Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary

This clinical practice guideline has 2 primary objectives. First, it recommends the replacement of the term “apparent life-threatening event” (ALTE) with a new term, “brief resolved unexplained event” (BRUE). Second, it provides an approach to evaluation and management that is based on the risk that the infant will have a repeat event or has a serious underlying disorder.

Clinicians should use the term BRUE to describe an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness. Moreover, clinicians should diagnose a BRUE only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination (see Tables 2 and 3 in www.pediatrics.org/cgi/doi/10.1542/peds.2016-0590). Among infants who present for medical attention after a BRUE, the guideline identifies (1) lower-risk patients on the basis of history and physical examination, for whom evidence-based guidelines for evaluation and management are offered, and (2) higher-risk patients, whose history and physical examination suggest the need for further investigation, monitoring, and/or treatment, but for whom recommendations are not offered (because of insufficient evidence or the availability of guidance from other clinical practice guidelines specific to their presentation or diagnosis). Recommendations in this guideline apply only to lower-risk patients, who are defined by (1) age >60 days; (2) gestational age ≥32 weeks and postconceptional age ≥45 weeks; (3) occurrence of only 1 BRUE (no prior BRUE ever and not occurring in clusters); (4) duration of BRUE <1 minute; (5) no cardiopulmonary resuscitation by trained medical provider required; (6) no concerning historical features; and (7) no concerning physical examination findings (Fig 1). This clinical practice guideline also provides implementation support and suggests directions for future research.

The term ALTE originated from a 1986 National Institutes of Health Consensus Conference on Infantile Apnea and was intended to replace the term “near-miss sudden infant death syndrome (SIDS).”¹ An ALTE was defined as “[a]n 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.”² Although the definition of ALTE enabled researchers to establish over time that these events were a separate entity from SIDS, the clinical application of this classification, which describes a constellation of observed, subjective, and nonspecific symptoms, has raised significant challenges for clinicians and parents in the evaluation and care of these infants.³ Although a broad range of disorders can present as an ALTE (eg, child abuse, congenital abnormalities, epilepsy, inborn errors of metabolism, and infections), for a majority of well-appearing infants, the risk of a recurrent event or a serious underlying disorder is extremely low.

ALTEs can create a feeling of uncertainty in both the caregiver and the clinician. Clinicians may feel compelled to perform tests and hospitalize the patient even though this may subject the patient to unnecessary risk and is unlikely to lead to a treatable diagnosis or prevent future events.^2,4,5 Understanding the risk of an adverse outcome for an infant who has experienced an ALTE has been difficult because of the nonspecific nature and variable application of the ALTE definition in research. A recent systematic review of nearly 1400 ALTE publications spanning 4 decades concluded that risk of a subsequent or underlying disorder could not be quantified because of the variability in case definitions across studies.³ Although there are history and physical examination factors that can determine lower or higher risk, it is clear that the term ALTE must be replaced to advance the quality of care and improve research.

This guideline is intended for use primarily by clinicians providing care for infants who have experienced a BRUE, as well as their families. The guideline may be of interest to payers, but it is not intended to be used for reimbursement or to determine insurance coverage. This guideline is not intended as the sole source of guidance in the evaluation and management of BRUEs and specifically does not address higher-risk BRUE patients. Rather, it is intended to assist clinicians by providing a framework for clinical decision making. It is not intended to replace clinical judgment, and these recommendations may not provide the only appropriate approach to the management of this problem.

This guideline is intended to provide a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, and improve patient outcomes. It includes recommendations for diagnosis, risk-based stratification, monitoring, disposition planning, effective communication with the patient and family, guideline implementation and evaluation, and future research. In addition, it aims to help clinicians determine the presence of a serious underlying cause and a safe disposition by alerting them to the most significant features of the clinical history and physical examination on which to base an approach for diagnostic testing and hospitalization. Key action statements are summarized in Table 1.

ALTE

apparent life-threatening event

BRUE

brief resolved unexplained event

SIDS

sudden infant death syndrome

Joel S. Tieder, MD, MPH, FAAP, Chair

Joshua L. Bonkowsky, MD, PhD, FAAP, Pediatric Neurologist

Ruth A. Etzel, MD, PhD, FAAP, Pediatric Epidemiologist

Wayne H. Franklin, MD, MPH, MMM, FAAP, Pediatric Cardiologist

David A. Gremse, MD, FAAP, Pediatric Gastroenterologist

Bruce Herman, MD, FAAP, Child Abuse and Neglect

Eliot Katz, MD, FAAP, Pediatric Pulmonologist

Leonard R. Krilov, MD, FAAP, Pediatric Infectious Diseases

J. Lawrence Merritt, II, MD, FAAP, Clinical Genetics and Biochemical Genetics

Chuck Norlin, MD, FAAP, Pediatrician

Robert E. Sapién, MD, MMM, FAAP, Pediatric Emergency Medicine

Richard Shiffman, MD, FAAP, Partnership for Policy Implementation Representative

Michael B.H. Smith, MB, FRCPCH, FAAP, Hospital Medicine

Jack Percelay, MD, MPH, FAAP, Liaison, Society for Hospital Medicine

Kymika Okechukwu, MPA