Brief Resolved Unexplained Events Symptoms Frequently Result in Inappropriate Gastrointestinal Diagnoses and Treatment.

OBJECTIVE: To determine associations between presenting symptoms and oropharyngeal dysphagia diagnoses, gastroesophageal reflux disease (GERD) diagnoses, and treatment with acid suppression medication in infants with brief resolved unexplained event (BRUE). STUDY DESIGN: We performed a prospective cohort study of infants with BRUE to review presenting symptoms and their potential impact on testing and treatment. Videofluoroscopic swallow study (VFSS) results and explanatory diagnoses were obtained from medical record review; acid suppression use was determined by parental survey. Binary and multivariable logistic regression models were used to evaluate associations between presenting symptoms and obtaining VFSS, VFSS results, GERD diagnoses, and acid suppression medication. RESULTS: Presenting symptoms were varied in 157 subjects enrolled at 51.0 ± 5.3 days of age, with many symptoms that may be related to GERD or dysphagia. Of these, 28% underwent VFSS with 71% abnormal. Overall, 42% had their BRUE attributed to GERD, and 33% were treated with acid suppression during follow-up. Presenting symptoms were significantly associated with the decision to obtain VFSS but not with abnormal VFSS results. Presenting symptoms were also associated with provision of GERD explanatory diagnoses. Both presenting symptoms and GERD explanatory diagnoses were associated with acid suppression use (aOR 2.3, 95% CI 1.03-5.3, P = .04). CONCLUSIONS: Presenting symptoms may play a role in clinicians' decisions on which BRUE patients undergo VFSS but are unreliable to make a diagnosis of oropharyngeal dysphagia. Presenting symptoms may also influence assignment of GERD explanatory diagnoses that is associated with increased acid suppression medication use.

Intussusception Initially Diagnosed as a Brief Resolved Unexplained Event (BRUE).

Brief resolved unexplained event (BRUE) are transient and worrying episodes observed in infants and are characterized by changes in skin color, breathing, muscle tone, and/or responsiveness. We describe the case of a female infant who was initially diagnosed with BRUE but was later determined to have intussusception. She presented to our emergency department with a transient pallor and a single episode of vomiting that resolved before her visit. Physicians did not detect any abnormalities on physical or laboratory examinations, so she was diagnosed with BRUE and discharged to be re-evaluated the next day. After returning home, she vomited several times. The patient revisited our hospital the following day and was definitively diagnosed with intussusception using ultrasonography, which was successfully treated using fluoroscopy-guided hydrostatic reduction. This case was initially diagnosed as a BRUE; however, re-evaluation helped in identifying the proper diagnosis of intussusception. Physicians should exercise caution when diagnosing patients with BRUE. When the diagnostic criteria are not completely met, follow-up should be conducted, assuming that the patient has a potentially serious condition.

Brief resolved unexplained event: Severity-associated factors at admission in the pediatric emergency ward.

OBJECTIVE: A brief resolved unexplained event (BRUE) is a recent clinical entity that has now replaced the term "infant discomfort". Despite the availability of recent recommendations, identification of patients requiring further examination remains difficult. METHOD: We aimed to identify factors associated with severe pathology and/or recurrence by studying the medical files of 767 patients admitted to the pediatric emergency department of a French university hospital for a BRUE. RESULTS: Overall, 255 files were studied; 45 patients had a recurrence and 23 patients had a severe diagnosis. The most frequently found etiology was gastroesophageal reflux in the benign diagnosis group and apnea or central hypoventilation in the severe diagnosis group. Prematurity (p = 0.032) and time since last meal >1 h (p = 0.019) were the main factors associated with severe disease. Most of the routine examination results remained non-contributive to the etiology. CONCLUSION: As prematurity is a factor associated with severe diagnosis, special attention should be given to this population, without subjecting them to multiple tests, since the main complication was found to be apnea or central hypoventilation. Prospective research is needed to establish the usefulness and prioritization of diagnostic tests for infants who are at "high risk" of experiencing a BRUE.

Análisis de causas atribuidas a "BRUE" entre los años 2017 a 2020 / Analysis of etiologies attributed to "BRUE" between the years 2017 to 2020

El término BRUE describe un evento en un lactante menor, repentino, breve, ya resuelto y sólo aplica cuando no existe una explicación para este episodio. Es escasa la literatura nacional e internacional sobre el estudio etiológico en BRUE. Objetivos: Caracterizar lactantes con episodio de BRUE y hacer un análisis etiológico. Métodos: Estudio retrospectivo, descriptivo lactantes hospitalizados por BRUE. Resultados: Se encontraron 50 lactantes con BRUE, la mayoría de ellos presentó un solo evento y ninguno requirió reanimación cardiopulmonar. Las características principales de los eventos fueron apnea, cianosis y tono disminuido. Las etiologías encontradas, más habituales, fueron reflujo gastro-esofágico, infección respiratoria, mala técnica alimentaria y crisis epilépticas. La evaluación clínica fue el principal elemento diagnóstico. Discusión: Nuestro análisis etiológico concuerda con la literatura nacional e internacional. La anamnesis y examen físico son la principal herramienta diagnóstica. Es fundamental contar con guías, adaptadas a la realidad nacional y local, que dirijan el estudio de lactantes con BRUE.

BRUE is an event occurring in an infant when the observer reports a sudden, brief, and now-resolved episode. BRUE is a diagnosis of exclusion and is used only when there is no explanation for the event after conducting an appropriate history and physical examination. There is little literature on the etiological study in BRUE. Objectives: To characterize infants with a BRUE episode and to carry out an etiological analysis. Methods: A retrospective study including infants who have experienced a BRUE between the years 2017 to 2020. Results: 50 infants with BRUE, most of them presented a single event and none required cardiopulmonary resuscitation. The main characteristics of the events were apnea, cyanosis and decreased tone. The most common etiologies found were gastroesophageal reflux, respiratory infection, poor feeding technique, and seizures. History and physical examination are the fundamental diagnostic tools. Discussion: Our etiological analysis agrees with the national and international literature. The clinical evaluation was the main diagnostic tool. It is essential to create local guidelines for the evaluation investigation and management of infants with BRUE.

Home Cardiorespiratory Monitoring in Infants at Risk for Sudden Infant Death Syndrome (SIDS), Apparent Life-Threatening Event (ALTE) or Brief Resolved Unexplained Event (BRUE).

Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than one year of age which remains unexplained after a thorough case investigation, including performance of a complete autopsy, examination of the death scene, and review of the clinical history. About 90% of SIDS occur before six months of age, the peak incidence is between two and four months, and the median age for death is elven weeks. The clinical, social, and economic relevance of SIDS, together with the evidence that prevention of this syndrome was possible, has significantly stimulated research into risk factors for the development of SIDS in the hope of being able to introduce new effective preventive measures. This narrative review discusses the potential relationships between apparent life-threatening events (ALTE) or brief resolved unexplained events (BRUE) and SIDS development, and when a home cardiorespiratory monitor is useful for prevention of these conditions. A literature analysis showed that home cardiorespiratory monitoring has been considered a potential method to identify not only ALTE and BRUE but SIDS also. ALTE and BRUE are generally due to underlying conditions that are not detectable in SIDS infants. A true relationship between these conditions has never been demonstrated. Use of home cardiorespiratory monitor is not recommended for SIDS, whereas it could be suggested for children with previous ALTE or severe BRUE or who are at risk of the development of these conditions. However, use of home cardiorespiratory monitors assumes that family members know the advantages and limitations of these devices after adequate education and instruction in their use.

Déjà Vu: Recurrent Sudden Cardiac Arrests in a Child With an Anomalous Left Coronary Artery.

Sudden cardiac arrest from anomalous coronary artery from the opposite sinus of Valsalva is rarely observed in children under 10 years of age. We report a 7-week-old infant with a brief resolved unexplained event from left anomalous aortic origin of a coronary artery who underwent unroofing and again developed syncope at 8 years of age. Ischemia was detected by stress echocardiography both times. (Level of Difficulty: Advanced.).

Pacientes con diagnóstico de "BRUE" atendidos en hospital pediátrico chileno. Aplicando nueva terminología / Patients with diagnosis of "Sids" treated in chilean pediatric hospital. Applying new terminology

La posible relación entre apneas durante la infancia temprana y Síndrome de Muerte Súbita del Lactante (SMSL) nunca ha sido demostrada, existiendo evidencias de que ambas condiciones podrían no estar relacionadas. La Academia Americana de Pediatría (AAP) define ALTE (Acute Life Threatening Event), como un evento brusco e inesperado que incluye manifestaciones de apnea junto con cambios de coloración cutánea y de tono muscular, donde el observador cree que el niño ha muerto. La AAP ha propuesto recientemente la sustitución del término ALTE por Brief Resolved Unexplained Events (BRUE). El nuevo concepto permite categorizar eventos breves, resueltos e inexplicados, para optimizar mejor el recurso en salud, a través de objetivar el evento y entregando estrategias de manejo categorizando el riesgo. Objetivo: Describir las características clínicas y letalidad de los pacientes menores de 12 meses que consultan por BRUE en un hospital de referencia. Materiales y métodos: Estudio transversal descriptivo con revisión de ficha de 46 pacientes de la Unidad de Lactantes y Nutrición del Hospital Dr. Luis Calvo Mackenna, con diagnóstico de BRUE, entre enero a diciembre de 2017. Resultados: Del total de pacientes con BRUE, 45% fueron hombres y 55% mujeres. La edad promedio fue de 1,37 + 0,51 meses. En 70% se demostró una etiología, de estas 31% con enfermedad por reflujo gastroesofágico (ERGE), siendo ésta la causa más frecuente seguida de un 19% con infecciones respiratorias agudas (IRA) y 9% causas neurológicas. En el 30% fueron causas idiopáticas. Conclusión: En nuestro estudio las causas más frecuentes de BRUE fueron ERGE e infecciones respiratorias. Durante el período de estudio ningún paciente estudiado falleció, por lo que no encontramos relación entre apneas del lactante y síndrome de muerte súbita.

The possible relationship between apneas during early childhood and Sudden Infant Death Syndrome (SIDS) has never been demonstrated, and there is evidence that the two conditions may not be related. The American Academy of Pediatrics (AAP) defines ALTE (Acute Life Threatening Event), as an abrupt and unexpected event that includes manifestations of apnea along with changes in skin color and muscle tone, where the observer believes that the child has died. The AAP has recently proposed replacing the term ALTE with Brief Resolved Unexplained Events (BRUE). The new concept makes it possible to categorize brief, resolved and unexplained events, to better optimize the health resource, through objectifying the event and delivering management strategies by categorizing the risk. Objective: To describe the clinical characteristics and lethality of patients younger than 12 months who consult for BRUE in a referral hospital. Materials and methods: Descriptive cross-sectional study with revision of the file of 46 patients from the Infant and Nutrition Unit of the Dr. Luis Calvo Mackenna Hospital, with a diagnosis of BRUE, between January and December 2017. Results: Of the total number of patients with BRUE, 45% were men and 55% women. The average age was 1.37 + 0.51 months. An etiology was demonstrated in 70%, of these 31% with gastroesophageal reflux disease (GERD), this being the most frequent cause, followed by 19% with acute respiratory infections (ARI) and 9% with neurological causes. In 30% they were idiopathic causes. Conclusion: In our study, the most frequent causes of BRUE were GERD and respiratory infections. During the study period, no patient studied died, so we found no relationship between apnea in the infant and sudden death syndrome.

Management of Infants with Brief Resolved Unexplained Events (BRUE) and Apparent Life-Threatening Events (ALTE): A RAND/UCLA Appropriateness Approach.

Unexpected events of breath, tone, and skin color change in infants are a cause of considerable distress to the caregiver and there is still debate on their appropriate management. The aim of this study is to survey the trend in prevention, decision-making, and management of brief resolved unexplained events (BRUE)/apparent life-threatening events (ALTE) and to develop a shared protocol among hospitals and primary care pediatricians regarding hospital admission criteria, work-up and post-discharge monitoring of patients with BRUE/ALTE. For the study purpose, a panel of 54 experts was selected to achieve consensus using the RAND/UCLA appropriateness method. Twelve scenarios were developed: one addressed to primary prevention of ALTE and BRUE, and 11 focused on hospital management of BRUE and ALTE. For each scenario, participants were asked to rank each option from '1' (extremely inappropriate) to '9' (extremely appropriate). Results derived from panel meeting and discussion showed several points of agreement but also disagreement with different opinion emerged and the need of focused education on some areas. However, by combining previous recommendations with expert opinion, the application of the RAND/UCLA appropriateness permitted us to drive pediatricians to reasoned and informed decisions in term of evaluation, treatment and follow-up of infants with BRUE/ALTE, reducing inappropriate exams and hospitalisation and highlighting priorities for educational interventions.

Diagnostic Evaluation Low Yield for Patients with a Lower-Risk Brief Resolved Unexplained Event.

In contrast to patients with an apparent life-threatening event (ALTE), the American Academy of Pediatrics recommends very limited evaluation for patients categorized as lower-risk brief resolved unexplained event (BRUE). This retrospective review aims to explore potential missed diagnostic opportunities for patients with a lower-risk BRUE (n = 10) through comparison with a subset of patients with ALTE (n = 72). None of the patients with a lower-risk BRUE had laboratory, imaging or ancillary studies that were diagnostic. Among patients with ALTE, 5 had laboratory and 3 had imaging studies that were diagnostic. None of the patients with a lower-risk BRUE had recurrent events during hospitalization or a serious underlying diagnosis identified within the 90 day follow-up period. As recommended by the AAP, patients with a lower-risk BRUE do not need diagnostic evaluation and can be discharged home with outpatient follow-up.

Achondroplasia is associated with increased occurrence of apparent life-threatening events.

AIM: To assess the clinical picture underlying apparent life-threatening events (ALTEs) occurring in infants with achondroplasia and provide guidance for evaluation after an event. METHODS: A population of 477 individuals with achondroplasia was retrospectively reviewed, and information regarding possible ALTEs was recorded in a REDCap database. RESULTS: ALTEs occurred in the first year of life in 18 of 477 individuals (3.8%). Most (14/18, 78%) occurred in the first 6 months of life and presented as episodes of apnoea and/or seizures. Of affected infants, 8/18 (44%) had more than one episode. Many of the initial ALTEs arose while infants were in car seats (11/18, 61%). Assessment following ALTEs most often demonstrated either craniocervical junction concerns and/or seizures, with 12/18 (67%) patients undergoing cervicomedullary decompression and 5/18 (28%) starting on anti-epileptic medications after the event. CONCLUSION: Although this study is limited in size and was retrospective, it shows that infants with achondroplasia appear to be at high risk for ALTEs. Evaluation after an event should include neuroimaging of the foramen magnum, inpatient hospital observation including respiratory monitoring and electroencephalography, and a car seat challenge.

COVID-19-associated apnea and circumoral cyanosis in a 3-week-old.

BACKGROUND: Data regarding coronavirus disease 2019 (COVID-19) cases and outcomes in infants are sparse compared to older pediatric and adult populations. CASE PRESENTATION: We present a three-week-old full-term male with a history of mild hypoxic ischemic encephalopathy (HIE) who was admitted as an inpatient twice for episodes of apnea and perioral cyanosis. The patient tested positive for COVID-19 and negative for other common respiratory viruses at both admissions. CONCLUSIONS: To our knowledge, this is the first report of apnea and perioral cyanosis associated with COVID-19 in an infant. This case highlights a previously undocumented COVID-19 presentation and suggests that even mildly symptomatic infants warrant viral diagnostic testing in an effort to prevent further spread of the disease.

Aplicación de una nueva terminología "BRUE: Eventos breves, resueltos e inexplicados": definiciones y recomendaciones / Application of a new terminology "BRUE: Brief, resolved and unexplained events": definitions and recommendations

Resumen: Hace tres décadas se propuso el término Apparent Life-Threatening Events (ALTE), siendo incorpo rado paulatinamente en el enfrentamiento clínico de estos pacientes; permitiendo determinar riesgos, atribuir causas y realizar tratamientos específicos. Sin embargo, llevó a realizar estudios y hospitalizaciones en muchas instancias considerados innecesarios, generando un aumento de los costos sanitarios. Por estos motivos nace el concepto de Brief Resolved Unexplained Events (BRUE), que pretende disminuir la subjetividad del evento y focalizar una estrategia de manejo según determina ción del riesgo. En el siguiente artículo se analizan diferencias entre ALTE y BRUE según consensos internacionales y chilenos, profundizando en el enfrentamiento e incorporando consideraciones de relevancia para la práctica clínica cotidiana de lactantes que presentan un BRUE.

Abstract: Three decades ago, the term Apparent Life-Threatening Events (ALTE) was proposed and was gra dually incorporated into the clinical approach of these patients, allowing to determine risks, attribute causes, and perform specific treatments. However, this led to studies and hospitalizations considered unnecessary in many cases, increasing health costs. For this reason, the concept of Brief Resolved Unexplained Events (BRUE) was created, in order to reduce the subjectivity of the event and focus a management strategy according to the risk determination. This article analyzes the differences bet ween ALTE and BRUE according to international and Chilean consensus, deepening the approach and incorporating relevant considerations for the daily clinical practice with infants who present a BRUE.

Monitorización cardio respiratoria domiciliaria en lactantes / Home respiratory cardio monitoring in infants

Home cardio-respiratory monitoring began over 40 years ago with the aim of preventing sudden infant death. Although it has been shown that monitoring does not meet this objective, its prescription has been maintained in various clinical situations and with very different criteria. Consensus on the subject has not been able to define precisely the type of monitoring or the time required for different diseases. Among the diseases that still consider the indication of cardio-respiratory monitoring at home are: persistent apnea of prematurity, high-risk BRUE (Brief Resolved Unexplained Events), neurological or metabolic diseases with compromise of the respiratory center, convulsive cough, pathologic gastroesophageal reflux and technology-dependent patients (high flow nasal cannula (CNAF), noninvasive ventilation (NIV), invasive mechanical ventilation (IMV) to tracheostomy, and others). A review is presented on the development of cardio-respiratory monitoring at home, highlighting the true usefulness of this technology with a general proposal, which must be evaluated on a case-by-case basis and always taking into account the conditions that must be met to perform adequate monitoring and useful.

La monitorización cardio-respiratoria en domicilio se inició hace más de 40 años con el objetivo de prevenir la muerte súbita del lactante. Aun cuando se ha demostrado que la monitorización no cumple este objetivo, se ha mantenido su prescripción en diversas situaciones clínicas y con criterios muy diversos. Consensos acerca del tema no han llegado a definir con precisión el tipo de monitorización ni el tiempo requerido para distintas enfermedades. Dentro de las enfermedades que todavía consideran la indicación de monitorización cardio-respiratoria en domicilio se encuentran: apnea persistente del prematuro, BRUE (episodio breve resuelto inexplicado) de alto riesgo, enfermedades neurológicas o metabólicas con compromiso del centro respiratorio, tos convulsiva, reflujo gastroesofágico patológico y pacientes dependientes de tecnología (cánula nasal de alto flujo (CNAF), ventilación no invasiva (VNI), ventilación mecánica invasiva (VMI) a traqueostomía, y otros). Se presenta una revisión sobre el desarrollo de la monitorización cardio-respiratoria en domicilio, resaltando la verdadera utilidad que tendría esta tecnología con una propuesta general, que debe evaluarse caso a caso y siempre teniendo en cuenta las condiciones que deben cumplirse para realizar una monitorización adecuada y útil.

A criança com Brief Resolved Unexplained Event no primeiro ano de vida: intervenção especializada de enfermagem / The child with Brief Resolved Unexplained Event in the first year of life: specialized nursing intervention

Desde sempre que os eventos adversos no 1º ano de vida constituem um desafio para profissionais de saúde e são motivo de ansiedade para os cuidadores de um lactente. Na década de 1960, estes eventos designavam-se Sudden Infant Death Syndrome e possuíam uma conotação de fatalidade sem prenúncio. Posteriormente, na década de 1980 transitaram para Apparent Life-Threatening Event, sugerindo uma ameaça à vida e desprovido de objetividade, necessária à elaboração de um diagnóstico. Desta necessidade emergiu o Brief Resolved Unexplained Event (BRUE) em 2016, cuja natureza mais específica permitiu a categorização do risco de recorrência de eventos num algoritmo, o qual constitui um importante instrumento de trabalho para os profissionais de saúde que prestam cuidados a estes lactentes. Devido ao seu carácter recente, a enfermagem destaca a importância de se globalizar a transição de ALTE para BRUE, de ser usado este conceito em detrimento do seu antecessor e de fomentar a atualização das equipas de profissionais de saúde, assim como os ensinos aos cuidadores do lactente, potenciando a intervenção especializada de enfermagem sobre o lactente e respetiva estrutura familiar. O objetivo deste relatório é descrever, de modo reflexivo, analítico e crítico, as atividades desenvolvidas em contexto clínico de serviço de urgência de pediatria e cuidados intensivos neonatais, que deram resposta aos objetivos gerais no processo de aquisição e desenvolvimento de competências comuns de Enfermeiro Especialista e especializadas de Enfermeiro Especialista na área de Pessoa em Situação Crítica, nomeadamente à criança com BRUE no 1º ano de vida. No Modelo de Dreyfus adaptado à enfermagem ancorou-se o desenvolvimento das áreas de perícia de saberes e competências científicas, técnicas e humanas na prestação de cuidados de enfermagem especializados de elevada qualidade ao cliente crítico, estando atento às suas necessidades de forma holística, não esquecendo a família como vetor de informação e potencial cuidador. Este processo formativo foi sustentado pela Teoria de Sistemas de Betty Neuman, assim como pelo Modelo de Parceria de Cuidados de Anne Casey, ambos ancorados nos pilares da enfermagem pediátrica.

Adverse events in early childhood has been a challenge for pediatric healthcare professionals and a torment for parents and caregivers, since a long time. In the 60's, these events were called Sudden Infant Death Syndrome, which imprinted a sense of fatality that could not be predicted. Later on, in the 80's, the Apparent Life-Threatening Event emerged, suggesting a threat to a child's life and had no objectivity, which is required to perform a diagnosis. Therefore, in 2016, based on this necessity, the Brief Resolved Unexplained Event (BRUE) was created, possessing a more specific nature, that allowed the stratification of the risk category of recurrence of these events in an algorithm, as an important work tool for healthcare professionals that assist these infants. Due to the fact that it's a very recent concept, Nursing highlights the need for ALTE's transition into BRUE to be globalized, advocates for the use of BRUE's concept instead of ALTE's and fosters the healthcare professionals update as well as caregivers' education, promoting specialized nursing interventions in an infant and his family. The purpose of this report is to describe, in a reflective, analytic and critical way, the developed activities in the pediatric emergency department and neonatal intensive care unit internships, that fulfilled the general objectives outlined in the process of acquiring and developing common and specific skills of the Specialized Nurse in Critical Care Patients area of expertise, namely to the child who experiences a BRUE in the first year of life. The development of knowledge proficiency and scientific, technical and human skills in specialized nursing healthcare of high quality to the critical patient, were based on Dreyfus Model, adapted by Benner to Nursing, requiring constant awareness to human needs in a holistic manner, always considering family as an information vector and potential caregivers. This academic practice was built on Betty Neuman's Systems Model, as on Anne Casey's Partnership Model of Nursing Care, both anchored in Nursing Pediatrics foundations.

Brief Resolved Unexplained Events: Analysis of an Apparent Life Threatening Event Database.

OBJECTIVE: To identify the proportion of patients previously diagnosed with apparent life-threatening events (ALTE) who would meet criteria for brief resolved unexplained events (BRUE) and to identify rates of adverse outcomes in subgroups: ALTE not meeting criteria for BRUE, lower-risk BRUE, and higher-risk ALTE. METHODS: We performed a secondary analysis of a single-center prospective registry of patients diagnosed with ALTE in a tertiary care emergency department from March 1, 1997 to October 31, 2007. We identified the proportion of patients meeting criteria for BRUE, and the proportion of patients with BRUE meeting lower-risk criteria. We assessed outcomes of patients in subgroups. RESULTS: Seven hundred and sixty-two patients were included. Adverse outcomes included recurrent ALTE (n = 49), aspiration (n = 9), trauma (n = 8), and death (n = 4). Three hundred and twenty-six of 762 (42.8%) met criteria for BRUE. Seventy of 326 (21.5%) met criteria for lower-risk BRUE. Adverse outcomes occurred in 40 of 436 (9.2%) with ALTE not meeting criteria for BRUE, 2 of 70 (2.9%) with lower-risk BRUE, and 23 of 256 (9.0%) with higher-risk BRUE. Of 4 patients who died, 1 had an ALTE not meeting criteria for BRUE and 3 had non-lower-risk BRUE. The BRUE risk criteria identified all BRUE patients that died or had substantial morbidity as higher-risk. CONCLUSIONS: Less than half of patients with ALTE meet criteria for BRUE. Of those who do, one-fifth is lower-risk. In this series, the risk-stratification in the BRUE criteria identified those patients at highest risk of adverse outcomes. Further research is required to risk-stratify patients with BRUE.

Thoracoscopic posterior tracheopexy during primary esophageal atresia repair: a new approach to prevent tracheomalacia complications.

BACKGROUND: Esophageal atresia (EA) is usually accompanied by some form of tracheomalacia (TM). During the early phases in life, excessive dynamic collapse of the trachea can cause a wide spectrum of symptoms ranging from mild complaints to apparent life-threatening events (ALTE's) or brief resolved unexplained events (BRUE's). Therapeutic strategies for severe TM include aortopexy to lift the anterior weakened cartilaginous rings or posterior tracheopexy of the floppy membranous tracheal intrusion. In this study, we describe the development of a new approach in which the posterior tracheopexy is performed directly during the primary thoracoscopic correction of EA. METHODS: In 2017, all nine consecutive EA patients with trachea-esophageal fistula underwent a rigid tracheo-bronchoscopy (RTB) evaluation during induction of anesthesia prior to the thoracoscopic EA repair. A floppy posterior membrane was diagnosed in four patients. During the subsequent thoracoscopic procedure, the posterior membranous trachea was fixed to the anterior longitudinal spinal ligament with non-absorbable sutures. Then, the anastomosis was made between the two esophageal pouches. RESULTS: On preoperative RTB, two patients had a severe (70-90%) mid-tracheal collapse of the pars membranacea and two patients had a moderate (33-40%) mid-tracheal collapse. Thoracoscopic posterior tracheopexy with two or three sutures was possible in all four patients, prior to the formation of the esophageal anastomosis. Median time per suture was 6 min (range 4-12 min). All operative procedures were uneventful. A median follow-up of 6 months (range 4-9 months) revealed that all patients showed further recovery without any TM symptoms or ALTE/BRUE. CONCLUSIONS: This is the first report that introduces a new approach to thoracoscopic posterior tracheopexy during primary EA repair. We believe that this technique can prevent the potentially deleterious sequelae of mild to severe TM that may complicate the lives of EA patients. Also, a second, sometimes complex surgical procedure can be prevented as the posterior tracheopexy is performed during the primary thoracoscopic EA correction. LEVEL OF EVIDENCE: IV.

What to Do when Babies Turn Blue: Beyond the Basic Brief Resolved Unexplained Event.

The term "brief resolved unexplained event" was created to replace "apparent life-threatening event," narrowing the definition and providing evidence-based guidelines for management. The emphasis is placed on using clinical clues to classify patients as low risk or exclude them from the categorization altogether. Infants who meet low-risk classification can be briefly observed in the emergency department and be discharged home. Infants who demonstrate elements suggestive of a specific etiology should be evaluated and treated accordingly. Patients who demonstrate no specific findings yet who are high risk should be evaluated for the most common etiologies of apneic events and be admitted.

Risk of Death in Infants Who Have Experienced a Brief Resolved Unexplained Event: A Meta-Analysis.

OBJECTIVE: To estimate an upper bound on the risk of death after a brief resolved unexplained event (BRUE), a sudden alteration in an infant's breathing, color, tone, or responsiveness, previously labeled "apparent life-threatening event" (ALTE). STUDY DESIGN: The meta-analysis incorporated observational studies of patients with ALTE that included data on in-hospital and post-discharge deaths with at least 1 week of follow-up after hospital discharge. Pertinent studies were identified from a published review of the literature from 1970 through 2014 and a supplementary PubMed query through February 2017. RESULTS: The 12 included studies (n = 3005) reported 12 deaths, of which 8 occurred within 4 months of the event. Applying a Poisson-normal random effects model to the 8 proximate deaths using a 4-month time horizon yielded a post-ALTE mortality rate of about 1 in 800, which constitutes an upper bound on the risk of death after a BRUE. CONCLUSIONS: This risk is about the same as the baseline risk of death during the first year of life. The meta-analysis therefore supports the return-home approach advocated in a recently published clinical practice guideline-not routine hospitalization-for BRUE patients who have been evaluated in the emergency department and determined to be at lower risk.