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Will a new approach improve practice?

Robohm-Leavitt, Christina MS, PA-C, DFAAPA

Journal of the American Academy of PAs: July 2019 - Volume 32 - Issue 7 - p 14
doi: 10.1097/01.JAA.0000558360.08858.5b

Christina Robohm-Leavitt is program director and regional dean of the PA program at Texas Tech University Health Sciences Center School of Health Professions in Midland, Tex.



Infants who present with a marked change in tone and altered responsiveness can present a clinical challenge. Parents who witness these incredibly frightening moments have a natural reaction to call an ambulance and immediately rush to the ED or clinic. But upon arrival, the baby has a normal examination, and as parents attempt to recall the events leading up to the incident, clinicians may question whether the parents are overreacting when there is no specific diagnosis.

On page 38 of this issue, John P. Bastin, MHS, PA-C, CPAAPA, reviews the new guideline for managing brief resolved unexplained events (BRUEs) in infants. Previously, this group of symptoms was called an apparent life-threatening event or ALTE, a term established after the variability in definitions between diagnoses such as “near-miss sudden infant death syndrome” and “prolonged infantile apnea.”1 However, ALTE was not a well-defined term, leaving clinicians a challenging decision-making process for the disposition of the child. Reassuring a parent is difficult when the word life-threatening is used to describe the working diagnosis for their infant. For infants presenting with BRUE symptoms, clinicians may question the need for further testing and an observation period to consider conditions that could have a negative outcome for the infant and family. This often leads to extensive evaluation for potential underlying illnesses and may increase parental anxiety. However, the likelihood of finding a serious underlying condition has been shown to be quite low.2

The new term, BRUE, is an effort to more accurately represent the event.3 The new guideline and terminology help to provide clinicians with more certainty in classifying infants as low- or high-risk of having an underlying disorder causing the symptoms, based on careful history and physical examination.

Bastin's article guides busy clinicians in evaluating a child presenting with a BRUE, so they can reduce unnecessary testing and hospitalization. The diagnosis is still one of exclusion of another cause of a disorder, but the guideline provides criteria to help in the decision-making process. As clinicians, we need to carefully evaluate infants with potential red flags for pathology. It takes time to have a clear description of the event to exclude a specific underlying cause. If a cause is identified, the event is not a BRUE. But in absence of any specific signs or symptoms following a thorough history and examination, the new criteria do provide additional direction in the evaluation to help in determining the best approach to caring for the infant and educating parents. The guideline recommends conservative management for infants who meet specific criteria, letting clinicians educate parents and place them at ease about the likelihood that their child has a serious disorder.

Will the guideline change our practice? Quality improvement methods to update clinician education on the new terminology and guideline can lead to practice change as demonstrated at one hospital.4 The supplemental data accompanying the new guideline provide a toolkit of resources for patient education, quality metrics, and additional education.1 Using the implementation tools may reduce admission rates and resource use, resulting in better-quality patient-centered care.

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1. Dunne K, Matthews T. Near-miss sudden infant death syndrome: clinical findings and management. Pediatrics. 1987;79(6):889–893.
2. Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic testing in infants who have had an apparent life-threatening event. Pediatrics. 2005;115(4):885–893.
3. Tieder JS, Bonkowsky JL, Etzel RA, et al Clinical practice guideline: brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: executive summary. Pediatrics. 2016;137(5):e20160591.
4. Kumar R, Shrestha D, Yewale S, Verma R. Implementation of the new BRUE (brief resolved unexplained event) guidelines: a quality improvement and cost-saving initiative. Acad Pediatr. 2018;18(5):e47–e48.
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