Pediatrics [ALTE / BRUE AND SIDS]

ALTE – the OLD term ALTE definition

Apparent Life-Threatening Event. A concerned caregiver is Frightened observer plus any combination of…
alerted to a change in baby. That change could be related to color - Change in color: red, blue, or pale
(red, white, or blue), tone (jerking, flaccid), or breathing (too fast, - Change in muscle tone: hypertonic or hypotonic
too slow, stopping). This terminology led to significant - Change in respirations: Choking, gagging, or apnea
investigations where none were needed. Even the name ALTE
implies that “something should be done.” It turns out that the cause Features by Etiology
of the ALTE can often be identified based on the history alone with Seizures Eye deviation, limb-jerking
a little support by the physical exam. Most of the time, it’s Infection Temperature instability
idiopathic - no investigation is warranted. Fussy baby
Cardiac Difficulty with feeding
The most common causes were GERD, Seizures, and Lower Murmur
respiratory tract infections. Other causes included abuse, sepsis, and Failure to thrive
heart disease. When we used to teach ALTE, people “worked up” Abuse Evidence of trauma
all these things. And most of the time it was negative. We don’t use Femur, Skull fracture
ALTE anymore because we spent too much money and didn’t find
anything.

It’s still good to know these links from history, physical to disease,
because under the new BRUE, we investigate only what is clinically
reasoned to be present, not a shotgun approach to cover everything.

BRUE – the NEW term

The Brief Resolved Unexplained Event. The emphasis is now not BRUE definition
on the scare of being “potentially life threatening” (most ALTEs < 1 year old + < 1 min duration + …
were not), but rather on “can I explain the event?” and “do I need to - Change in color: red, blue, or pale
do anything about it?” The way this was achieved was to divide the - Change in muscle tone: hypertonic or hypotonic
event into a low-risk BRUE (do nothing) and a high-risk BRUE - Change in respirations: Choking, gagging, or apnea
(investigate further). The definition is similar to ALTE, but cleaner - Change in responsiveness
– < 1year old and <1 min duration with any change in color, tone,
breathing, or responsiveness. The concerned provider piece was BRUE
removed and replaced with an objective time frame, and a clear Low-Risk High-Risk
definition of what low-risk and high-risk are. Low-risk means do No History History suggestive of dz
nothing (reassurance). High-risk means do something (but that No Physical Physical suggestive of dz
something is not defined by the diagnosis of BRUE, only defined No CPR CPR performed
by what you, the doctor, have identified in the history and physical). 1st Time, non-recurring Multiple, Recurring
There isn’t a “BRUE workup” – there’s only the focused lab or Age, Term >60 days Not old enough
imaging assessment because the pediatrician is a good doctor, Age, >32 wk GA
knows the illness scripts for disease, and thinks there’s an actual Preterm And
diagnosis to explore. > 45 wk PC
Action Action
SIDS Reassurance only NO SET WORKUP
Sudden infant death syndrome is defined as death of an infant Go after workup based on
when we can’t find the reason on autopsy or during review of the history and physical
scene. \

THERE IS NO LINK BETWEEN ALTE/BRUE AND SIDS .

SIDS PREVENTION
SIDS is a diagnosis you make when baby is dead. That’s not good. Back to sleep Flatten occiput
So ALL of the emphasis is on SIDS prevention. Place the infant on Don’t share a bed
their back, on hard (not fluffy) cribs, don’t share a bed period Smoking cessation
(emphasis is with adults sleeping with baby in their bed, but twins
should be kept separately), and parent should stop smoking. You
DON’T do prophylactic assessments or interventions to reduce
SIDS. That means NO ecg, NO apnea monitors, NO pulse
oximetry, NO X-rays or CT scans. Just practice good prevention
techniques for SIDS.

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