Apparent Life-Threatening Events and Brief Resolved Unexplained Events in Children

Educational Objectives

The goal of this program is to improve management of brief resolved unexplained events (BRUE). After hearing and assimilating this program, the clinician will be better able to:

1. Differentiate the clinical presentation of child abuse from BRUE.
2. Optimize use of imaging for BRUE in children.

Summary

Terminology: brief resolved unexplained events (BRUEs) is the new term for apparent life-threatening events (ALTEs); infants with sepsis are always a concern as it can develop quickly and often presents subtly; the terminology transition is important, but not every infant or clinical case fits neatly into guidelines, requiring a flexible approach; clinical intuition is vital; if something feels off, further investigation is necessary even if the cause is unclear

History of ALTE: ALTEs were first described by the National Institutes of Health in 1986 as frightening episodes associated with sudden death, including sudden infant death syndrome (SIDS); before the Back to Sleep campaign, these were considered high-risk, sometimes requiring cardiorespiratory monitoring; early research linked ALTEs to SIDS, but much of it was flawed; a critical case involved a mother with 5 SIDS deaths, later revealed as infanticide; misguided research led to widespread use of monitors, which often caused unnecessary distress because of false alarms; in 2016, the American Academy of Pediatrics (AAP) introduced the term BRUE, defined as an unexplained episode in an infant <1 yr old involving changes in color, breathing, tone, or responsiveness, with no clear cause after examination; low-risk BRUE patients are >32 wk gestation, have a post-conceptional age of ≥45 wk, and experienced only one short episode without requiring cardiopulmonary resuscitation (CPR); a concerning history, eg, a caregiver reporting the need to shake the baby, warrants further evaluation

ALTE vs SIDS: comparing past cases, ALTEs typically occur in infants <2 mo, often observed during waking hours, and were unaffected by the Back to Sleep campaign; SIDS, in contrast, affects slightly older infants, often occurring between midnight and 6 am, with incidence decreasing after sleep environment improvements; initially, babies slept on soft surfaces with bumpers, but now they should sleep on firm, bare surfaces without blankets, toys, or pillows

Risk factors of ALTE: possible causes of these episodes include reflux, gastrointestinal issues (eg, volvulus, hernias), swallowing disorders, neurologic conditions (eg, seizures), central nervous system hemorrhages, child abuse, airway obstructions (eg, laryngomalacia), congenital issues, and cardiac arrhythmias; the use of oximetry has reduced cardiac-related cases, but anomalies (eg, an aberrant coronary artery) still present later; metabolic disorders, infections (eg, respiratory syncytial virus [RSV], COVID), and exposure to illicit drugs or medications can also contribute

History for ALTE: a thorough history is crucial, including details of the event, who witnessed it, and the reliability of the historian; environmental factors, infant positioning, recent feeding, and presence of blood in the nose or mouth are key red flags; observing whether the baby was conscious, appeared post-ictal, or had seizure-like movements is critical, as well as determining how the episode resolved; viral infections, prior episodes, and exposure to over-the-counter or illicit drugs should be considered; prematurity and neonatal history matter; a 24-wk infant has different risks than a full-term infant; feeding difficulties, noisy breathing, and stridor indicate underlying pathology; witnessed apneic episodes often feel longer than they are, similar to how time perception changes during resuscitation efforts; it is important to determine if CPR was truly needed, whether emergency medical services was called, and if the baby returned to normal immediately or remained irritable or dazed; identifying whether the baby is genuinely ill is crucial, as viral infections can cause apnea

Drug exposure: is a significant risk, with infants sometimes presenting unresponsive because of fentanyl, methamphetamine, or other substances in the home; these cases frequently result in fatal outcomes; understanding the full history, medical background, and potential external factors helps guide appropriate management

Family history: a thorough evaluation of family history is crucial when assessing sudden unexplained death, especially in first or secondary relatives <35 yr, including unexplained accidents or drownings; infants with siblings who had ALTEs should also be considered; if a family member has long QT syndrome, an electrocardiography should be done; a family history of arrhythmia is also significant

Social history: plays a role in assessing risks; living conditions matter, whether the baby is in a stable home or in a car; if sleeping upright in a car seat, positional asphyxia can occur; environmental factors (eg, stress) and the presence of non-parental caregivers should be evaluated; exposure to toxins, passive smoke, and recent illnesses (eg, pertussis) should also be considered; social support, financial stability, and caregiver concern are key; if the family seems indifferent to the event, it raises red flags; admitting a baby impacts the family, especially those with precarious employment; the involvement of child protective services or law enforcement provide insights; a social work evaluation can help assess if caregivers have histories of mental illness or substance abuse

Child abuse vs BRUE: considerations include inconsistent or changing histories, developmental inconsistencies (eg, claims of a 1 mo old rolling over), unexplained bruising, or negative caregiver attitudes toward the baby; physical examination findings, eg, craniofacial abnormalities indicate physiologic issues rather than abuse; growth assessments are essential, failure to thrive, disproportionate head growth, or signs of hydrocephalus could signal serious conditions (eg, brain tumors); conjunctival hemorrhages are a red flag for child abuse; retinal hemorrhages require ophthalmologic documentation; torn frenulum suggests forced feeding or trauma; rib tenderness, crepitus, arrhythmias, and abdominal abnormalities must be evaluated; rib fractures are typically older when visible on imaging; skeletal surveys are needed for fractures in non-ambulatory infants; femur fractures in otherwise healthy infants are suspicious; there is significant overlap between BRUE and child abuse; history and physical examinations are critical in differentiating these cases; while radiologic imaging is generally avoided in BRUE, red flags warrant skeletal surveys and head imaging; computed tomography identify fractures and large bleeds, while magnetic resonance imaging help with timing

Management of BRUE: the AAP discourages the use of the term ALTE and provides guidelines for BRUE management; if everything checks out, minimal intervention is needed; caregivers should be educated, and CPR training can be offered; if pertussis is prevalent in the community, a test is warranted; a 12-lead electrocardiography is done if concerns arise; monitoring should last 4 to 8 hr before discharge; unnecessary tests and home monitoring should be avoided for low-risk cases; acid suppression and antiepileptic medications should not be prescribed without a diagnosis; viral testing and hospital admission solely for monitoring are not recommended; some families, especially first-time parents or those who conceived through in-vitro fertilization, require extended observation for reassurance; higher-risk BRUE cases need individualized evaluation; multicenter study of 15 pediatric and community hospital emergency departments (Tieder et al [2021]) showed that few high-risk BRUE cases resulted in serious diagnoses, with seizures and airway anomalies being the most common findings; risk factors included episodes over a minute, abnormal medical history, altered responsiveness, or repeat emergency department visits, which indicates a need for admission, according to speaker; the AAP risk criteria had a 90% negative predictive value but only a 23% positive predictive value, meaning false positives were common

Hospitalization for BRUE: rarely alters outcomes, with most diagnostic benefits seen in seizure and airway anomaly cases; evaluation of high-risk patients should focus on history and physical examination; the pH probe is the most helpful diagnostic test in these cases; new guidelines help distinguish low-risk from high-risk BRUE cases; cardiac apnea monitors have not prevented deaths despite their historical use

Other aspects of BRUE: pathologic events should raise suspicion for sepsis, RSV, coronavirus, or child abuse; following updated guidelines while recognizing that infants do not always fit medical textbook presentations is essential in clinical practice

Readings

Chaiyachati BH, Wood JN. Brief resolved unexplained events vs. child maltreatment: a review of clinical overlap and evaluation. Pediatr Radiol. 2021;51(6):866-871. doi:10.1007/s00247-020-04793-z; DeLaroche AM, Nama N, Tieder JS. Acute care management of brief resolved unexplained events. Pediatr Emerg Care. 2025;41(3):245-250. doi:10.1097/PEC.0000000000003277; Denis M, Brulé C, Lauzier B, et al. Brief resolved unexplained event: Severity-associated factors at admission in the pediatric emergency ward. Arch Pediatr. 2023;30(6):389-395. doi:10.1016/j.arcped.2023.05.005; Doswell A, Anderst J, Tieder JS, et al. Diagnostic testing for and detection of physical abuse in infants with brief resolved unexplained events. Child Abuse Negl. 2023;135:105952. doi:10.1016/j.chiabu.2022.105952; Duncan DR, Liu E, Growdon AS, et al. A prospective study of brief resolved unexplained events: risk factors for persistent symptoms. Hosp Pediatr. 2022;12(12):1030-1043. doi:10.1542/hpeds.2022-006550; Haddad R, Parker S, Farooqi A, et al. Diagnostic evaluation low yield for patients with a lower-risk brief resolved unexplained event. Glob Pediatr Health. 2021;8:2333794X20967586. Published 2021 Feb 1. doi:10.1177/2333794X20967586; Mittal MK, Tieder JS, Westphal K, et al. Diagnostic testing for evaluation of brief resolved unexplained events. Acad Emerg Med. 2023;30(6):662-670. doi:10.1111/acem.14666; Tieder JS, Sullivan E, Stephans A, et al. Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study. Pediatrics. 2021;148(1):e2020036095. doi:10.1542/peds.2020-036095.

Disclosures

For this program, members of the faculty and the planning committee reported nothing relevant to disclose. Dr. Ackerman's lecture includes off-label or investigational use of a product, therapy, or device.

Acknowledgements

Dr. Ackerman was recorded at Aloha Update: Pediatrics 2024, held October 26 to November 11, 2024, in Maui, HI, and presented by Children’s Hospital Los Angeles Medical Group. For information about upcoming CME activities from this presenter, please visit https://www.chla.org/chla-medical-group. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

PD711902

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.