BRUE and ALTE

A BRUE is a Brief Resolved Unexplained Event and has somehow replaced the old term of ALTE, allowing us to identify a lower risk group amongst children. It is a ‘consensus’ decision and although appears helpful may not be so.

CASE:
A 3 month old is brought in by his parents. He had an episode where his conscious level dropped, he seemed to stop breathing and was limp and blue. This lasted for approximately 20 seconds and scared the parents who were about to commence mouth to mouth resuscitation. He is now happy and looks fine. The vitals are normal and there is nothing else to find in the diagnosis.

Can this child go home? This presentation scares me, I must admit, however we now have some kind of recommendations that we can use.

The American Academy of Paediatrics has produced a guideline for the recognition and management of this ‘new’ condition.

DEFINITION OF BRUE

The episode must last for LESS than ONE MINUTE, in a LESS than ONE YEAR OLD and is associated with one or more of:

1. Cyanosis or pallor
2. Absent, decreased, or irregular breathing
3. Hypertonia or Hypotonia
4. Altered level of responsiveness

Further, the child should be back to normal baseline by presentation and
No condition can be found on history or examination, to explain the episode.

LOW RISK BRUE

The Lower risk group of those patients with BRUE have the following characteristics:

More than 60 days old
Born at >32 weeks and corrected age >45 weeks
First BRUE
No CPR required by a trained provider
No history that is concerning including, toxic exposures, history of sudden death in family etc
No examination findings of concern i.e. murmurs

The recommended approach to the lower risk group is:
Investigations
These should be limited to: Pertussis testing, 12-lead ECG.
Within the department pulse oximetry monitoring with serial observations should be carried out for a period of time.
There should be no other testing or monitoring and there should be no treatment for acid suppression epilepsy commenced.
Disposition
Shared decision-making with the family should be used to decide if the child is discharged.
Resources should be given to the caregiver for CPR training.(I’m not sure that I’ll be offering this to parents)