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Hospital admission of infants with signs of physiologic compromise or high risk factors may be useful as further events may be identified through monitoring in the hospital. This is not necessary for a majority of infants with BRUE who have shown not concerns on history, physical and laboratory testing. A clinical decision rule found 3 variables (obvious need for admission, significant medical history,>1 apparent life-threatening event in 24 hours) that identified most but not all infants with apparent life-threatening events necessitating admission.
In addition home monitoring has not shown to benefit patients with benign H&Ps and initial workup.
If the history and physical do not suggest a probable etiology (idiopathic BRUE), then the description of the event and concerning risk factors should be considered in order to determine further investigation of the infant. A systemic review concluded that for well-appearing infants where the H&P did not suggest a specific diagnosis or that the event was life-threatening; routine laboratory testing OR testing for gastroesophageal reflux is unlikely to assist in diagnosis or management. However, if the event appeared to be life-threatening or the patient has high risk factors, further laboratory workup and admission may be beneficial.
H&P alone establishes a diagnosis in 21 percent of cases, with diagnosis confirmed in an additional 49 percent with testing. However, of all tests ordered only 18 percent were positive with 6 percent contributing to the diagnosis.
A detailed physical exam is necessary in all patients with BRUE. Special attention should be paid to: vital signs (especially oxygen saturation), subtle signs of trauma (bruising, lack of extremity use, bulging fontanel), growth (height, weight, head circumference), appropriate developmental status/reflexes for age, distress (respiratory difficulty/obstruction, sweating with feeds) or any signs of congenital abnormalities (dysmorphism, tone).
The patient's history is often the most helpful resource in identifying potential sources for an BRUE episode. In addition to the episode itself a complete past medical history, family history, and social/environmental history should be performed to identify high risk features and etiologies. Special emphasis should be placed on social concerns for abuse as these are often overlooked in the initial presentations of these infants. A detailed listing of all medications and other substances in the household should be reviewed for possible toxic or environmental exposures.
BRUEs are caused by a large, diffuse array of etiologies. Over 50 percent are identifiable for history and physical with confirmatory testing. However, the remaining 1/2 of cases may never have specific etiology identified. Common etiologies include:
Lower percentages (0.5 to 3 percent) of poisoning, anaphylaxis, serious bacterial infections, cardiac disease, upper airway obstruction, metabolic disorders and other rare disorders make up the additional etiologies.
In the past BRUE/ALTE was thought to be an "early-warning" sign for Sudden Infant Death Syndrome (SIDS). However, recent studies have shown no causal relationship between ALTE and SIDS. Although some patients with SIDS have had a prior ALTE (~5 percent), the vast majority have not. Furthermore, interventions that have markedly decreased the incidence of SIDS (prone sleeping) have not decreased the incidence of ALTE. The primary age of SIDS patients (2 - 4 months) is different than that of ALTE (< 2 months). Also, ALTE primarily occurs during daylight hours (8a - 8p) while SIDS occurs overnight (12a - 6a).
Put together, this evidence suggests that SIDS and BRUE are independent entities and the workup and management of BRUE should focus on the identification of a specific historical or physical exam finding associated with a known disease entity.
The historical term ALTE (now replaced with "BRUE") was defined by a consensus conference in 1986 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 of 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. Previously used terminology such as "aborted crib death" or "near-miss SIDS should be abandoned because it implies a possibly misleadingly close association between this type of spell and SIDS."
In the literature, ALTE has been defined in different manners giving an estimated to be 0.05 to 1 percent incidence. Most of these episodes occur before 2 months of age (especially before 10 weeks of age). Risk factors for having an ALTE are prior episodes, respiratory illness, young age, materal smoking, prematurity, post-mature infants and first-born infants.
BRUE was defined in the 2016 AAP clinical practice guideline as:
Clinicians should use the term BRUE to describe an event occurring in an infant <1 year of age when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following:
Moreover, clinicians should diagnose a BRUE only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination