BRUE The New ALTE

24 day old boy, product of full term SVD uncomplicated pregnancy.

presented to the ER with history of 1 apnic episode.

The episodes were described by the mother to occur for 1 minute and stop spontaneously, some were associated with feeding.

Associated with cyanosis of the mouth and facial congestion

No up rolling of the eyes or abnormal repetitive movement of the limbs

No post episode sleeping or drowsiness

No hx of sweating during feeding and fatigue

No hx of fever

No change in urine color frequency ,or smell

No change in bowl habit

• Previous episode 2 days ago.

The Difference between ALTE and BRUE

How to Approach?

High Risk

Criteria of Low Risk

Why The change in Terminology?

History

Examination

• History of the event
• State immediately before the event
• State during the event
• End of the event
• State after event
• Present history
• Past medical history
• Family historyenvironmental history
• Social history
• Consider possible child abuse

• General appearance
• Growth variables
• Vital signs
• Skin
• HEENT
• Neck
• Chest
• heart
• Abdomen
• Genitalia
• Extremities
• Neurological

• infants < 2 months of age
• <32 weeks preterm
• event > minute
• >1 event in past 24hr or multiple BRUE
• Ill-appearing or abnormal vitals
• Abnormalities in past medical history
• Need for resuscitation
• Family history of SIDS

• Age > 60 days
• Prematurity: gestational age ≥32 weeks 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

• ALTE definition is difficult to apply to clinical care and research.
• Distinguish the evaluation and management of asymptomatic infants.
• A definition needs enough precision.
• Prevent the overuse of medical interventions
• Distinguish infants with lower risk.
• The use of ALTE as a diagnosis may reinforce the caregivers’ perceptions that the event was indeed “life-threatening”

Apparent Life-Threatening Event (ALTE)

“an episode that is frightening to the observer and that is characterized by some combination of apnea, color change, marked change in muscle tone, choking, or gagging.

In some cases, the observer fears that the infant has died.”

Differential Diagnosis

Brief Resolved Unexplained Event (BRUE)

• Dissemination and implementation efforts are needed to facilitate guideline use across pediatric medicine, family medicine, emergency medicine, research, and patient/family communities.
• The more-precise definition, the classification of lower- and higher-risk groups, the recommendations for the lower-risk group, and the implementation toolkit will serve as the basis for future research

BRUE The New ALTE

An event occurring in an infant <1 year of age

The observer reports a sudden, brief, and now resolved episode of ≥1 of the following:

• Cyanosis or pallor
• Absent, decreased, or irregular breathing
• Marked change in tone (hypertonia or hypotonia)
• Altered level of responsiveness

Thank you

Case 1

Mada Ali Sultan

65 days old girl, FT SVD uncomplicated pregnancy

Presented to the ER with history of 1 apnic episode

It was witnessed by the mother, less than 1 min and stop spontaneously, not related to feeding, No choking

No cyanosis, no abnormal breathing

No abnormal movement

No LOC

No fever

No change in urine color frequency ,or smell

No change in bowl habit

No previous episodes

Case 2

Supervised by:

How would you

approach

these cases?

Dr. Mesbah Alshumrani

Objectives:

• The new terminology.
• The replacement of the term apparent life threatening event (ALTE) with a new term, brief resolved unexplained event (BRUE).
• Why change in terminology?
• Difference between ALTE and BRUE.
• An approach to patient evaluation.
• Evidence-based management recommendations, or key action statements, for lower-risk patients.