Maryam Razavi

maryam.razavi@cambio.se

@CambioCDS

To stratify patients who present with a BRUE into low and higher-risk categories and evaluation and management of patient categorized as lower risk.

Use in Infants <1 year old presenting for evaluation after a brief, unexplained, and now resolved event consisting of ≥1 of the following: - Cyanosis or pallor. - Absent, decreased, or irregular breathing. - Marked change in tone. - Altered level of responsiveness. Can be used in inpatient, outpatient, and emergency department settings. Note that choking, gagging, and red color change, which were part of the ALTE definition, are not part of the BRUE Criteria. Formula: To be classified as a BRUE, all of the following must be true: - Infant <1 year old. - Asymptomatic on presentation (no URI symptoms, no fever). - No explanation for the event after conducting history and physical (e.g. GER, feeding difficulties). - History of sudden, brief, and now resolved episode consisting of ≥1 of the following: -- Cyanosis or pallor. -- Absent, decreased, or irregular breathing. -- Marked change in tone (hyper or hypotonia). -- Altered level of responsiveness. Then, for a BRUE to be classified as low risk, all of the following must also be true: - Episode duration <1 minute. - >2 months of age. - No history of prematurity.* - No prior BRUE. - No need for CPR by medical provider. *≥32 weeks gestational age or ≥45 weeks postconceptional age for infants born at <32 weeks. Recommendations and Level of evidence and Recommendation: - Recommendation Should Do: Assess social risk factors to detect child abuse (L=C- S= M). Offer CPR training resources (L= C- S=M). Educate about BRUEs (L=C- S=M). Use shared decision-making (L=C- S=M). - Recommendation Should NOT Do: Chest x-ray(L=B- S=M). BG or ABG (L=B- S=M). Overnight sleep study (L=B- S=M). Echo (L=C- S=M). Home cardiorespiratory monitoring (L=B- S=M). Neuroimaging (CT- MRI- or ultrasonography) to detect neurologic disorders (L=C- S=M). EEG to detect neurologic disorders (L=C- S=M). Antiepileptic medication (L=C-S=M). WBC count, blood culture or CSF analysis or culture to detect occult bacterial infection (L=B-S=S). - Recommendation May Do: Briefly monitor with pulse oximetry and serial observation (L=D -S= W). 12-lead EKG (L=C- S= W). Pertussis testing (L=B- S=W). - Recommendation Not Needed: Admission solely for cardiorespiratory monitoring (L=B- S=W). Neuroimaging (CT MRI or ultrasonography) to detect child abuse (L=C - S=W). Urinalysis (bag or catheter) (L=C - S=W). Respiratory viral testing (L=C-S=W). Serum lactic acid or bicarbonate (L=C-S=W). Blood glucose (L=C- S=M). Abbreviation Description: Level A: Intervention: well-designed and well-conducted trials, meta-analyses.Diagnosis: Independent gold standard studies. Level B: Trials or diagnostic studies with minor limitations.Consistent findings from multiple observational studies. Level C: Single or few observational studies, or multiple studies with inconsistent findings or major limitations. Level D: Expert opinion.Case reports. Reasoning from first principles. M: Moderate S: Strong W: Weak

Not use in infants >=1 year old, symptomatic patients (e.g. fever, respiratory distress) or those with obvious cause for prior symptoms.

1. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. 2016;137(5) 2.Zwemer E, Claudius I, Tieder J. Update on the Evaluation and Management of Brief Resolved Unexplained Events (Previously Apparent Life-Threatening Events). Rev Recent Clin Trials. 2017;12. doi:10.2174/1574887112666170816150104. 3. Claudius I, Keens T. Do all infants with apparent life-threatening events need to be admitted?. Pediatrics. 2007;119(4):679-83. 4. Al-kindy HA, Gélinas JF, Hatzakis G, Côté A. Risk factors for extreme events in infants hospitalized for apparent life-threatening events. J Pediatr. 2009;154(3):332-7, 337.e1-2. 5. Mittal MK, Sun G, Baren JM. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care. 2012;28(7):599-605. 6. Kaji AH, Santillanes G, Claudius I, et al. Do infants less than 12 months of age with an apparent life-threatening event need transport to a pediatric critical care center?. Prehosp Emerg Care. 2013;17(3):304-11. 7. Tieder JS, Altman RL, Bonkowskya JL, et al. Management of apparent life-threatening events in infants: a systematic review. J Pediatr. 2013;163(1):94-9.e1-6.

OBSERVATION.brief_resolved_unexplained_events_brue_criteria_for_infants.v0