🛑 Chapter 5: ALTE / BRUE

Nelson's Pediatric Symptom-Based Diagnosis | Apparent Life-Threatening Event · Brief Resolved Unexplained Event · Apnea · Color Change · Tone Change · Differential Diagnosis

🔍 ALTE/BRUE: Key Concepts

📊 Definitions
ALTE (historic): frightening event with apnea, color change, tone change, choking/gagging. BRUE (2016 AAP): event <1 min in infant <1 year, resolved, unexplained after history/exam. Low-risk BRUE criteria.
🔄 Low-Risk BRUE Criteria
Age >60 days, gestational age ≥32 weeks, post-conceptual age ≥45 weeks, event <1 min, no CPR needed, no concerning history/exam. These infants need minimal testing/observation.
⚠️ High-Risk Features
Prematurity, multiple events, cyanosis, need for resuscitation, abnormal exam, family history of SIDS/early death, child maltreatment concerns. Require hospitalization and targeted workup.
💧 Common Underlying Diagnoses
GERD (most common association), seizures (15-25%), lower respiratory infection (RSV, pertussis), inborn errors of metabolism, cardiac arrhythmias (long QT), child abuse.
🧬 Differential Diagnosis by System
GI: GER, intussusception. Neuro: seizures, breath-holding, CCHS. Infectious: pertussis, bronchiolitis, UTI. Cardiac: arrhythmia, cardiomyopathy. Metabolic: hypoglycemia, ammonia.
🚩 Red Flags for Serious Etiology
Need for CPR, cyanosis, recurrent events, age <60 days, family history of sudden death, dysmorphism, hepatomegaly, abnormal neuro exam, retinal hemorrhages.

💡 Key Takeaway: BRUE replaces ALTE to emphasize that most are benign, but a thorough history and physical are crucial to identify high-risk infants who need further evaluation for serious underlying conditions (seizures, cardiac, metabolic, abuse).

🩺 Clinical Approach to ALTE/BRUE: Step-by-Step Algorithm

🔹 Step 1: Determine if event meets BRUE definition
• Age <1 year, event <1 minute, resolved, unexplained after thorough history and physical.
• If not meeting criteria → broader evaluation for specific diagnosis.
🔹 Step 2: Apply low-risk BRUE criteria (all must be present)
• Age >60 days, gestational age ≥32 weeks, post-conceptual age ≥45 weeks.
• Only 1 event, duration <1 minute, no CPR by trained provider.
• No concerning historical features (e.g., multiple events, family history of sudden death, suspected abuse).
• Normal physical exam (including growth, neuro, cardiac, dysmorphism).
🔹 Step 3: Low-risk BRUE management
• No routine labs, imaging, or monitoring required.
• Educate caregivers on safe sleep, CPR, and when to return.
• Provide close follow-up (within 24-48 hours).
🔹 Step 4: High-risk BRUE or non-BRUE evaluation
• Hospitalization for observation and targeted testing.
• Consider: CBC, blood gas, glucose, electrolytes, lactate, ammonia, calcium.
• ECG (prolonged QT), pertussis/RSV PCR, CXR, EEG, and neuroimaging if indicated.
• Consider child maltreatment (skeletal survey, retinal exam).
🔹 Step 5: Common diagnoses to rule out
• GERD (avoid over-attribution; temporal association not causation).
• Seizure (EEG if recurrent or concerning movements).
• Pertussis or RSV (apnea in young infants).
• Long QT syndrome (family history, syncope).
• Inborn error of metabolism (dysmorphism, acidosis, hyperammonemia).