What s a BRUE? /pr. broo / EDAP Conference September 8, 2016 Josh Siembieda, MD FAAP

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1 What s a BRUE? /pr. broo / EDAP Conference September 8, 2016 Josh Siembieda, MD FAAP

2 Objectives Review history of the definition of ALTE Discss the AAP BRUE Clinical Practice Gideline Overview of the differential diagnosis, workp, management, and evalation of a BRUE Review common infant conditions that may mimic a BRUE

3 History of ALTE Historical Context (Prior to May 2016): NIH Consenss Statement 1986 an episode that is frightening to the observer and that is characterized by some combination of apnea, color change, marked change in mscle tone, choking, or gagging. In some cases, the observer fears that the infant has died. An ALTE is a risk factor for sdden death (inclding SIDS). An ALTE may be associated with increased morbidity. Cardiorespiratory monitoring or an alternative therapy is medically indicated for certain grops of infants at high risk for sdden death. These grops inclde infants with one or more severe ALTEs reqiring moth-to-moth resscitation or vigoros stimlation.

4 Why the name change? sbjective and non-specific no age relies on parental observations, NOT clinician NO recommendations SCARY name

5 Historical Challenges often asymptomatic and well appearing in ED decision to order tests and/or hospitalize not always clear extensive, nnecessary tests = high stress and cost to the family. no standard approach

6 Incidence Trly Unknown per 1000 live births 0.6% to 0.8% of all ED visits for children < 1y

7 BRUE Brief Resolved Unexplained Event AAP Clinical Practice Gidelines, May 2016

8 The BRUE Patient Infants < 1 year old Patient has retrned to baseline (RESOLVED) History, PE, VS all reassring No explanation after appropriate hx and PE (UNEXPLAINED)

9 The BRUE Event Less than 1 minte (BRIEF) > 1 of the following: cyanosis or pallor absent, decreased, or irreglar breathing marked change in tone altered LOC

10 Now what?

11 Next Steps Consider potential cases Low vs High risk Testing? Disposition?

12 DDx of ALTE/BRUE Gastroesophageal reflx (31%) Seizre (18%) Lower respiratory tract infection (8%) ENT probs (3.6%) Cardiac (0.8%) Metabolic (1.5%) UTI (1.1%) Unknown (23%) Abse Systematic Review by McGovern & Smith, Arch Dis Child 2004; 89:

13 What to ask? HPI Time/dration Awake vs asleep Last feeding Color/Tone change PMH Similar episodes Neonatal corse Rx and OTC meds Resscitative measres Recent Illness Change in behavior Sleeping conditions

14 What to ask? Fam Hx SIDS, ALTE/BRUE Seizres Cardiac, metabolic, etc Social History Caretakers Smoking Meds/drgs in home

15 High Risk BRUE Age < 60 days Prematrity (GA <32wks or PC age <45wks) Prior BRUE CPR by medical provider Concerning history and/or PE

16 Low Risk BRUE Age > 60 days Not prematre (GA >32wks and PCA >45wks) First BRUE Less than 1 min No CPR by trained provider No concerning history or PE findings

17 I m going home!!!!!

18 Shold Edcate caregivers abot BRUEs Offer resorces for CPR training Recommend close otpatient follow p

19 May Obtain 12-lead ECG Obtain pertssis testing Briefly monitor patients with continos plse oximetry and serial observations

20 Shold Not Send blood, CSF stdies Order metabolic workp Order CXR, EEG, echo, GER stdies Start home cardio-resp monitoring Prescribe GER or sz meds

21 Need Not Obtain VRP, UA, BG, neroimaging Admit solely for cardiorespiratory monitoring

22 Considerations for possible child abse Mltiple or changing versions of the history/circmstances History/circmstances inconsistent with child s developmental stage History of nexplained brising Incongrence between caregiver expectations and child s developmental stage, inclding assigning Negative attribtes to the child

24 Beyond a BRUE High risk BRUE workp common neonatal/infant findings

25 References National Instittes of Health Consenss Development Conference on Infantile Apnea and Home Monitoring, Sept 29 to Oct 1, Pediatrics. 1987;79(2): Sarohia M, Platt S, et al. Apparent Life Threatening Events in Children: Practical Evalation and Management. Pediatric Emergency Medicine Practice. Vol 11, Nmber 4. April Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent LifeThreatening Events) and Evalation of Lower-Risk Infants. Pediatrics. 2016;137(5):e /14/2016 Ilene Cladis ALTE Update/BRUE.

26 Thank yo for all yo do! Qestions?

CLINICAL PRACTICE GUIDELINE Guidance for the Clinician in Rendering Pediatric Care EXECUTIVE SUMMARY FROM THE AMERICAN ACADEMY OF PEDIATRICS

CLINICAL PRACTICE GUIDELINE Guidance for the Clinician in Rendering Pediatric Care Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower- Risk Infants: Executive