ALTE to BRUE: Assessing the Implications of the American Academy of Paediatrics First Clinical Practice Guideline for the Management of Apparent Life Threatening Events

Background: Apparent Life Threatening Events (ALTE) can prove challenging due to lack of consensus on management. In 2016, the American Academy of Paediatrics produced its first clinical practice guideline to address this. These propose a nomenclature change, replacing ALTE with a new term Brief Resolved Unexplained Event (BRUE), criteria to risk stratify infants, and management of lower risk infants. It is unclear what proportion of infants will be reclassified as low-risk and the potential health service implications of this.

Objective: To assess the potential health service utilisation implications of AAP Guidelines specific to Apparent Life Threatening Events.

Methods: Retrospective review of ALTE presentations (January–December 2016) to a large Paediatric Emergency Department. Cases were reclassified as low-risk BRUE if they met all the following criteria: age>60 days; gestational age >32/40 or post-conceptual age >45 weeks; 1^st event; no CPR required by trained provider; no significant past medical history; no concerning historical features or physical examination findings; event lasting < 1 minute duration.

Results: Data from 39 patients diagnosed with an ALTE were analysed (mean age 8.1+/-9.9wks; 20 (51.3%) female). Of these 9 (23.1%) were reclassified as a low-risk event (mean age 17.3+/-10.7wks; 7 (77.7%) female). This group had a median length of stay of 2 days, with a total of 20 infant bed days used (19.1% of total ALTE cohort). 54 (18.3%) of total ALTE-related investigations were conducted on this group.

Discussion/Conclusion: This is the first study to assess the impact of introducing AAP Guidelines specific to ALTE presentations. 1 in 4 presenting with an ALTE can be reclassified as a low-risk BRUE. Benefits to both the patient and hospital are evident, including reduction of unwarranted invasive investigations, unnecessary radiation exposure plus avoidance of hospital admissions. The new guidelines offer a simplified means to risk stratify and manage these patients.