This case presentation describes a 10 day old male infant who presented with hurried respiration and bluish discoloration of the lips. The infant's history included an uneventful pregnancy, birth and postnatal period until 10 days of age. On examination, the infant had a weak cry, poor activity and tachycardia. Investigations showed elevated white blood cell count and C-reactive protein. During the hospital course, the infant remained obtunded with shallow breathing and multiple episodes of apnea requiring stimulation. Neuroimaging was normal. An echocardiogram was also normal. On the 4th day of admission, the infant required intubation for prolonged apnea. The infant was discharged as the attenders could not afford further

1. CASE PRESENTATION

2. • B/O Reshma Prakash D11 Mch from Honnali
was admitted to our hospital on
28th,November
• C/C:
H/O Hurried respiration
H/O Bluish discoloration of lips
• With above complaints local GP was consulted
who noticed 3 episodes of apnea in
30mins,Hence referred to our institute.

3. • Antenatal History:G4P3L2,Concieved
spontaneously.Regular ANC with Iron and folic
acid supplements.
• Birth History:FTND in Honnalli Govt Hospital,B
wt-2.6kg,Cried immediately.Breast fed within
30mins.
• Postnatal:Uneventful upto D10 .

4. • There was no h/o cough,cold prior to onset of
symptoms.
• No h/o cough,cold ,in family.
• H/O sibling death at 45 days of age,with h/o
abdominal distension.

5. • On Examination:Baby Pink,Weak cry and poor
activity.
HR-136/min. N volume and regular.
RR-54cpm,Regular
Spo2:96% with HBO2
Temp-97.6F
• Head to Toe examn:AF at level,No facial
dysmorphisms.

6. • R/S:No retractions,B/L CREPS(+)
• CVS:S1,S2 heard ,short systolic murmur best
heard in lower lt. parasternal area
• CNS:CRAT-poor,AF 2*2 ,AT level
Moro Reflexe:Sluggish

7. TERM/AGA/M/LOS-?MENINGITIS
WITH PNEUMONIA

8. Investigations:
• CBC:Hb:14.8%,WBC count:3790/cumm
PMN:55%,ANC-2070/cumm
Plt:1,72 Lac/cumm
I:T=0.01
• CRP:31.3mg/L
• RFT,Electrolytes,LFT-Normal
• ABG-Normal gas values with normal base defict.
• CSF study:Normal

9. Course in Hospital
• D1-Baby continued to remain Obtunded,shallow
respiration and multiple episodes of apnea in
hospital requiring tactile stimulation.
• Neuroimaging was done to rule out IC Bleed-
Normal study.
• 2D Echo-Normal.
• On D4 of admission was intubated for prologed
apnea .
• DAMA as attenders were not affordable.

10. TERM/AGA/M/LOS/PERSISTENT
ENCEPHALOPATHY PRESENTING AS
ALTE

11. APPARENT LIFE THREATENING
EVENT(ALTE)
&
BRIEFLY RESOLVED
UNEXPLAINED EVENT(BRUE)

12. Introduction:
• Many no. of infants present with acute events-
unexpected change in breathing, color or behaviour.
• It is not a specific diagnosis, but rather a "chief
complaint" that brings an infant to medical
attention.
• Challenge is to identify the infants who may
benefit from further testing and prolonged
observation.

13. Epidemology:
• Studies estimated that ALTEs occur in 3:10,000 to
41:10,000 infants.
• Lesser risk factors include premature birth or low
birth weight and maternal smoking.
• Most common explanatory diagnosis were
GERD,Seizures,RTI.
The main risk factors for acute events in infants
described as ALTE are feeding difficulties,recent upper
respiratory symptoms, and age younger than two
months, or a history of previous episodes

14. Definition: ALTE
• This description was established by expert consensus in
1986.
• Previously used terminology such as near-miss sudden
infant death syndrome (SIDS) or aborted crib death were
abandoned.
An apparent life-threatening event (ALTE) is defined as an
episode that is frightening to the observer and is
characterized by some combination of
1) apnea (central or obstructive),
2) color change (cyanotic, pallid, erythematous or plethoric)
3)change in muscle tone (usually diminished).
4)choking or gagging.

15. ‘Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent
LifeThreatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics.
2016;137(5):e20160591
In 2016, the American Academy of Pediatrics (AAP)
released a new clinical practice guideline that
recommended the replacement of the term ALTE
with a new term, brief resolved unexplained event
(BRUE).’

16. Definition BRUE:
• In an infant younger than 1 year :
-when the observer reports a sudden, brief(<1min),
and now resolved episode of ≥1 of the following:
• Only when the infant is asymptomatic on
presentation.
• when there is no explanation for the episode
after a focused history and physical examination.
(1) Cyanosis or Pallor
(2) Absent, decreased, or irregular breathing.
(3) Marked change in tone (hyper- or hypotonia)
(4) Altered level of responsiveness

19. ALTE vs BRUE
ALTE
• No age limit.
• May be due to specific
cause.
• Care givers perception.
• Color change
• Redness and rubor present
BRUE
• Age limit Upto 1 year.
• Only if no other explanation.
• Clinician characterization.
• Cyanosis or pallor
• Not included
ALTE
BRUE

20. ALTE vs BRUE
ALTE
• Apnea only.
• Change in muscle tone
• Includes choking & gagging
• Conciousness-not included
BRUE
• Irregular,diminished,or
absent breathing.
• Hypo or Hypertonia
• Not in defintion
• Altered level of
conciousness.

21. Evaluation:History
• Most important diagnostic tool –detail description of
event.
• The history should include information about any
previous apneic events.
 recent illnesses or symptoms.
the pregnancy and perinatal period.
the infant's usual behavior-sleep and feeding habits.
 family history(including a history of siblings with
similar episodes, sudden deaths, early deaths, genetic,
metabolic,cardiac, and neurologic problems).
a social history (including the presence of smoking,
alcohol or substance use in the home, and a list of
medications in the home)

24. Histoty pointers towards specific
diagnosis:
Gastroesophageal reflux (GER) and/or laryngospasm:
• Gross emesis or oral regurgitation that occurred at
the time of the event.
• Acute events caused by laryngospasm typically
occur during feeding, or shortly after feeding,
especially if the infant is in a supine position
• If symptoms are recurrent and/or the infant has
underlying neurologic or developmental
abnormalities, further evaluation for swallowing
dysfunction may be warranted.

25. • A respiratory tract infection should be
suspected based on symptoms (eg, history of
nasal congestion,cough, and/or fever).
• Features suggestive of seizures include loss of
muscle tone and unresponsiveness during the
episode, and no history of choking or gagging.
• A history of previous episodes of severe
events should particularly prompt
consideration of child abuse,especially if the
events occurred in the presence of a single
caretaker and required CPR.

26. Examination:
• Measurement of height, weight, and head
circumference and comparison of these values to
standards for age and gender
• Measurement of vital signs, including pulse oximetry.
• Examination for physical signs of trauma (bruising, sub
conjunctival or retinal hemorrhage, bulging anterior
fontanel)
• Neurologic examination, including alertness and tone
• Evaluation for respiratory distress or upper airway
obstruction, including assessment of facial
dysmorphism
• Developmental assessment, including assessment of
developmental reflexes

28. Risk Classification of BRUE:
(1) Lower-risk patients on the
basis of history and
physical examination, for
whom evidence based
guidelines for evaluation
and management are
offered.
(2) Higher-risk patients, whose
history and physical
examination suggest the
need for further
investigation, monitoring,
and/or treatment, but for
whom recommendations
are not offered (because of
insufficient evidence or the
availability of guidance from
other clinical practice
guidelines specific to their
presentation or diagnosis).

30. Management of Low risk BRUE:
Recommended steps:
• Educate caregivers about BRUEs, and the low risk for
infants with these characteristics.
• Offer resources for training in cardiopulmonary
resuscitation (CPR).
• Engage in shared decision-making about further
evaluation and disposition.
• Arrange for a follow-up check with a medical provider
within 24 hours to identify infants with evolving
medical concerns that would require further evaluation
and treatment.

31. Management of Low risk BRUE:
Optional steps:
• A brief period of in-hospital observation (eg, one to
four hours) with continuous pulse oximetry and serial
observations.
• 12-lead electrocardiogram with attention to QT
interval.
• Testing for pertussis (especially for infants with
suggestive symptoms).
• Respiratory virus testing,such as for respiratory
syncytial virus, is reasonable if a rapid testing method
is available.However, this testing is not required in
these low-risk infants, who by definition have no
respiratory symptoms and are >2 months of age

34. Evaluation of High risk BRUE:
• If there are clinical features that suggest a specific
diagnosis (eg, upper respiratory tract infection or
child abuse), the evaluation may be targeted
toward that concern.
• If there are no clinical features suggesting a
specific diagnosis, a general screening evaluation
includes a complete blood count, urinalysis,
plasma concentrations of glucose, electrolytes,
calcium and magnesium, blood urea nitrogen, a
chest radiograph, and an electrocardiogram.

35. D/D for High risk ALTE/BRUE
• GER/Laryngospasm
• Neurolgical problems(seizures)
• Repiratory tract infections
• Child abuse
• Cardiac disease
• Upper airway obstruction
• Bacterial infection
• Metabolic disorders.
• Toxin ingestion

36. Disposition:
• In-hospital observation with cardio respiratory monitoring is
indicated for infants whose initial evaluation (whether by
history, examination, or other diagnostic studies) suggests
physiologic compromise.
• Includes infants with a history of more than one acute event
within the previous 24 hours or any other warning signs
prompting additional evaluation .
• Other reasons to consider hospitalization include: suspicion
of trauma, neglect, poisoning or abuse; an other
wiseunwell-appearing infant (such as failure to thrive of
unknown etiology); social risk factors; or perceived need to
monitor and observe feedings.

37. Warning Signs:
• The presence of the following warning signs increase the
likelihood that the acute event is medically significant and
may have a specific pathologic cause.
• Infants with these signs should be admitted to the hospital
for observation with cardiorespiratory monitoring, with
specific evaluation guided by the history
-Symptoms at the time of evaluation, including toxic
appearance, lethargy, unexplained recurrent vomiting, or
respiratory distress.
-Significant physiologic compromise during the event.
Concerning symptoms include generalized sustained cyanosis
or loss of consciousness, need for resuscitation by a trained
CPR provider (more than just stimulation).

38. Warning Signs-contd
• Bruising or any other evidence of trauma.
• History of prior events in this patient, especially
within the past 24 hours, or clusters of events.
• History of clinically significant events or unexpected
death in a sibling.
• History that raises suspicion for the possibility of child
maltreatment, such as an inconsistent description of
the event, prior report for child maltreatment in the
family, or a description that is inconsistent with the
child's developmental stage.
• Dysmorphic features, congenital anomalies, and/or
known syndrome

39. Home Monitoring:
• Studies of infants with a history of ALTE and
who remain asymptomatic have failed to
demonstrate a therapeutic benefit of home CR
monitoring.
• Infants who may particularly benefit from
home monitoring include premature infants
with recurrent episodes of apnea and
bradycardia, or infants with unstable airways
or chronic lung disease.

40. Recurrence Risk:
• The risk for recurrence of apparent life-
threatening events (ALTE) ranges from 10 to 25
percent in different reports.
• Substantially lower for infants meeting the
narrower criteria for BRUE.
• Infants who present with multiple acute events
preceding the hospital admission are more likely
to have an underlying disease as compared with
those with single events.
• Infants younger than two months of age require
special attention because they are at increased
risk for occult infection or undiagnosed
congenital disorders

41. Death:
• The overall risk of subsequent death in infants
who have experienced ALTE is estimated to be
less than 1 percent and substantially lower for
those meeting the narrower criteria for BRUE
• Infants with recurrent events requiring
cardiopulmonary resuscitation (CPR) have a
very high risk of subsequent death, ranging
from 10 to 30 percent .

42. ALTE & SIDS
• Vast majority of SIDS victims do not experience
acute events or apnea prior to death.
• Studies over the past two decades have failed to
confirm a causal relationship between pre
existing apnea and SIDS
• ALTE is unlikely to be a predictor of SIDS because
ALTE refers to a heterogeneous group of
problems with different causes and severities,
ranging from benign to near-fatal.

43. • Over 80 percent of SIDS deaths occur between
midnight and 6 AM whereas 82 percent of ALTE
episodes occur between 8 AM and 8 PM.
• The peak incidence of ALTE is during the first two
months of life, whereas the peak incidence of SIDS is
between two and four months of age .
• Interventions to prevent SIDS (eg, supine sleeping)
have not resulted in a decreased incidence of ALTE .
• The risk factors for SIDS and ALTE differ . Prone
sleeping, lack of breastfeeding, and maternal smoking
were risks for SIDS, whereas behavioral characteristics
(eg, previous episodes of apnea, pallor, cyanosis, or
feeding difficulties) were risk factors for ALTE .
• Prematurity and low birthweight are much stronger
risk factors for SIDS than for ALTE

44. References:
• National Institutes of Health Consensus Development Conference
on Infantile Apnea and Home Monitoring, Sept 29 to Oct 1, 1986.
Pediatrics 1987; 79:292.
• Tieder JS, Bonkowsky JL, Etzel RA. Brief resolved unexplained events
(formerly apparent life-threatening events) and evaluation of lower-
risk infants: Executive summary. Pediatrics 2016;137:e2 0160591.3.
• Kiechl-Kohlendorfer U, Hof D, Peglow UP, et al. Epidemiology of
apparent life threatening events.Arch Dis Child 2005; 90:297.
• Michael J Corwin, MD. Acute events in infancy including brief
resolved unexplained event (BRUE),UpTodate :Oct 11, 2016
• Brand DA, Altman RL, Purtill K, Edwards KS. Yield of diagnostic
testing in infants who have had an apparent life-threatening event.
Pediatrics 2005; 115:885.
• Claudius I, Keens T. Do all infants with apparent life-threatening
events need to be admitted.Pediatrics 2007; 119:679.
• Brooks JG. Apparent life-threatening events and apnea of infancy.
Clin Perinatol 47. 1992; 19:809.

45. THANK YOU