Apparent Life-threatening Events Research Articles

Clinical Characteristics and Outcomes of Patients Admitted with Brief Resolved Unexplained Events to a Tertiary Care Pediatric Intensive Care Unit.

The aim of this study was to determine outcomes of patients admitted to a tertiary care pediatric intensive care unit (PICU) with brief, resolved, unexplained event (BRUE), and to review the diagnostic and treatment options utilized for such patients. A retrospective data analysis was conducted for infants and children who were admitted to the PICU at a tertiary hospital with a diagnosis of BRUE over a period of three years (2015-2017). The study included 30 infants, 15 males, and 15 females. All patients survived to hospital discharge. The most frequent presenting symptoms and signs were apnea (73.3%), cyanosis (60.0%), and cough (20.0%). The most frequent reported affected systems were respiratory (33.3%), gastrointestinal (20%), and infection-related illness (20.0%). We conclude that the careful history taking, complete physical examination, and the appropriate workup for patients with BRUE play an integral role in optimum health service and utilization of critical care beds. Survival to hospital discharge with no serious in-hospital events warrants the adaptation of evidence-based medicine guidelines to stratify such patients based on the risk of recurrence or a serious underlying condition. Prospective multicenter studies are recommended to explore the effectiveness of such guidelines implementation on outcomes and diagnostic testing in such patients to optimize the utilization of the limited critical care beds.

Is there a common denominator for Brief Resolved Unexplained Events, Sudden Infant Death Syndrome, and alleged Shaken Baby Syndrome?

We propose the medical hypothesis that a common denominator may be the precursor for Brief Resolved Unexplained Events (BRUE), cases of Sudden Infant Death Syndrome (SIDS) as well as to cases of alleged Shaken Baby Syndrome (SBS) without external signs of trauma. Although previous studies have emphasized differences, we have focused on the overarching common denominators of the three conditions in terms of mechanism theories.In consequence, fatal cases with subdural hemorrhage (SDH) classified as SBS could be classified as high risk BRUE with SDH. Fatal cases without SDH could be classified as SIDS. Non-fatal cases with SDH and retinal hemorrhages (RHs), currently classified as SBS, could be classified as BRUE with SDH and RHs, leaving a fourth group of BRUE without SDH and RHs.While both the BRUE and the SIDS diagnoses have been refined and developed, alleged abusive head trauma (AHT) cases with and without external signs of trauma have been indiscriminately combined. This is analogous to indiscriminately grouping together, e.g., headache due to a brain tumor or headache after head trauma. Alleged AHT cases with external signs of trauma and high velocity impact might be explained by the traditional AHT mechanism theories, whereas the one-third of all alleged AHT cases without external signs of trauma could be explained by the hypoxia cascade theory and/or other non-shaking theories.

Guidance to reduce the risk of Sudden and Unexpected Postnatal Collapse

Early skin-to-skin contact (SSC) between mothers and healthy term newborns is a key part of the Unicef Baby Friendly Initiative Standards. SSC immediately after birth provides cardiorespiratory stability, improves prevalence and duration of breastfeeding, improves maternalinfant bonding and decreases maternal stress. There is a concern about cases of sudden unexpected postnatal collapse during a period of SSC with the infant prone on the mother´s chest. Said collapse includes both severe apparent lifethreatening event and sudden unexpected early neonatal death in the first week of life. Even if considered rare, consequences are serious with death in half of the cases and remaining disability in majority of the cases reported. For these reasons during SSC and for at least the first 2 hours after delivery, health care personnel in the delivery and recovery room should observe and assess for any sign of decompensation in the infant.

Brief Resolved Unexplained Event: Not Just a New Name for Apparent Life-Threatening Event.

This study aimed to evaluate patients who presented to the pediatric emergency department with an apparent life-threatening event (ALTE) to (1) determine if these patients would meet the criteria for brief resolved unexplained event (BRUE), a new term coined by the American Academy of Pediatrics in May, 2016; (2) risk stratify these patients to determine if they meet the BRUE low-risk criteria; and (3) evaluate outcomes of patients meeting the criteria for BRUE. We conducted a retrospective chart review of patients who presented to a large urban academic center pediatric emergency department with an ALTE from January 2013 to May 2015 (before the publication of the BRUE guideline). Children ≤12 months of age were identified by the International Classification of Diseases, Ninth/Tenth Revision. Two physician reviews were performed to determine if patients met the ALTE diagnostic criteria. Data were then extracted from these charts to complete objectives. Seventy-eight patients met the diagnostic criteria for ALTE. Only 1 of those patients met the diagnostic criteria for BRUE, but not for low-risk BRUE. This patient underwent an extensive inpatient evaluation and was eventually discharged after monitoring with a benign diagnosis. Most patients did not meet the criteria for BRUE because the event was not unexplained. Only 1 patient who presented to the ED with ALTE met the criteria for BRUE, and this patient did not meet the low-risk criteria. This study corroborates previous research on BRUE and continues to highlight the importance of conducting a thorough history and physical examination on all patients presenting to the ED with concerning events.

Application of the BRUE Definition and Risk Stratification on an ALTE Population: a European Essay

Recent adapted guidelines on the approach of apparent life-threatening events (ALTE) propose a new definition of the phenomenon: brief resolved unexplained events (BRUE) and a risk stratification aimed at reducing unnecessary and expensive medical procedures. We applied the BRUE directives to a series of ALTE patients which required the intervention of the emergency medical service (ES) and/or the emergency department (ED) and were addressed to the Reference Center for Paediatric Sleep Medicine and Sudden Infant Death Syndrome in the Piedmont region between 2009 and 2015 to identify the number of BRUE cases and to classify them as lower or higher risk. We performed a retrospective file review. ALTE patients < 1 year admitted to a ES or ED were considered eligible; the American Academy of Pediatrics (AAP) Guidelines were used to identify BRUEs and to stratify them in lower and higher risk categories. A total of 790 ALTEs were eligible, 164/790 met the BRUE criteria; 62/164 were considered lower risk BRUE, according to their demographic features. Only few ALTEs matched the BRUE criteria in our study population (about 1/5). It was observed that demographic characteristics strongly influenced stratification to lower risk BRUE (8% of the initial sample group). Our data confirm that the AAP guidelines can be useful in the management of BRUE, but especially in the hands of well-trained and experienced physicians in this field.

Brief resolved unexpected event: prevalence, etiology and epidemiologic characteristics in Lebanon. a retrospective study of hospitalizations in a tertiary-care center

Objective: A Brief Resolved Unexplained Event (BRUE) is a common condition in infancy. However, no epidemiological study has been undergone in Lebanon. This study aims to establish the prevalence and the characteristics of the population hospitalized after a BRUE. Material and methods: A single-center retrospective study performed from 1998 to 2018 included 156 hospitalized infants, aged less than one year old, in a tertiary medical center. Data were collected from hospital archives. Results: Most infants (92.9%) hospitalized after a BRUE were aged less than 6 months old, with a slight masculine predominance (52.6%). No pathognomonic symptom was identified. In terms of recurrence of the initial episode, it occurred in 55.1% of the cases. A transfer to a reanimation unit took place in 35.9% of patients, with an average stay of 6.3 days. Two infants were deceased and six were readmitted for the same chief complaint. Final confirmed diagnosis was a Gastro-Esophageal Reflux (GER) in 60.9%. Consequently, a milk change occurred in 17.9% and a GER treatment in 65.4%. Conclusion: Infants younger than one year and hospitalized for a BRUE present a majority of confirmed GER diagnosis, and seem to have an excellent prognosis.

Outcome Prediction of Higher-Risk Brief Resolved Unexplained Events.

Brief resolved unexplained events (BRUEs) are classified as higher risk on the basis of patient and event characteristics, but there is limited evidence to guide management decisions. The authors of this study aim to describe patients with a higher-risk BRUE, determine the yield of diagnostic evaluation, and explore predictors of clinical outcomes. A retrospective medical record review was conducted for patients ≤365 days of age who were evaluated in a tertiary-care pediatric emergency department with a discharge diagnostic code indicative of a BRUE. Demographic and clinical characteristics, including diagnostic evaluation, are reported. Univariate and multivariate analyses were used to test the association of risk factors with clinical outcomes (serious underlying diagnosis, recurrent events, and return hospitalization). Of 3325 patients, 98 (3%) met BRUE criteria and 88 were classified as higher risk; 0.6% of laboratory and 1.5% of ancillary tests were diagnostic, with 4 patients having a serious underlying diagnosis. Nine patients had recurrent events during hospitalization, and 2 were readmitted for a recurrent BRUE after their index visit. Prematurity was the only characteristic significantly associated with an outcome, increasing the odds of a recurrent event (odds ratio = 9.4; P = .02). The majority of patients with a BRUE are higher risk, but the yield of diagnostic evaluation is low. Published risk criteria do not appear to be associated with adverse clinical outcomes except for prematurity and recurrent events. Future multicentered prospective studies are needed to validate risk stratification and develop management guidance for the higher-risk BRUE population.

Sodium channel myotonia may be associated with high-risk brief resolved unexplained events

Brief resolved unexplained events (BRUEs) have numerous and varied causes posing a challenge to investigation and management. A subset of infants with the neuromuscular disorder sodium channel myotonia, due to mutations in the SCN4A gene, experience apnoeic events due to laryngospasm (myotonia) of the upper airway muscles that may present as a BRUE. We sought to ascertain the frequency, severity and outcome of infants carrying the G1306E SCN4A mutation commonly associated with this presentation. We report 14 new cases of individuals with the G1306E mutation from three unrelated families and perform a literature review of all published cases. Infants with the G1306E mutation almost universally experience laryngospasm and apnoeic events. The severity varies significantly, spans both low and high-risk BRUE categories or can be more severe than criteria for a BRUE would allow. At least a third of cases require intensive care unit (ICU) care. Seizure disorder is a common erroneous diagnosis. Apnoeas are effectively reduced or abolished by appropriate treatment with anti-myotonic agents. Probands with the G1306E mutation who are family planning need to be counselled for the likelihood of post-natal complications. There is readily available and extremely effective treatment for the episodic laryngospasm and apnoea caused by this mutation. Proactively seeking clinical evidence of myotonia or muscle hypertrophy with consideration of CK,EMG and genetic testing in high risk BRUEs or more complex apnoeic events may reduce avoidable and prolonged ICU admissions, patient morbidity and potentially mortality.

Impact of Guidelines Regarding Brief Resolved Unexplained Events on Care of Patients in a Pediatric Emergency Department.

This study aimed to determine if the 2016 clinical practice guidelines regarding brief resolved unexplained events (BRUE) impacted our institutional approach to infants with BRUE. We sought to determine the statement's impact on admission rates, emergency department (ED) length of stay, and return ED visits or readmissions. We conducted a retrospective chart review of patients who presented to the ED at a tertiary pediatric hospital from January 2014 to June 2019. Diagnostic workup (laboratory testing, imaging, monitoring) in the ED was recorded. Cohorts of patients presenting pre- and post-2016 guideline were compared using χ2 and t tests. Subanalysis of higher-risk and lower-risk infant groups was also performed. The demographics of the 2 cohorts were not significantly different. Comparison showed significant reductions in invasive testing after the guideline, both overall (P = 0.005), and specifically regarding comprehensive metabolic panel, blood culture, urine culture, and chest x-ray. Infants meeting higher-risk criteria also showed decreases in invasive testing (P = 0.02). Admission to the hospital and ED lengths of stay decreased in the post-American Academy of Pediatrics statement cohort (P < 0.001 and P = 0.007, respectively). There were no increases in readmissions or repeat ED visits. This study revealed significant reduction in invasive testing, shorter lengths of ED stays, and lower admission rates at a tertiary care children's hospital after the release of the American Academy of Pediatrics BRUE guideline with no increase in return ED visits or readmissions.

Laparoscopic Fundoplication for the Surgical Management of Gastroesophageal Reflux Disease in Children.

Gastroesophageal reflux (GER) is common in infants generally resolving in early childhood. However, gastroesophageal reflux disease (GERD) is diagnosed when persistent troublesome symptoms and/or complications of GER develop. These symptoms and complications can significantly affect the quality of life, thus requiring medical or surgical treatment. Medical management is typically trialed, but operative treatment is indicated with severe symptoms such as aspiration pneumonia, apneic episodes, bradycardia, apparent life-threatening events, severe vomiting, failure to thrive, esophagitis, stricture, and failed medical therapy. We review the recent literature on the indications and outcomes for laparoscopic fundoplication in the management of pediatric GERD.

Thoracoscopic aortopexy for symptomatic tracheobronchomalacia

AimSymptomatic tracheobronchomalacia can be fatal. Successful treatment includes aortopexy. We report outcomes of the thoracoscopic approach in a single centre. MethodsAll patients undergoing thoracoscopic aortopexies from 2009 to 2018 were retrospectively reviewed. Data was reported as median (interquartile range). Risk factors for subsequent tracheostomy were analyzed with logistics regression model, p < 0.05 as significant. ResultsTwenty-one patients with mid to distal tracheomalacia (n = 17) and bronchial involvement (n = 4) were determined on bronchoscopy, tracheobronchogram, or CT thorax. Preoperative patient demographics and comorbidities, e.g., gastro-oesophageal reflux disease, prematurity, and cardiac anomalies were recorded. Indications for thoracoscopic aortopexy were apparent life-threatening event(s) (n = 14), recurrent chest infections (n = 5), and failure to wean invasive ventilation (n = 2). Thoracoscopic aortopexies (n = 20) with conversion to open (n = 1) were performed. Intraoperative bleeding (n = 2) occurred, and chest tube (n = 1) was inserted for monitoring. Intraoperative bronchoscopy (n = 17) confirmed improvement of tracheomalacia. Anesthetic time was 140 (90–160) minutes. Postoperatively, 2 patients had dehiscence of the aorta from the sternum. They underwent redo open aortopexy with posterior tracheopexy, and 1 required subsequent tracheostomy. Another 2 patients required tracheostomies. Potential risk factors for subsequent tracheostomy were investigated, and only the association of tracheobronchomalacia was close to significance (OR 16 (95% CI 0.95–267.03), p = 0.05). Follow up duration was 365 (72–854) days. Symptoms resolution occurred in n = 17 (81%) of patients. ConclusionDifferent modalities were used to delineate the site of tracheobronchomalacia and its etiology. Tracheomalacia with bronchial involvement may be a risk factor for subsequent tracheostomy. Level of EvidenceLevel 3 (Case Series).

Long-Term Follow-Up of Infants After a Brief Resolved Unexplained Event-Related Hospitalization.

A brief resolved unexplained event (BRUE) in infancy is a common reason for visiting the emergency department. However, little is known about the long-term outcomes of such an event. This study evaluates future mortality, morbidity, and/or developmental outcome after a BRUE. A single-center retrospective study performed in 2009 to 2013 included 87 hospitalized infants (<1 year old) fitting the American Academy of Pediatrics' criteria of a lower-risk BRUE, with 2 exceptions: no time limit to duration of episode and no age limit of ≥60 days. Hospitalized infants were followed up for up to 5 years via a telephone questionnaire to assess mortality rates, developmental delay, neurological/cardiovascular morbidity, and future hospitalizations. Most infants (94%) who experienced a BRUE were hospitalized before 6 months of age. No cases of mortality occurred. In terms of developmental outcome, 1 child (1.15%) was diagnosed as having a global developmental delay and 12 (13.7%) with a language delay, similar to prevalence rates by age in the United States. Three children (3.4%) were diagnosed as having an autism spectrum disorder, with higher prevalence rates than the global average. Simple febrile and nonfebrile seizures were seen at a rate similar to the general population. None of the children developed cardiovascular disease. Rehospitalization occurred in 22% of cases: 90% for common acute pediatric causes and 10% for recurrent choking events secondary to gastroesophageal reflux disease. Low-risk hospitalized infants younger than 1 year who experienced a BRUE seem to generally have an excellent prognosis.

Changes in the Management of Children With Brief Resolved Unexplained Events (BRUEs).

In May 2016, the American Academy of Pediatrics published a clinical practice guideline for brief resolved unexplained events (BRUEs). We evaluated for changes in the management of BRUE after guideline publication. Using a pediatric multicenter administrative database, we compared rates of admission, testing, revisits, and diagnoses in patients diagnosed with a BRUE or apparent life-threatening event (ALTE) during 2017 with rates of admission, testing, revisits, and diagnoses in patients diagnosed with ALTE during 2015. We used interrupted time series analysis to test if the guideline was associated with changes in admission rate for all patients with ALTE or BRUE between 2015 and 2017. We stratified analyses by age (0-60 and 61-365 days). A total of 9501 patients were included (5608 in 2015 and 3893 in 2017). The admission rate decreased by 5.7% (95% confidence interval, 3.8% to 7.5%) for infants 0 to 60 days and by 18.0% (95% confidence interval, 15.3% to 20.7%) for infants 61 to 365 days from 2015 to 2017. Patients in 2017 had lower rates of EEG, brain MRI, chest radiography, laboratory testing, and urinalyses compared with patients in 2015. In the interrupted time series analysis model (n = 13 977), guideline publication was associated with decreasing admission rates (0.2% per week) for infants 61 to 365 days (P < .001). Compared with patients evaluated in 2015, patients with BRUE or ALTE in 2017 have lower rate of admissions and testing. Findings may be due to changes in the definition of BRUE and guideline recommendations.

Sleep-related risk and worrying behaviours: a retrospective review of a tertiary centre's experience.

This retrospective study aims at helping physicians select babies considered at risk for fatal events during sleep. It does so by describing the clinical features and outcome of worrying infants' behaviour during sleep, with the activation of an emergency medical service and/or emergency department, subsequently referred to the Centre for Paediatric Sleep Medicine and sudden infant death syndrome, Regina Margherita Children's Hospital, Turin, Italy. We analysed the medical records of infants < 12months whose parents reported they had worrying behaviour during sleep in the period 1 January 2009- 31 December 2015. Regional guidelines suggest performing anamnesis and capillary blood gas analysis in case of apparent life-threatening events. There were 33 males, average age 55 ± 54.37days. On arrival at the emergency medical service/emergency department 97% infants were asymptomatic; 61% patients had a capillary blood gas analysis as suggested by the regional guidelines. A clear acid-base disorder was observed in two infants, asymptomatic at medical evaluation, that had assumed an unsafe sleeping position. Two patients presented recurrence of the episode at 3months.Conclusions: Most worrying infant behaviour during sleep can be related to paraphysiological phenomena; capillary blood gas analysis and anamnesis are pivotal to identify the cases at risk of fatal events.What is Known:• Events that happen during sleep often frighten the parents of newborns. This fear may be induced by the fact that Sudden Infant Death Syndrome typically occurs during sleep.• This tragic event is unpredictable by any clinical features or findings in instrumental examinations and cannot be prevented with an early resuscitation.What is New:• In our retrospective study, most worrying infant behaviour during sleep can be related to paraphysiological phenomena.• Capillary blood gas analysis and anamnesis collection were crucial to identify the only two life-threatening events.

SIDS, BRUE, and Safe Sleep Guidelines.

1. Maria Behnam-Terneus, DO*,† 2. Melissa Clemente, MD* 1. *Division of Pediatric Hospital Medicine and 2. †Medical Education Department, Nicklaus Children’s Hospital/Nicklaus Children’s Health System, Miami, FL * Abbreviations: AAP: : American Academy of Pediatrics ALTE: : apparent life-threatening event BRUE: : brief resolved unexplained event CPSC: : Consumer Product Safety Commission SIDS: : sudden infant death syndrome SUID: : sudden unexpected infant death In 2016, the American Academy of Pediatrics (AAP) published a clinical practice guideline in which they recommended redefining apparent life-threatening event with the more specific term brief resolved unexplained event (BRUE). The purpose of this review is to detail how to apply the BRUE classification guidelines in practice. The recently updated AAP guidelines for sudden infant death syndrome prevention and safe infant sleeping environment are also discussed. After completing this article the reader should be able to: 1. Distinguish and explain the defining characteristics and epidemiology of sudden unexpected infant death, sudden infant death syndrome (SIDS), brief resolved unexplained event (BRUE), and apparent life-threatening event. 2. Apply the new BRUE guidelines and risk stratification to determine lower-risk versus higher-risk patients. 3. Review management recommendations for lower-risk BRUE. 4. Delineate risk factors and prevention recommendations for SIDS. 5. Explain the updated American Academy of Pediatrics recommendations for a safe infant sleeping environment. In April 2016, the American Academy of Pediatrics (AAP) published a new clinical practice guideline for brief resolved unexplained events (BRUEs). This new term, risk classification, and management recommendations replaced what was formerly known as an apparent life-threatening event (ALTE). BRUE describes transient events without a clear etiology after a thorough medical evaluation by a clinician, in contrast to ALTE, in which the definition refers to the subjective experience of a frightening event by a caregiver is detailed. In addition, the new guideline recommendations differentiate a BRUE from episodes that might warrant further investigation secondary to an increased risk of a serious underlying condition. The purpose of this review is to clarify the differences between these 2 definitions, as well as to distinguish them …

An Unusual Case of Apparent Life-Threatening Events

Apparent life-threatening event (ALTE) occurs in 0.5–10/1000 live births. ALTEs are defined as episodes characterized by a combination of apnea, color change, altered muscle tone, choking, and gasping. All are very frightening to the observer. The most common ALTE etiologies are gastroesophageal reflux disease, epilepsy, and respiratory tract infections, which make up 50% of all ALTE cases.

Causative and common PHOX2B variants define a broad phenotypic spectrum.

Paired Like homeobox 2B (PHOX2B) is a gene crucial for the differentiation of the neural lineages of the autonomic nervous system (ANS), whose coding mutations cause congenital central hypoventilation syndrome (CCHS). The vast majority of PHOX2B mutations in CCHS is represented by expansions of a polyalanine region in exon 3, collectively defined PARMs (PolyAlanine Repeat Mutations), the minority being frameshift, missense and nonsense mutations, defined as NPARMs (Non-PARMs). While PARMs are nearly exclusively associated with isolated CCHS, most of NPARMs is detected in syndromic CCHS, presenting with neuroblastoma and/or Hirschsprung disease. More recently, evidence of a complex role of PHOX2B in the pathogenesis of a wider spectrum of ANS disorders has emerged. Indeed, common and hypomorphic PHOX2B variants, including synonymous, polyalanine-contractions, gene deletions may influence the occurrence of either apparent life-threatening event (ALTE), Sudden Infant Death Syndrome (SIDS), neuroblastoma, or isolated HSCR, likely through small effects on PHOX2B expression levels. After an introduction to the role of PHOX2B in the ANS development, causative mutations, common variants, and gene expression deregulation of the PHOX2B gene are discussed, though the involvement of synonymous variants and contractions requires further confirmations with respect to ANS disorders and molecular mechanisms underlying the PHOX2B phenotypic heterogeneity.

Brief Resolved Unexplained Events: Analysis of an Apparent Life Threatening Event Database

ObjectiveTo identify the proportion of patients previously diagnosed with apparent life-threatening events (ALTE) who would meet criteria for brief resolved unexplained events (BRUE) and to identify rates of adverse outcomes in subgroups: ALTE not meeting criteria for BRUE, lower-risk BRUE, and higher-risk ALTE. MethodsWe performed a secondary analysis of a single-center prospective registry of patients diagnosed with ALTE in a tertiary care emergency department from March 1, 1997 to October 31, 2007. We identified the proportion of patients meeting criteria for BRUE, and the proportion of patients with BRUE meeting lower-risk criteria. We assessed outcomes of patients in subgroups. ResultsSeven hundred and sixty-two patients were included. Adverse outcomes included recurrent ALTE (n = 49), aspiration (n = 9), trauma (n = 8), and death (n = 4). Three hundred and twenty-six of 762 (42.8%) met criteria for BRUE. Seventy of 326 (21.5%) met criteria for lower-risk BRUE. Adverse outcomes occurred in 40 of 436 (9.2%) with ALTE not meeting criteria for BRUE, 2 of 70 (2.9%) with lower-risk BRUE, and 23 of 256 (9.0%) with higher-risk BRUE. Of 4 patients who died, 1 had an ALTE not meeting criteria for BRUE and 3 had non–lower-risk BRUE. The BRUE risk criteria identified all BRUE patients that died or had substantial morbidity as higher-risk. ConclusionsLess than half of patients with ALTE meet criteria for BRUE. Of those who do, one-fifth is lower-risk. In this series, the risk-stratification in the BRUE criteria identified those patients at highest risk of adverse outcomes. Further research is required to risk-stratify patients with BRUE.

Implementation of the new BRUE (Brief Resolved Unexplained Event) Guidelines: A Quality Improvement and Cost-Savings Initiative

Background: Significant variation exists in the evaluation and management of patients experiencing a Brief Resolved Unexplained Event (BRUE), erstwhile known as Apparent Life-Threatening Event (ALTE). In May 2016, the AAP published the first Clinical Practice Guidelines (CPG) specific for patients experiencing BRUE. The CPG provide an approach to evaluation based on risk stratification, as well as management recommendations for the lower-risk infants. We suspect based on anecdotal experience that our institution does not adhere to the current guidelines. This …

A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event.

In 2016, the American Academy of Pediatrics published a clinical practice guideline that more specifically defined apparent life-threatening events as brief resolved unexplained events (BRUEs) and provided evidence-based recommendations for the evaluation of infants who meet lower-risk criteria for a subsequent event or serious underlying disorder. The clinical practice guideline did not provide recommendations for infants meeting higher-risk criteria, an important and common population of patients. Therefore, we propose a tiered approach for clinical evaluation and management of higher-risk infants who have experienced a BRUE. Because of a vast array of potential causes, the initial evaluation prioritizes the diagnosis of time-sensitive conditions for which delayed diagnosis or treatment could impact outcomes, such as child maltreatment, feeding problems, cardiac arrhythmias, infections, and congenital abnormalities. The secondary evaluation addresses problems that are less sensitive to delayed diagnosis or treatment, such as dysphagia, intermittent partial airway obstruction, and epilepsy. The authors recommend a tailored, family-centered, multidisciplinary approach to evaluation and management of all higher-risk infants with a BRUE, whether accomplished during hospital admission or through coordinated outpatient care. The proposed framework was developed by using available evidence and expert consensus.