What is the focus of clinical history in the evaluation of a brief resolved unexplained event (BRUE) (apparent life-threatening event) (ALTE)?

Updated: Feb 28, 2019
  • Author: Patrick L Carolan, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Key questions related to the history of the episode include the following:

  • Who observed the event? Recognize that second-hand accounts may vary from the history provided by direct observers who were present at the time.

  • What was the description of the event? A caregiver’s description of the infants’ color, respiration, and muscle tone is key. Care must be taken to distinguish central cyanosis (lips and oral mucous membranes) from acrocyanosis (hands and feet). Infants who are coughing, choking, or gagging may exhibit a ruddy or plethoric facial color that may be interpreted as “turning blue.” Determine whether apnea was present, and, if so, whether it appeared to be central (lack of respiratory effort) or obstructive (respiratory effort with inadequate airflow). Distinguish apnea that lasted more than 15-20 seconds from periodic breathing, in which respiratory rate and tidal volumes fluctuate and are accompanied by brief pauses in breathing that typically last less than 5-10 seconds.

  • Was the infant limp, or was muscle tone increased during or after the event?

  • Were any seizurelike movements observed?

  • Was any resuscitation required, or did the event spontaneously resolve? Recall that caregivers may provide mouth-to-mouth resuscitation to spontaneously breathing infants with intact perfusion, fearing that the infant’s life is threatened.

  • Was the infant born at term, or was the infant premature?

  • Does the infant have any other significant health issues?

  • Were any pregnancy or labor and delivery complications reported?

  • Are any factors that predispose to neonatal sepsis noted?

  • Has the infant previously exhibited symptoms of gastroesophageal reflux or aspiration of thin liquids? These symptoms may include coughing, choking, or gagging during or after feeding; frequent or excessive spitting-up; persistent nasal stuffiness; or frequent hiccups. Acid reflux disease is suggested by excessive irritability, arching, and straining behaviors displayed during or following a feeding.

  • Are the newborn metabolic screening findings normal?

  • Does the family have a history of seizures, metabolic disorders, previous sudden infant death syndrome (SIDS), or unexplained death in infancy or childhood?

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