SGEM Xtra: Strange BRUE

Date: October 2nd, 2019   Reference: Ramgopal et al. Changes in the Management of Children With Brief Resolved Unexplained Events (BRUEs). Pediatrics 2019 Guest Skeptic: Dr. Katie Noorbakhsh is a pediatric emergency physician at the Children’s Hospital of Pittsburgh. This is an SGEM Xtra and it was inspired by the recent publication in Pediatrics on BRUEs. This will not be a traditional nerdy critical appraisal. We wanted to change things up a bit and just have a conversation about this topic. BRUE stand for a Brief Resolved Unexplained Event. It is a diagnosis of exclusion in an asymptomatic infant on presentation (no URI symptoms, no fever). The formal definition of a BRUE is: “A resolved event in an infant (less than one year) as described by an observer lasting less than one minute that includes one or more of the following: Color: Cyanosis or pallor Breathing: Absent, decreased or irregular Muscle Tone: Marked change (hyper or hypotonia) Level of Consciousness: Altered Here is another way to describe BRUEs. It is a diagnosis of exclusion that applies to infants under the age of 12 months. Most of the definition is in the name itself. It is Brief– it lasts less than 60 seconds It is Resolved– the infant is well appearing by the time we evaluate them It is Unexplained– If you think this episode can be explained as a seizure or a choking episode or gastroesophageal reflux, it is not a BRUE The Event includes one or more of the following four things: Change in Color– Specifically cyanosis or pallor Change in Breathing– Breathing is absent, decreased or irregular Change in Tone– Hyper or hypotonia or a Change in Level of Consciousness(LOC) It was previously called an ALTE (Apparent Life-Threatening Event) ALTE was defined in 1986 as “a frightening episode to the caregiver with apnea, choking, gagging, or changes in color, or muscle tone.” (McGovern and Smith). The diagnosis could have caused a great deal of anxiety in parents/caregivers. The name was not reassuring and the definition was vague. The Journal of Pediatrics published a systematic review of literature regarding the Management of ALTE in 2013 and one of the findings was that there was very little agreement in the literature on how to apply the definition. If even the folks who are really expert in the topic are not applying the definition consistently, then perhaps it’s time for a new definition. The change in name took place in 2016. The subcommittee on ALTEs in the AAP published a practice guideline renaming ALTEs to brief resolved unexplained events (BRUEs) in 2016. The New description broke things down into HIGH risk criteria and LOW risk criteria. High Risk Criteria: Prematurity (Gestational age less than 32 weeks and less than 45 weeks post conception) Age less than 60 days (two months) More than one event Low Risk Criteria:  Gestational age at least 32 weeks and post conception age at least 45 weeks Age greater than 60 days (two months) First BRUE Duration of event less than one minute No CPR by trained medical provider *No concerning historical features or physical findings There is an list of concerning historical features or physical findings at the end of this blog. Risk stratifying BRUE patients help direct management. High risk patients require a full evaluation and consideration for admission or observation should be considered. Low risk patients are broken up into four categories: Should do, should not do, may do and need not do. Should: Educate care givers about BRUE, shared decision making to guide management, recommend CPR training, and assess social risk factors to detect child abuse Should Not: CBC, blood cultures, CSF, electrolytes, VBGs or ABGs, ECHO, errors of metabolism, CXR, EEG, GERD study, neuroimaging, home monitoring, overnight sleep study, acid suppression or antiepileptic medication May Do: Pertussis testing,