Defining Risk Factors for Children Following a BRUE: The Need to Revisit the AAP BRUE Guideline

Pediatricians and emergency medicine physicians have long struggled with the evaluation and management of well-appearing infants presenting to the emergency department after what parents have described as a near-death experience. In 1986, the American Academy of Pediatrics (AAP) defined these events as apparent life-threatening events (ALTEs).¹  These were events that were characterized as frightening to the caregiver and involved some combination of apnea, choking, gagging, color changes, or changes in muscle tone. Over the years since then, many investigators have sought to identify the risk to infants who have experienced such an event. However, studies were often limited by the vagueness of the original definition, which included some aspect of a subjective understanding of the event by a parent or other caregiver. In 2016, the AAP published a new practice guideline that changed the name for these events from “ALTE” to “brief resolved unexplained event” (BRUE), sought to better define these events, and described low-risk criteria that could be used to safely discharge patients to home after an event.²  However, it remains unclear as to the overlap in patient populations between these two groups, BRUE and ALTE. This is especially important because much of the published literature pertains to patients who have experienced an ALTE and not a BRUE. To date, there are limited data specific to patients who have experienced a BRUE, and the management of patients who fit under the new guideline remains confusing. In addition, although the guideline provided some guidance in identifying infants at low risk for serious events after a BRUE, it provided little guidance in determining which patients might benefit from a more comprehensive evaluation or admission for observation.

In this issue of Pediatrics, Tieder et al³  conducted a retrospective cohort study of patients less than one year of age who had presented to 15 pediatric and community hospitals with a BRUE. In their study, Tieder et al sought to evaluate how well the recently published practice guideline accurately identified those infants at low risk and those at high risk for a serious adverse outcome after their BRUE. Tieder et al sought to better define risk criteria as well as characteristics of a BRUE that would identify those patients at higher risk for a serious adverse outcome after a BRUE. A better understanding of risk criteria would improve recommendations for practitioners with respect to determining appropriate diagnostic testing and need for hospitalization after an event.

Importantly, the author’s study identified a “serious underlying condition” in 4% of patients presenting after a BRUE, but, more importantly, only 13% of patients met criteria for low risk as identified by the AAP practice guideline.³  Thus, in using the AAP guideline, 87% of patients were classified as “higher risk,” although only 63% were hospitalized. The identification of any of the AAP guideline’s higher-risk factors had “an excellent negative predictive value (NPV) but a poor positive predictive value (PPV) for all outcomes.”³  Nearly 3% of patients had an event recurrence during their initial visit, 7% of patients had a return visit after discharge from the emergency department, and 11% had a return visit after hospital discharge. The results of this study suggest that, although the AAP criteria are helpful in identifying patients at low risk for serious adverse events after a BRUE, they unfortunately identify most patients as not low risk. Although the study provides important information for caregivers in managing patients after a BRUE, as well as guidance for parents, especially in regard to hospitalization after an event, it suggests that the AAP guidelines for BRUE would benefit from further revisions.

To that end, this study helps to better define high-risk criteria for patients after a BRUE. This is especially important to providers who care for these patients because the recently published AAP guideline helped to only identify those patients thought to be low risk. In fact, in this study, most patients did not meet low-risk criteria and few of the identified AAP risk factors were actually associated with adverse outcomes. In addition, because the AAP guideline reclassified and redefined ALTE as BRUE, previously published data pertaining to an ALTE cannot be extrapolated or used in the management of patients with a BRUE. Not all ALTEs are BRUEs, but all BRUEs are ALTEs. Although many providers are interested in understanding which patients are at low risk for an adverse event after a BRUE, it may be more important to have a better understanding of which patients are at higher risk. For example, it has long been known that a percentage of patients who present for evaluation after an ALTE are likely victims of child abuse, specifically abusive head trauma.^4–6  It is likely that child abuse accounts for a similar number of patients presenting after a BRUE. Identifying victims of child abuse is of paramount importance because the likelihood of escalation of injury with subsequent abuse is extremely high. Tieder et al identified 7 patients in their study as victims of abusive head trauma. Importantly, 6 of the 7 patients were not diagnosed during their first visit. Having a better understanding of the clinical factors that suggest a child is at high risk for an adverse outcome after a BRUE would greatly improve management and provide support for admission or discharge of these children from the emergency department.

This study helps to further define risk factors for children after a BRUE and will help better refine the AAP BRUE guideline. The AAP guideline was developed on the basis of published data pertaining to ALTEs, a somewhat nebulously defined diagnosis, and thus was limited in its recommendations. Importantly, the guideline was not able to help identify those patients at higher risk for an adverse outcome. Results of this study suggest that the AAP guideline should be enhanced and revised, and this study could be used to begin that process. Enhancing and refining the AAP guideline for BRUE will provide better guidance to pediatricians and emergency medicine physicians who manage children presenting after a BRUE.

AAP

American Academy of Pediatrics

ALTE

apparent life-threatening event

BRUE

brief resolved unexplained event