SGEM Xtra: Strange BRUE

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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, ECG, brief monitor with pulse oximetry and serial observation
Not Needed: Viral respiratory tests, urinalysis (bag or catheter), blood glucose, serum lactic acid or bicarbonate, neuroimaging (to detect child abuse) or admit to hospital solely for cardiorespiratory monitoring

Here is the flow diagram that was published with the clinical practice guidelines. It can be a great teaching tools and does a nice job of walking through the definitions and recommendations.

Here is a table listing the recommendations, level of evidence and the strength of the recommendations.

Reference: Ramgopal et al. Changes in the Management of Children With Brief Resolved Unexplained Events (BRUEs). Pediatrics 2019

Again, we are not doing a typical SGEM structured critical review. But we will be going over some of the elements of a review.

Clinical Question: What are the changes in the management of BRUE after guideline publication?

Patients were included in the study if they were less than or equal to 365 days of age found in a Pediatric Health Information System. This is an administrative database that contains ED, inpatient, ambulatory surgery, and observation data from children’s hospitals in the United States affiliated with the Children’s Hospital Association.

They excluded five sites because of insufficient or incomplete data. Comparisons were made between patients diagnosed with ALTE or BRUE between 2015 and 2017. Patients were identified using ICD-9 and ICD-10 codes for the primary or secondary diagnosis or ALTE and BRUE between 2015 and 2017. The primary outcome was rate of admission. The secondary outcomes were rates of revisits and studies performed on index visit. We compared patients admitted in 2015 (before the 2016 guidelines) to those admitted in 2017 (after the 2016 guidelines).

The study included 9,501 patients (5,608 in 2015 and 3,893 in 2017). The admission rate decreased from 2015 to 2017. For infants 0 to 60 days the decrease was 5.7% (95% confidence interval, 3.8% to 7.5%). For infants 61 to 365 days the decrease was 18% (95% confidence interval, 15.3% to 20.7%).

The rates of testing also changed. Patients in 2017 had lower rates of EEG, brain MRI, chest radiography, laboratory testing, and urinalyses compared with patients in 2015.

There were some limitations to the study:

Things associated with using an administrative database like coding accuracy
Converting ICD-10 to ICD-9 codes
Granularity of the data was not complete enough to investigate the changes in management of BRUE after the implementation of the new guidelines
A 30% decrease of BRUE from 2015 to 2017 that is unexplained
External validity to countries other than the United States of America

Authors’ Conclusions: “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.”

What do you tell the parents or caregivers when discharging a low risk BRUE?

Dr. Katie Noorbakhsh

“This part is so important. I usually start off by acknowledging the family’s concerns. I will say something like, I know that it was really upsetting and scary when your baby had this episode today, but the good news is that everything you have told me and everything that I see on exam today is very reassuring. It is not uncommon for young infants to have a concerning episode that goes away on its own and we aren’t really sure what happens. In fact, it’s common enough that we have a name for it. We call it a Brief Resolved Unexplained Event. Now it’s unexplained so we don’t know exactly why your baby had this event, which is challenging to me because I like knowing why things happen, but what we do know what we should look for to tell us that a baby is safe to go home. And your baby has all of the things that we look for, she’s a little bit older, she just had one episode that resolved quickly and on its own, and she looks so well now.

I am really glad that you guys came in when you were worried about her. I think you did the right thing. And if anything changes, if you think she is having trouble breathing, if she ever looks blue, if she isn’t eating or peeing well, if she isn’t acting like herself or if you just can’t put your finger on it but something is making you worry, then call your doctor or just come on back in and see us. We will be happy to take care of you.”

Other FOAMed: Don’t Forget the Bubbles (BRUE vs. ALTE: have the new guidelines made a difference?

Let me know what you think SGEMers about the way we covered the paper this time. Did you like it or hate it? Should I try this again or stick to the original formula? Send me an email at TheSGEM@gmail.com to let me know your thoughts.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.

Historical Features To Be Considered in the Evaluation of a Potential BRUE

Considerations for Possible Child Abuse:
- Multiple or changing versions of the history/circumstances
- History/circumstances inconsistent with child’s developmental stage
- History of unexplained bruising
- Incongruence between caregiver expectations and child’s developmental stage,
- including assigning negative attributes to the child
History of the Event:
- General description
- Who reported the event?
- Witness of the event? Parent(s), other children, other adults? Reliability of historian(s)?
- State immediately before the event?
  - Where did it occur (home/elsewhere, room, crib/floor, etc)?
  - Awake or asleep?
  - Position: supine, prone, upright, sitting, moving?
  - Feeding? Anything in the mouth? Availability of item to choke on? Vomiting or spitting up?
  - Objects nearby that could smother or choke?
- State during the event:
  - Choking or gagging noise?
  - Active/moving or quiet/flaccid?
  - Conscious? Able to see you or respond to voice? Muscle tone increased or
  - decreased? Repetitive movements?
  - Appeared distressed or alarmed?
  - Breathing: yes/no, struggling to breathe?
  - Skin color: normal, pale, red, or blue?
  - Bleeding from nose or mouth?
  - Color of lips: normal, pale, or blue?
- End of event:
  - Approximate duration of the event?
  - How did it stop: with no intervention, picking up, positioning, rubbing or clapping
  - back, mouth-to-mouth, chest compressions, etc?
  - End abruptly or gradually?
  - Treatment provided by parent/caregiver (eg, glucose-containing drink or food)?
  - 911 called by caregiver?
- State after event:
  - Back to normal immediately/gradually/still not there?
  - Before back to normal, was quiet, dazed, fussy, irritable, crying?
Recent History:
- Illness in preceding day(s)? If yes, detail signs/symptoms (fussiness, decreased activity, fever, congestion, rhinorrhea, cough, vomiting, diarrhea, decreased intake, poor sleep)
- Injuries, falls, previous unexplained bruising?
Past Medical History
- Pre-/perinatal history
- Gestational age
- Newborn screen normal (for IEMs, congenital heart disease)?
- Previous episodes/BRUE?
- Reflux? If yes, obtain details, including management
- Breathing problems? Noisy ever? Snoring?
- Growth patterns normal?
- Development normal? Assess a few major milestones across categories, any concerns about development or behavior?
- Illnesses, injuries, emergencies?
- Previous hospitalization, surgery?
- Recent immunization?
- Use of over-the-counter medications?
Family History:
- Sudden unexplained death (including unexplained car accident or drowning) in first- or second-degree family members before age 35, and particularly as an infant?
- Apparent life-threatening event in sibling?
- Long QT syndrome?
- Arrhythmia?
- Inborn error of metabolism or genetic disease?
- Developmental delay?
Environmental History
- Housing: general, water damage, or mold problems?
- Exposure to tobacco smoke, toxic substances, drugs?
Social History
- Family structure, individuals living in home?
- Housing: general, mold?
- Recent changes, stressors, or strife?
- Exposure to smoke, toxic substances, drugs?
- Recent exposure to infectious illness, particularly upper respiratory illness,
- paroxysmal cough,pertussis?
- Support system(s)/access to needed resources?
- Current level of concern/anxiety; how family manages adverse situations?
- Potential impact of event/admission on work/family?
- Previous child protective services or law enforcement involvement (eg, domestic violence, animal abuse), alerts/reports for this child or others in the family (when available)?
- Exposure of child to adults with history of mental illness or substance abuse?

Physical Examination Features To Be Considered in the Evaluation of a Potential BRUE

General Appearance
- Craniofacial abnormalities (mandible, maxilla, nasal)
- Age-appropriate responsiveness to environment
Growth Variables: Length, weight, occipitofrontal circumference
Vital Signs: Temperature, pulse, respiratory rate, blood pressure, oxygen saturation
Skin: Color, perfusion, evidence of injury (eg, bruising or erythema)
Head: Shape, fontanelles, bruising or other injury
Eyes:
- General, extraocular movement, pupillary response
- Conjunctival hemorrhage
- Retinal examination, if indicated by other findings
Ears: Tympanic membranes
Nose and mouth
- Congestion/coryza
- Blood in nares or oropharynx
- Evidence of trauma or obstruction
- Torn frenulum
Neck: Mobility
Chest: Auscultation, palpation for rib tenderness, crepitus, irregularities
Heart: Rhythm, rate, auscultation
Abdomen: Organomegaly, masses, distention tenderness
Genitalia: Any abnormalities
Extremities: Muscle tone, injuries, limb deformities consistent with fracture
Neurologic:
- Alertness, responsiveness
- Response to sound and visual stimuli
- General tone
- Pupillary constriction in response to light
- Presence of symmetrical reflexes
- Symmetry of movement/tone/strength