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We read with interest the clinical practice guideline by Tieder, et al. (1), proposing the new concept of Brief Resolved Unexplained Events (BRUE) replacing the old concept of apparent life-threatening events (ALTE) and the comments by Tate, et al (2). We agree that the majority of the causes of ALTE are proven not really life-threatening after the evaluation. However, we think that application of the concept of lower risk infants of BRUE and its practical recommendation might be cautious.
We have reported the analysis of 112 cases of ALTE at our institution and eighteen of them had recurrent episodes (3). We also analyzed these 112 cases of ALTE how many of them belong to the lower risk infant group of BRUE. We identified eighteen cases to belong to the lower risk group (unpublished data). Among this group, four of them had ALTE recurrence.
The BRUE guideline recommends that no necessary laboratory work to be avoided in the lower risk infants and it also recommends not to admit these infants to hospital for observation purpose. However, based on our experience, the majority of ALTE infants belong to the higher risk group and 22% (4/18) of lower risk infants presented the recurrent episodes after the first ALTE episode. Therefore, we suggest that the guideline should be examined who are really the lower risk infants and how to manage these lower risk infants, in prospective studies.
Satoshi Nakagawa, Riyo Ueda, and Osamu Nomura
1. Tieder JS,...
1. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life- Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. 2016;137(5):e20160590.
2. Tate C, Sunley R. Brief REsolved unexplained evsents (formerly apparent life-threatening events) and evaluation of lower risk infants. Arch Did Child Educ Pract Ed published online September 18, 2017.
3. Ueda R, Nomura O, Maekawa T, et al. Independent risk factors for recurrence of apparent life-threatening events in infants. Eur J Pedaitr 2017;176:443-448.