Apparent life-threatening events and brief resolved unexplained events: management of children at a Swiss tertiary care center

Abstract

AIMS OF THE STUDY: Apparent life threatening events (ALTEs) are highly stressful situations for the caregiver and commonly result in presentation of the child to an emergency department. As the events are usually brief and resolve in a short period of time, the entity is now called a brief resolved unexplained event (BRUE). Updated recommendations have been published in recent years on the management of BRUE, including a risk stratification to identify those at lower risk for subsequent events or severe underlying disorders. The aim of this study was to describe the epidemiology of ALTE and BRUE at our hospital and detail clinical practice of management in this population in a tertiary care children’s hospital in Switzerland. METHODS: We retrospectively analysed all cases of children with an ALTE or BRUE admitted to the University Children’s Hospital Basel between September 2009 and April 2018, identified using ICD-10GM coding. Electronic health records were used to extract data on diagnostic procedures, duration of admission and outcome. Infants with a lower-risk BRUE (defined as age >60 days and <1year, born at ≥32 weeks gestational age and postconceptional age ≥45 weeks, first BRUE episode with a duration of <1 minute and no cardiopulmonary resuscitation by trained medical provider required) were compared with those with a higher-risk BRUE/ALTE (not fulfilling all the criteria for lower-risk BRUE). RESULTS: A total of 65 patients with a median age of 42 days (interquartile range 20–67) were identified, of whom 15% were classified as having a lower-risk BRUE. A blood sample was analysed in 97% of patients, cranial ultrasound was performed in 63%, an electrocardiogram in 78% and polysomnography in 26%. The results remained normal in almost all patients and none had a further event recorded during admission. In one patient only QTc prolongation was detected as a potential serious underlying disease. CONCLUSIONS: Our data show that admission for more than 24 hours and extensive investigations for infants admitted for an ALTE/BRUE rarely led to identification of specific underlying causes. According to current recommendations, 15% of the admitted patients could be categorised as having a lower-risk BRUE and therefore hospital admissions and investigations can safely be reduced. We propose an adaptation of the current Swiss recommendations for ALTE/BRUE to optimise clinical management of children presenting with a BRUE.