Brief Resolved Unexplained Event (Apparent Life-Threatening Event)
Basics
Description
- Brief resolved unexplained event (BRUE) is a term suggested by the American Academy of Pediatrics (AAP) to replace the term apparent life-threatening event (ALTE).
- BRUE is a resolved episode in an infant <1 year of age that was sudden, brief, and characterized by any of the following:
- Absent, decreased, or irregular breathing
- Cyanosis or pallor
- Marked change in muscle tone (hyper- or hypotonia)
- Altered responsiveness
- ALTE was originally described in 1986.
- It disassociated apnea, color change, change in tone, choking or gagging with sudden infant death syndrome (SIDS), and triggered a research agenda for managing these patients.
- It was faulted for including diagnoses such as choking or gagging, including actively symptomatic patients, and labeling an event as “life-threatening” without clear justification.
- BRUE, by contrast, is used to describe a well-appearing patient with an event and symptoms that have resolved by the time of presentation to a medical practitioner.
- Identifies low risk for recurrence or a serious underlying disorder based on:
- Age >60 days
- Born ≥32 weeks’ gestation and have corrected age ≥45 weeks
- No CPR performed by trained medical provider
- Event lasting <1 minute
- First event
- Offers management recommendations for lower risk patients
- Identifies low risk for recurrence or a serious underlying disorder based on:
Epidemiology
- 43% of healthy term infants have at least one 20-second apneic episode over a 3-month period.
- 5.3% of parents recall seeing apnea.
- 0.2–0.9% of infants have an episode of apnea that results in an admission to the hospital.
Risk Factors
A greater risk for a future adverse event and/or serious underlying diagnosis is conferred by:
- Prematurity and <45 weeks postconceptual age
- Age ≤60 days
- Multiple events
- Events lasting >1 minute
- CPR by trained medical provider
- Suspected child maltreatment
Pathophysiology
No unifying pathophysiology because of the numerous potential presentations and underlying diagnoses
- Central apnea: disrupted propagation of respiratory signals from the brainstem along the descending neuromuscular pathways. Example diagnoses with similar presentations include:
- Apnea of prematurity
- Congenital central hypoventilation syndrome
- Obstructive apnea: neuromuscular respiratory effort disrupted by an occluded airway. Example diagnoses with similar presentations include:
- Obstructive sleep apnea
- Pierre Robin
- Mixed apnea: combination of central and obstructive apnea. Example diagnoses with similar presentations include:
- Laryngomalacia with a sedating ingestion
- Prematurity with superimposed upper respiratory viral infection
- Color change from decreased oxygenation or differential blood flow. Example diagnoses with similar presentations include:
- Cyanotic heart disease
- Acrocyanosis
- Altered muscle tone from central or autonomic nervous system disruption. Examples include:
- Seizure
- Breath-holding spell
- Altered responsiveness from effects on the cerebral hemispheres and/or reticular activating system. Example diagnoses with similar presentations include:
- Toxic ingestion
- Traumatic brain injury
Etiology
By definition, a BRUE is unexplained. ALTE could have had multiple different etiologies or be labeled as idiopathic.
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Citation
Cabana, Michael D., editor. "Brief Resolved Unexplained Event (Apparent Life-Threatening Event)." 5-Minute Pediatric Consult, 8th ed., Wolters Kluwer, 2019. Pediatrics Central, peds.unboundmedicine.com/pedscentral/view/5-Minute-Pediatric-Consult/618128/all/Brief_Resolved_Unexplained_Event__Apparent_Life_Threatening_Event_.
Brief Resolved Unexplained Event (Apparent Life-Threatening Event). In: Cabana MDM, ed. 5-Minute Pediatric Consult. Wolters Kluwer; 2019. https://peds.unboundmedicine.com/pedscentral/view/5-Minute-Pediatric-Consult/618128/all/Brief_Resolved_Unexplained_Event__Apparent_Life_Threatening_Event_. Accessed December 9, 2024.
Brief Resolved Unexplained Event (Apparent Life-Threatening Event). (2019). In Cabana, M. D. (Ed.), 5-Minute Pediatric Consult (8th ed.). Wolters Kluwer. https://peds.unboundmedicine.com/pedscentral/view/5-Minute-Pediatric-Consult/618128/all/Brief_Resolved_Unexplained_Event__Apparent_Life_Threatening_Event_
Brief Resolved Unexplained Event (Apparent Life-Threatening Event) [Internet]. In: Cabana MDM, editors. 5-Minute Pediatric Consult. Wolters Kluwer; 2019. [cited 2024 December 09]. Available from: https://peds.unboundmedicine.com/pedscentral/view/5-Minute-Pediatric-Consult/618128/all/Brief_Resolved_Unexplained_Event__Apparent_Life_Threatening_Event_.
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