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- BRUE has a strict age limit < 1yo
An episode that is frightening to the observer and is characterised by some combination of:
- apnoea (central or obstructive)
- colour change (cyanotic, pallid, or plethoric)
- change in muscle tone (usually diminished but may be stiffening)
- choking or gagging
- decreased consciousness
- Less than one minute duration but typically 20 – 30 seconds.
- Accompanied by a return to a baseline state
- Not explained by identifiable medical conditions.
Many parents/ carers will believe that the child is dead or going to die.
History should be taken, ideally first-hand, from persons who observed the infant during or immediately after the event.
- Description of event:
- Choking, gagging
- Breathing: yes/no or attempting to breathe
- Colour and colour distribution: normal, cyanosis, pallor, plethora
- Conscious state: responsive to voice, touch, or visual stimulus.
- Tone: stiff, floppy, or normal
- Movement including eye movements: purposeful, repetitive, or flaccid
- Circumstances and environment prior to event:
- Awake or asleep and position (prone / supine / side)
- Relationship of the event to feeding and history of vomiting
- Environment: sleeping arrangement, temperature, bedding
- Availability of items that could be swallowed, cause choking or suffocation.
- Illness in preceding days
- End of event
- Duration of event
- Circumstances of cessation: self-resolved, repositioned, stimulation, mouth to mouth, chest compressions
- Recovery phase: Rapid or gradual
- Residual symptoms
- Other history:
- Past medical history including previous events
- Sick contacts
- Family history of sudden death or significant childhood illness.
- Age less than 28 days
- Significant prematurity
- Significant prior medical illness
- Clinically unwell looking, abnormal physical examination
- Recurrent events before presentation
- More severe/prolonged ALTE symptoms and need for resuscitation measures
- Colour change (cyanosis or severe pallor)
- Absence of upper respiratory symptoms or a history of choking
If the infant has fully recovered, has benign examination findings and the event meets the criteria for a BRUE, the event can be risk stratified.
A lower risk BRUE occurs when there are no concerning features on history or examination AND:
- Age > 60 days
- Born ≥ 32 weeks gestation and corrected gestational age ≥ 45 weeks
- No CPR by trained healthcare professional
- First event (cannot be lower risk if event has been repeated)
- event lasted < 1 minute
- Vital signs (including oxygen saturations, temperature, HR, RR, BP)
- Blood glucose
- Nasopharyngeal aspirate for viruses
- ECG (measure QT interval)
- Urine dipstick and M,C&S
- Normal physiological response: laryngospasm, gagging
- Inflicted injury: (shaken baby, drug overdose, Factitious illness by proxy or intentional suffocation)
- Infection : Pertussis, septicaemia, pneumonia, meningitis,
- Airway obstruction: congenital abnormalities, infection, hypotonia
- Abdominal: intussusception, strangulated hernia, testicular torsion
- Metabolic problems: hypoglycaemia, hypocalcaemia, hypokalaemia, other inborn errors of metabolism
- Cardiac disease: congenital heart disease, arrhythmias, vascular ring, prolonged QT.
- Respiratory: inhaled FB
- Toxin / Drugs: accidental or non-accidental
- Neurological causes: head injury, seizures, infections, cerebral malformations etc
- Discharge if Term-babies who well on examination,related to feeding
- parents can be reassurance and educated to return if they have further concerns,
- early follow-up with their GP or a paediatrician.
- admit if any concern