Board Review: It's all about the little people!
A 4-month old female born at full term otherwise healthy presents to the ED after parents observed her “turning blue” and “breathing funny” for less than a minute that spontaneously self-resolved. Parents report no recent fever or illness and say this has never happened before. Upon arrival to the ED patient appears to be well appearing and in no acute distress, afebrile and with reassuring vital signs and physical exam. Parents ask if they can take her home. What do you do?
A. Tell the parents the baby needs to be admitted to the pediatric floor
B. Monitor the baby on pulse oximetry for another 2 hours and then discuss possible discharge with the parents
C. Tell the parents the baby is fine and discharge to home
D. Tell the parents the baby needs to be admitted to the PICU
B. This baby presents with a BRUE, a Brief Resolved Unexplained Event (formerly known as ALTE, Apparent Life-Threatening Event) as defined by:
Sudden, brief, and now resolved episode of one or more of the following in an infant < 1 year age:
1. Cyanosis or pallor
2. Absent, decreased, or irregular breathing
3. Marked change in tone (hyper- or hypotonia)
4. Altered responsiveness
5. No explanation for the event after full history and exam
And according to the most recent American Academy of Pediatrics guidelines, this patient is considered low risk according to the following criteria:
- Age >60 days
- Born >= 32 weeks' gestation and corrected gestational age >=45 weeks
- No CPR by trained medical provider
- Event lasted <1 minute
- First event
Therefore, this low risk patient may be safely discharged home with close pediatrician follow up after a period of observation and education provided to the parents about BRUEs. This is different than past practice where nearly all patients with BRUEs (then called ALTEs) were hospitalized. It should be noted that BRUEs can be related to a range of conditions both benign and more concerning. Possible etiologies include GERD, breath-holding spells, non-accidental trauma, and serious bacterial infection. The risk of a serious disorder presenting as a BRUE is unknown, therefore a thorough history and physical exam is essential.
See below for the AAP BRUE algorithm.
Joel S. Tieder, Joshua L. Bonkowsky, Ruth A. Etzel, Wayne H. Franklin, David A. Gremse, Bruce Herman, Eliot S. Katz, Leonard R. Krilov, J. Lawrence Merritt, Chuck Norlin, Jack Percelay, Robert E. Sapién, Richard N. Shiffman, Michael B.H. Smith, for the SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS
Pediatrics May 2016, 137 (5) e20160590; DOI: 10.1542/peds.2016-0590