SIDS, BRUE, and Safe Sleep Guidelines Maria Behnam-Terneus, DO,* † Melissa Clemente, MD* *Division of Pediatric Hospital Medicine and † Medical Education Department, Nicklaus Children’s Hospital/Nicklaus Children’s Health System, Miami, FL Practice Gaps In 2016, the American Academy of Pediatrics (AAP) published a clinical practice guideline in which they recommended redefining apparent life- threatening event with the more specific term brief resolved unexplained event (BRUE). The purpose of this review is to detail how to apply the BRUE classification guidelines in practice. The recently updated AAP guidelines for sudden infant death syndrome prevention and safe infant sleeping environment are also discussed. Objectives After completing this article the reader should be able to: 1. Distinguish and explain the defining characteristics and epidemiology of sudden unexpected infant death, sudden infant death syndrome (SIDS), brief resolved unexplained event (BRUE), and apparent life- threatening event. 2. Apply the new BRUE guidelines and risk stratification to determine lower-risk versus higher-risk patients. 3. Review management recommendations for lower-risk BRUE. 4. Delineate risk factors and prevention recommendations for SIDS. 5. Explain the updated American Academy of Pediatrics recommendations for a safe infant sleeping environment. INTRODUCTION In April 2016, the American Academy of Pediatrics (AAP) published a new clinical practice guideline for brief resolved unexplained events (BRUEs). This new term, risk classification, and management recommendations replaced what was formerly known as an apparent life-threatening event (ALTE). BRUE describes transient events without a clear etiology after a thorough medical evaluation by a clinician, in contrast to ALTE, in which the definition refers to the subjective experience of a frightening event by a caregiver is detailed. In addition, the new guideline recommendations differentiate a BRUE from episodes that might warrant further investigation secondary to an increased risk of a serious underlying condition. The purpose of this review is to clarify the differences between these 2 definitions, as well as to distinguish them from sudden infant death syndrome AUTHOR DISCLOSURE Drs Behnam-Terneus and Clemente have disclosed no financial relationships relevant to this article. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. ABBREVIATIONS AAP American Academy of Pediatrics ALTE apparent life-threatening event BRUE brief resolved unexplained event CPSC Consumer Product Safety Commission SIDS sudden infant death syndrome SUID sudden unexpected infant death Vol. 40 No. 9 SEPTEMBER 2019 443 at Siu School Of Medicine on December 3, 2019 http://pedsinreview.aappublications.org/ Downloaded from
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*Division of Pediatric Hospital Medicine and †Medical Education Department, Nicklaus Children’s Hospital/Nicklaus Children’s Health System, Miami, FL
Practice Gaps
In 2016, the American Academy of Pediatrics (AAP) published a clinical
practice guideline in which they recommended redefining apparent life-
threatening event with the more specific term brief resolved unexplained
event (BRUE). The purpose of this review is to detail how to apply the BRUE
classification guidelines in practice. The recently updated AAP guidelines
for sudden infant death syndrome prevention and safe infant sleeping
environment are also discussed.
Objectives After completing this article the reader should be able to:
1. Distinguish and explain the defining characteristics and epidemiology
of sudden unexpected infant death, sudden infant death syndrome
(SIDS), brief resolved unexplained event (BRUE), and apparent life-
threatening event.
2. Apply the new BRUE guidelines and risk stratification to determine
lower-risk versus higher-risk patients.
3. Review management recommendations for lower-risk BRUE.
4. Delineate risk factors and prevention recommendations for SIDS.
5. Explain the updated American Academy of Pediatrics
recommendations for a safe infant sleeping environment.
INTRODUCTION
In April 2016, the American Academy of Pediatrics (AAP) published a new
clinical practice guideline for brief resolved unexplained events (BRUEs). This
new term, risk classification, and management recommendations replaced
what was formerly known as an apparent life-threatening event (ALTE). BRUE
describes transient events without a clear etiology after a thorough medical
evaluation by a clinician, in contrast to ALTE, in which the definition refers to
the subjective experience of a frightening event by a caregiver is detailed. In
addition, the new guideline recommendations differentiate a BRUE from
episodes that might warrant further investigation secondary to an increased
risk of a serious underlying condition.
The purpose of this review is to clarify the differences between these 2
definitions, as well as to distinguish them from sudden infant death syndrome
AUTHOR DISCLOSURE Drs Behnam-Terneusand Clemente have disclosed no financialrelationships relevant to this article. Thiscommentary does not contain a discussionof an unapproved/investigative use of acommercial product/device.
ABBREVIATIONS
AAP American Academy of Pediatrics
ALTE apparent life-threatening event
BRUE brief resolved unexplained event
CPSC Consumer Product Safety
Commission
SIDS sudden infant death syndrome
SUID sudden unexpected infant death
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overbundling or head covering. It is safer to use no more
than 1 layer over what an adult would wear in the same
environment, such as 1 layer of clothing with a wearable
blanket. They also endorse parents to “room-share” with
the infant up to at least 6 months of age, but infants
should not “bed-share,” which includes sleeping in the
caregiver’s bed, couches, or any type of chair. (1)
It is also important for all health-care providers, including
staff in the nursery and the NICU, and any child care clinician
to model and endorse the safe sleep recommendations to
caregivers. It is important to approach parents in a nonjudg-
mental way and to continue to reaffirm safe sleep recommen-
dations during a baby’s first year. (1) These recommendations
have been publicized as the “ABCs of Safe Sleep: Alone, Back,
and Crib” at national, state, and local advocacy efforts and
adapted by various agencies. “Alone” refers to only the infant
being in the crib and excluding any caregivers, toys, pillows,
blankets, or bumpers from the crib. “Back” refers to supine
positioning for every sleep. “Crib” is for the use of a crib for
infant sleep that adheres to CPSC standards. (16)
Breastfeeding is also a strong recommendation. In 2016,
the authors of the AAP guidelines cited a meta-analysis of 18
studies on breastfeeding that showed reduced risk of SIDS. In
this 2011 study, it was concluded that the breastfeeding was
“protective against SIDS, and this effect is stronger when breast-
feeding is exclusive.” (17) An additional 2017 study by the same
authors, published after the safe sleep recommendations, looked
at what the duration of breastfeeding should be to show pro-
tection against SIDS. After conducting a multivariable pooled
analysis, authors found that a minimum of 2 months of any
breastfeeding, either exclusive or partial, was necessary to have
significant protection against SIDS and that it decreased the risk
by approximately 50%. (18) It was also found that “the protective
benefits of breastfeeding increase as the duration increases,”
which helps to reinforce the AAP recommendations of breast-
feeding for at least 6 months. (1)(18) These findings further
encourage clinicians to reassure parents that any breastfeeding,
whether exclusive or with formula supplementation, past the
infant’s age of 2 months significantly reduces the risk for SIDS.
Moreover, pacifiers have also been shown to have a protective
effect and as such should be used during daytime naps or
nighttime sleep; however, the mechanism as to why pacifiers
offer decreased SIDS risk is not yet known. A pacifier does not
need to be reinserted if it falls out. Its use may be delayed in
breastfeeding infants until breastfeeding is well established. Pac-
ifiers should not be placed around the neck (pacifier necklace) or
attached to the baby’s clothes or a stuffed toy because pacifier use
in this manner may cause strangulation or suffocation. (19)
In addition, “A” recommendations continue to advise
all women to have regular prenatal care. Women should
avoid any smoking, alcohol use, and illicit drug use
during pregnancy and after giving birth because there
is a proven increase in SIDS risk. (1) Children should
follow the AAP and Centers for Disease Control and
Prevention (CDC) immunization schedule, and it is
important to emphasize this to families as part of SIDS
prevention. (20) Data affirm that scheduled vaccinations
are protective and do not contribute to SIDS risk. (21)
“B” Level Recommendations (Inconsistent or Limited-Quality Patient-Oriented Evidence)Moderate-level recommendations reaffirm that the routine use
of homeapneamonitors in infants (includingpretermand those
with a sibling who died of SIDS) is not recommended because
monitor use has not proved to reduce the incidence of SIDS.
(1)(22) At this time, there are also no studies on the use of
commercially available vital sign and sleep monitoring systems
to reduce the risk of SIDS. (1) Caregivers ought to be advised that
these devices have not been proven to prevent SIDS and may
lead to false reassurance and false alarms that could lead to
unnecessary tests, overdiagnosis, and increased caregiver anx-
iety. (23) Furthermore, supervised “tummy time”when an infant
is awake is recommended tohelpwith thedevelopmentofmotor
milestones and avoidance of positional plagiocephaly, but prone
positioning should otherwise not be used for sleeping. (1)
“C” Level Recommendations (Based on Consensus,Disease-Oriented Evidence, Usual Practice, ExpertOpinion, or Case Series)There is a paucity of evidence to suggest that swaddling
reduces SIDS risk. (1) Some studies show that mortality may
increase if the swaddled baby rolls or is placed into a position
other than supine. (6)
Last, there should be continued research into the etiology
of SIDS, the provision of training for all health-care workers
on risk mitigation, improved surveillance, and establish-
ment of evidence-based standardized protocols, as well as
funding for public education campaigns. These continued
efforts by many will help to achieve the ultimate goal of
ending all SIDS events. (1)
ACKNOWLEDGMENT
The authorswould like to thankDr Joel S. Tieder for his insight
and expertise into the topic of BRUE as well as his assistance
and comments, which greatly improved the manuscript.
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References for this article are at http://pedsinreview.aappubli-
cations.org/content/40/9/443.
Summary• By consensus, the term apparent life-threatening event (ALTE)should no longer be used, and the term brief resolved unexplainedevent (BRUE) should be applied only if the specific event criteriaare met.
• By consensus, a BRUE must be further classified as lower risk(follow management recommendations as outlined) or higherrisk (manage based on physician determination for the specificevent).
• By strong evidence, ALTE/BRUE is not related to sudden infantdeath syndrome (SIDS), and interventions that have reduced SIDShave not reduced ALTE events.
• By strong evidence, clinicians should be aware of safe sleeprecommendations for infants and reinforce their importanceduring infancy as part of routine anticipatory guidance to families.
To view teaching slides that accompany this article,
visit http://pedsinreview.aappublications.org/
content/40/9/443.supplemental.
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1. A 4-month-old previously healthy child is found unresponsive in bed at 7 AM. The familycalls 911 and the infant is rushed to the emergency department (ED) by emergencymedical services with cardiopulmonary resuscitation in progress. After 15 minutes ofresuscitative efforts in the ED, the child is pronounced dead. Investigation by the medicalteam, detectives, and later autopsy show no cause for the death. Based on the standarddefinitions currently in use, which of the following categories best describes this event?
2. A 3-month-old infant is brought to the ED after an episode at home that caused briefchoking and cyanosis. Her mom states that the infant was given her usual feed of 4 oz offormula from the bottle, and 30 minutes later the mother found her gasping and chokingin bed, with formula coming from her mouth and bluish discoloration to her face andhands. Themother picked her up, patted her on the back, and cleared the airway. She gaveher baby 2 breaths by mouth but did not perform cardiopulmonary resuscitation. Theentire episode lasted approximately 30 seconds. She rushed her baby to the hospital,where the physical examination is completely normal. This infant was born at term and hasnever had an episode like this before. Growth and development are appropriate for age.Based on the available information, which of the following is the most likely diagnosis inthis patient?
A. ALTE.B. BRUE, high risk.C. BRUE, low risk.D. Choking with reflux.E. SIDS.
3. For the scenario described in question 2, which of the following is the best next step in themanagement of this patient?
A. Hospitalize for cardiorespiratory monitoring.B. Obtain a chest radiograph.C. Order a complete blood cell count and metabolic panel.D. Order blood for genetic testing.E. Send the child home after reassuring the mother.
4. The mother of a 3-week-old boy who died of SIDS 6 months ago embarks on a mission toraise awareness and educate about ways to prevent SIDS. She establishes a nonprofitorganization that provides a support group for mothers of infants who died of SIDS. Shealso provides educational awareness targeting parenting classes of expectant parents andproviding themwith ways to prevent the occurrence of SIDS. In her educational messages,she warns about which of the following conditions that have been positively associatedwith an increased risk of SIDS?
A. ALTE.B. BRUE, high risk.C. BRUE, low risk.D. Pacifier use during daytime sleep.E. Placing the child in a prone position to sleep.
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5. The parents of a normal term newborn infant ask you about the use of infant monitors.They would like to use one for their child because a friend of theirs had an infant who diedof SIDS. Which of the following is the best information you can give them about infantmonitors and SIDS?
A. Home monitor use has substantially reduced the rate of SIDS in term infants.B. Home monitors are recommended only for infants whose sibling died of SIDS.C. Home monitors have been shown to reduce the rate of SIDS in children with
congenital heart disease.D. Home monitors have been shown to reduce the rate of SIDS in premature infants.E. Home monitors have not been shown to reduce the rate of SIDS.
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DOI: 10.1542/pir.2017-02592019;40;443Pediatrics in Review
Maria Behnam-Terneus and Melissa ClementeSIDS, BRUE, and Safe Sleep Guidelines
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