Sometimes babies briefly stop breathing. Sometimes they can turn shades of blue. Sometimes, these things are not serious. The American Academy of Pediatrics (AAP) is recommending a new, less threatening label for such events, in hopes of reducing unnecessary treatment and stress.
Under the new guidelines, clinicians are advised to replace the term “apparent life-threatening event” (ALTE) with “brief resolved unexplained event” (BRUE) to better reflect the transient nature and lack of clear cause in these instances, says Joel Tieder, MD, MPH, a pediatric hospitalist at Seattle Children's Hospital in Washington and chair of the committee AAP’s Subcommittee on Apparent Life Threatening Events.
“Kids aren’t born with a manual. Sometimes infants do things that are normal for a baby, but parents don’t know about them (such as breath holding spells, periodic breathing of the newborn, and acrocyanosis),” says Tieder. “A lot of things that were once called an ALTE fall into this category. However, the BRUE definition is a diagnosis of exclusion to be applied after an evaluation by a pediatric provider. The guideline will help physicians manage patients who have events that cannot be explained.”
Apparent life-threatening events were first identified in the 1980s as a way to identify events that physicians thought may serve as a precursor to sudden infant death syndrome (SIDS). However Tieder says these events are not precursors to SIDS, and that ALTE was a poorly defined phrase that in many cases led to unnecessary hospitalization and testing that yielded no information other than confirmation of a healthy child.
Apparent life-threatening event was loosely defined 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 or 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,” according to AAP. It was also often diagnosed based merely on parental reports, and a BRUE diagnoses will require a physical examination and medical history. The AAP is also working on an implementation tool kit including an algorithm, quality measures, a caregiver handout, and a key driver diagram.
While a broad range of disorders may fall under this spectrum, AAP notes that a majority of infants who have such an event and appear well afterwards generally have “extremely low” risk of having a serious underlying disorder.
A BRUE, on the other hand, is an event during which a child aged less than 1 year has a sudden, brief, resolved episode of 1 of the following: cyanosis or pallor; absent, decreased, or irregular breathing; a marked change in tone (hypertonia or hypotonia); or an altered level of responsiveness.