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Gastrooesophageal reflux in infants
The BRUE guideline replaces the Apparent Life Threatening Event (ALTE) guideline. The ALTE is an older descriptive term for events that are characterised by some combination of “apnoea, colour change, change in muscle tone, or choking and gagging and are frightening to the observer”. This term has been replaced as it described events that ranged from normal physiological events to pathological events and so was not useful in determining diagnosis, treatment or prognosis.
A BRUE (Brief Resolved Unexplained Event) refers to an episode in an infant less than 12 months old which is:
The assessment of the event should be directed at determining the cause of the event and assess for risk factors for recurrence. The differential diagnoses of these events are broad.
History should be taken, ideally first-hand, from persons who observed the infant during or immediately after the event.
A detailed general physical examination is required, bearing in mind the differential diagnoses.
It is common for no specific diagnosis to be made after evaluation and a period of observation. The most common cause of these events is thought to be exaggerated airway reflexes in the setting of feeding, reflux, or increased upper airway secretions.
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:
A lower risk BRUE is unlikely to represent a presentation of a severe underlying disorder and is unlikely to recur.
A lower risk BRUE does not require any investigations. Depending on clinical suspicion, an ECG and pertussis swab may be performed.
For similar events that fall outside the lower risk BRUE criteria, consider performing the following investigations
If the infant requires ongoing acute treatment, the event is not considered to be a BRUE.
Infants who have had a lower risk BRUE may be discharged safely if their parents feel reassured and capable of caring for their infant at home. It should be acknowledged with the family, that these events are highly anxiety provoking and parents often feel that their child has nearly died.
If discharged, it is recommended that these infants have early medical follow up. In practice, many infants with a lower risk BRUE are admitted to hospital for observation.
Patients with a higher risk BRUE may still have a benign cause for their symptoms but should be admitted for observation, cardiorespiratory monitoring and paediatric review.
The event does not meet lower risk BRUE criteria.
There is a concern of a serious underlying disorder.
For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.
There is low clinical suspicion of a serious underlying disorder and the parents are reassured.
Last Updated August, 2017