4 Apparent Pediatric Life-Threatening Events

Question 1

What are apparent life-threatening events (ATLE)?

Answer 1

ALTE was defined as an episode that’s frightening to a caregiver and involves some combination of
- apnea
- color change (cyanosis, pallor, or plethora)
- change in muscle tone (limp or stiff)
- choking, or gagging.

Question 2

In 2016, the American Academy of Pediatrics more precisely defined these ATLE as

Answer 2

brief resolved unexplained events (BRUEs).

Question 3

Define BRUEs

Answer 3

A BRUE specifically includes infants <1 year of age who have experienced a brief (<1 minute), unexplained event consisting of one or more of the following features:
- cyanosis or pallor
- absent, decreased, or irregular breathing
- marked change in tone (hyper- or hypotonia)
- altered level of responsiveness

the infant must return to his or her baseline state of health after the brief event and have a reassuring history and physical exam after medical evaluation, including vital signs.

Question 4

The peak incidence of ATLE

Answer 4

The peak incidence is between 1 week and 2 months of age, with the majority of ALTE occurring before 10 weeks of age.

Question 5

Healthy infants often have cyclic periods of rapid breathing interposed with respiratory pauses, termed as

Answer 5

Periodic Breathing
- Periodic breathing is observed in nearly all preterm and most term infants, and lasts until about 2 months of age in term infants
- In addition irregular respirations are the hallmark of active sleep (later referred to as rapid eye movement sleep or dream sleep) at all ages
- irregular breathing during REM sleep continues into adulthood and is normal

Question 6

This breathing is considered pathologic

Answer 6

Apneic pauses of >20 seconds or those associated with changes in color, tone, or heart rate are considered pathologic.

Question 7

Central apnea may be seen in

Answer 7

bronchiolitis and pertussis

Question 8

Remarks on plethora

Answer 8

Plethora was not included in the definition of BRUE

Question 9

Remarks on pallor

Answer 9

Pallor is characteristic of the vasovagal response and can be seen in asociation with GER, choking on feeds, or a vagal event.

Question 10

What is Sandifer’s syndrome

Answer 10

Stiffening and arching behavior have been well described in infants with gastroesopahgeal reflux events (Sandifer’s syndrome)

Question 11

Remarks on altered sensorium

Answer 11

An altered level of responsiveness is part of the defnition of BRUE because it can be an important component of the event associated with a serious underlying disorder.

It was not part of the ALTE definition

Because of an immature nervous system, infants may normally appear somnolent, appear unresponsive briefly, or lose consciousness after a breath-holding spell.

Question 12

Common, benign explanation for BRUEs

Answer 12

GER / vomiting episode
URTI
Coughing or choking episode
Periodic breathing
Oral dysphagia
Breath-holding spell

Question 13

Common serious pathology for BRUEs

Answer 13

Seizure
LRTI
Laryngotracheomalacia
Inflicted injury

Question 14

Less common serious pathology for BRUEs

Answer 14

Maxillofacial obsruction or TEF
Arrhythmia / cardiac
Pertussis
Serious bacterial infection
Metabolic disease
Electrolyte / glucose
Poisoning

Question 15

Remarks on breath-holding spells

Answer 15

Breath-holding spells occur in 4% to 5% of children <8 years of age and entail a cessation of respiration at the end of expiration, usually in response to pain, anger, or fear

Spells typically last <1 minute and may be accompanied by cyanosis, pallor, syncope, and seizures.

Question 16

Criteria for BRUE

Answer 16

Age <1 y
Sudden, brief episode
Patient at baseline state of health after event
Event unexplained by history and PE
≥1 of the following:
- cyanosis or pallor
- absent, decreased, or irregular breathing
- marked change in tone
- altered level of responsiveness

Question 17

Criteria for lower-risk BRUE

Answer 17

> 60 days old
Born at a gestational age of ≥32 weeks and currently a postconceptual age ≥45 weeks
First and single event
Event lasting <1 minute

No CPR required by trained medical provider
No concerning historical features
No concerning physical exam features

Question 18

Disposition for low-risk BRUE patients

Answer 18

The AAP BRUE guidline recommends against routine admission of these infants.

Instead, a period of observation on pulse oximetry with serial exams lasting 1 to 4 hours can be offered.
the duratio of this period of observation is a good opportunity for shared decision making with caregivers

a follow-up exam in 24 hours is recommended

reassurance that BRUE is not considered a precursor to sudden infant death syndrome and CPR instruction resources may provide additional reassurance to caregivers

Question 19

Disposition for high-risk BRUE patients

Answer 19

Testing and hopsitalization are useful in higher-risk BRUE pateints, compared to lower-risk infants.

While admission is not mandatory in these patients, have a low threshold for admission and monitoring.

Question 20

highest risk for BRUE recurrence

Answer 20

Premature infants
infants 2 months old
infants with cyanosis
those with chronic medical conditions

Question 21

BRUE and SIDS

Answer 21

ED physicians and caregivers may worry about subsequent sudden infant death syndrome (SIDS) or occult illness in infants who have experienced BRUE or ALTE.

However, such patients are not at increased risk of SIDS

Overall postdischarge mortality in ALTE studies is 0% to 0.4%

Question 22

Other remarks for BRUE patients

Answer 22

For all BRUE patients, it is important to impart reassuarnce without offering false guarantees that another event will not occur.

Currently, home monitors are not recommended for lower-risk BRUE patients.