Journal Information
Vol. 93. Issue 4.
Pages 261-262 (01 October 2020)
Vol. 93. Issue 4.
Pages 261-262 (01 October 2020)
Scientific Letter
Open Access
Replacing “Apparent Life Threatening Event” (ALTE) with “Brief Resolved Unexplained Event” (BRUE). A retrospective review of the ALTEs that meet the criteria of a BRUE
Sustitución de ALTE por BRUE: revisión retrospectiva de los ALTE que cumplen criterios de BRUE
Tania Carbayo Jiméneza,
Corresponding author

Corresponding author.
, Pilar Cedena Romerob, Isabel Gimeno Sánchezb
a Servicio de Neonatología, Hospital Doce de Octubre, Madrid, Spain
b Unidad de Lactantes y Pediatría General, Servicio de Pediatría, Hospital Doce de Octubre, Madrid, Spain
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To the Editor:

In 2016, the American Academy of Pediatrics (AAP) published a guideline recommending replacing the term apparent life-threatening event (ALTE) with the term brief resolved unexplained event (BRUE) with the aim of identifying lower-risk patients (with a low probability of a repeat event or of severe underlying disease) that do not require hospital admission or further investigation.1

The authors of the guideline considered that a more specific term was necessary because ALTE is a concept that encompasses a broad range of disorders (from periodic breathing to sepsis), which can generate a feeling of uncertainty in the clinician and thus compel performance of unnecessary tests.2 The alternative term, BRUE, is intended to reflect the transient nature and lack of clear aetiology of such events and remove the “life-threatening” notion that is the source of such anxiety. The guideline proposed that the evaluation of each infant should be based on the level of risk of the event and established recommendations for the management of low-risk cases.3

Based on this change, we carried out a study with the aim of retrospectively reviewing the cases of patients admitted with a diagnosis of ALTE that met the criteria for BRUE.4 Then, we determined which cases in the group meeting the criteria for BRUE would qualify as higher or lower risk, which would allow us to determine the number of infants in who performance of tests and hospital admission may have been deemed unnecessary. Until May 2018, our hospital had a protocol for management of ALTE that called for admission of all patients with ALTE.5,6

Between January 2013 and December 2017, there were 194 patients with an admitting diagnosis code of ALTE. During this period, there was no diagnosis code for BRUE. We excluded 52 infants for who we did not find data allowing us to determine whether the event would qualify as a BRUE. The final sample included 142 patients, 68 female and 74 male, with a median age at admission of 37 days (range, 2–461 days), 95 of who were aged less than 2 months.

Of the 142 patients, 68 (48%) did not meet the criteria for BRUE because a cause for the event had been identified during the history-taking or physical examination (cold symptoms, fever, vomiting, abnormal breath sounds on auscultation), the event had not resolved at the time of arrival to the emergency department, or the patient was aged more than 1 year.

Of the 74 cases (52%) that met the criteria for BRUE, 69 (93%) qualified as higher-risk BRUE. The most frequent reasons for classification as higher-risk BRUE were age less than 2 months or corrected age less than 45 weeks (51 cases), repeat event (18 cases), event duration greater than 1 min (16 cases), concerning social assessment (5 cases) and family history of sudden death (4 cases). Several patients met more than one higher-risk criterion. None of the infants was classified as higher-risk based on need for cardiopulmonary resuscitation (CPR) by a trained medical provider.

Of the 5 infants that met the criteria for lower-risk BRUE, 3 underwent diagnostic tests (blood tests, cranial ultrasound, echocardiogram, electroencephalogram). All test results were normal, save for the incidental finding in the echocardiogram of a haemodynamically insignificant aorto-pulmonary collateral arteries and patent foramen ovale in 1 patient. In these infants, there were no abnormalities in the vital signs during the hospital stay, repeat episodes or diagnosis of severe underlying disease. The mean length of stay in these 5 patients was 1.8 days.

In the group of 69 patients that met the criteria for higher-risk BRUE, diagnostic tests were performed in 48% in the emergency department and in 74% during the hospital stay. Ten percent of these patients experienced a repeat event during the stay. Abnormal test results or relevant diagnoses from testing included diagnosis of convulsive seizures in 1 infant, 1 case of congenital hypothyroidism (the results of the newborn screening for metabolic diseases became available during the hospital stay), 1 case of respiratory infection by respiratory syncytial virus, 1 case of meningitis caused by enterovirus and detection of haemodynamically insignificant aorto-pulmonary collateral arteries in 1 infant. The mean length of stay in this group was 2.6 days.

Recent guidelines recommend educating parents on how to perform CPR. Such training was only delivered in 3 cases (2%): all 3 met the criteria for higher-risk BRUE, and 2 were managed with home cardiorespiratory monitoring.

There are limitations to our study, chief of which is its retrospective design.

Only half of the infants admitted due to ALTE met the criteria for BRUE. Most infants that experienced these events were aged less than 2 months, which made them qualify as higher risk on account of the age criterion. Only 7% of patients with BRUE met the criteria for lower risk BRUE, so testing and hospital admission could only have been avoided in this percentage of the total.

J.S. Tieder, J.L. Bonkowsky, R.A. Etzel, W.H. Franklin, D.A. Gremse, B. Herman, et al.
Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants.
D.A. Brand, R.L. Altman, K. Purtill, K.S. Edwards.
Yield of diagnostic testing in infants who have had an apparent life-threatening event.
Pediatrics, 115 (2005), pp. 885-893
E. Zwemer, I. Claudius, J. Tieder.
Update on the evaluation and management of brief resolved unexplained events (previously apparent life-threatening events).
Rev Recent Clin Trials, 12 (2017), pp. 233-239
M. Colombo, E.S. Katz, A. Bosco, M.L. Melzi, L. Nosetti.
Brief resolved unexplained events: Retrospective validation of diagnostic criteria and risk stratification.
Pediatr Pulmonol., 54 (2019), pp. 61-65
A. Jiménez Asin, J. Ruiz Contreras.
Episodio aparentemente letal.
Manual de Urgencias de Pediatría. Hospital Doce de Octubre, 1st ed., pp. 91-99
T. Carbayo Jiménez, P. Cedena Romero.
Eventos breves resueltos e inexplicados/episodio aparentemente letal (BRUE/ALTE).
2nd ed., Ergon, (2018), pp. 127-133

Please cite this article as: Carbayo Jiménez T, Romero PC, Sánchez IG. Sustitución de ALTE por BRUE: revisión retrospectiva de los ALTE que cumplen criterios de BRUE. An Pediatr (Barc). 2020;93:261–262.

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