestation and postconceptional age ≥45 weeks
First BRUE (no previous BRUE ever and not occurring in clusters)
Duration of event <1 minute
No CPR required by trained medical provider
No concerning historical features
No concerning physical examination findings
Those deemed to be low risk do not need any imaging or laboratory testing.

You can find the full updated guideline here:
http://pediatrics.aappublications.org/content/early/2016/04/21/peds.2016-0590

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