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Prezioso G, Perrone S, Biasucci G, Pisi G, Fainardi V, Strisciuglio C, Marzano FN, Moretti S, Pisani F, Tchana B, Argentiero A, Neglia C, Caffarelli C, Bertolini P, Bersini MT, Canali A, Voccia E, Squarcia A, Ghi T, Verrotti C, Frusca T, Cecchi R, Giordano G, Colasanti F, Roccia I, Palanza P, Esposito S. Management of Infants with Brief Resolved Unexplained Events (BRUE) and Apparent Life-Threatening Events (ALTE): A RAND/UCLA Appropriateness Approach. Life (Basel) 2021; 11:171. [PMID: 33671771 PMCID: PMC7926945 DOI: 10.3390/life11020171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Giovanni Prezioso
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | - Serafina Perrone
- Unit of Neonatology, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.P.); (S.M.); (F.C.); (I.R.)
| | - Giacomo Biasucci
- Pediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29122 Piacenza, Italy;
| | - Giovanna Pisi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | - Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | - Caterina Strisciuglio
- Department of Woman, Child and General and Specialistic Surgery, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Francesco Nonnis Marzano
- Department of Chemistry, Life Sciences and Environmental Sustainability, University of Parma, 43126 Parma, Italy;
| | - Sabrina Moretti
- Unit of Neonatology, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.P.); (S.M.); (F.C.); (I.R.)
| | - Francesco Pisani
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | | | - Alberto Argentiero
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | - Cosimo Neglia
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | - Carlo Caffarelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
| | | | - Maria Teresa Bersini
- Primary Care Pediatrics, AUSL of Parma, 43126 Parma, Italy; (M.T.B.); (A.C.); (E.V.)
| | - Andrea Canali
- Primary Care Pediatrics, AUSL of Parma, 43126 Parma, Italy; (M.T.B.); (A.C.); (E.V.)
| | - Emanuele Voccia
- Primary Care Pediatrics, AUSL of Parma, 43126 Parma, Italy; (M.T.B.); (A.C.); (E.V.)
| | - Antonella Squarcia
- Unit of Neuropsychiatry of Children and Adolescents, AUSL Parma, 43126 Parma, Italy;
| | - Tullio Ghi
- Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (T.G.); (T.F.)
| | | | - Tiziana Frusca
- Obstetrics and Gynaecology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (T.G.); (T.F.)
| | - Rossana Cecchi
- Legal Medicine Section, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Giovanna Giordano
- Pathology Unit, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Filomena Colasanti
- Unit of Neonatology, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.P.); (S.M.); (F.C.); (I.R.)
| | - Ilenia Roccia
- Unit of Neonatology, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (S.P.); (S.M.); (F.C.); (I.R.)
| | - Paola Palanza
- Unit of Neuroscience, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy;
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (G.P.); (G.P.); (V.F.); (F.P.); (A.A.); (C.N.); (C.C.)
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Piumelli R, Davanzo R, Nassi N, Salvatore S, Arzilli C, Peruzzi M, Agosti M, Palmieri A, Paglietti MG, Nosetti L, Pomo R, De Luca F, Rimini A, De Masi S, Costabel S, Cavarretta V, Cremante A, Cardinale F, Cutrera R. Apparent Life-Threatening Events (ALTE): Italian guidelines. Ital J Pediatr 2017; 43:111. [PMID: 29233182 PMCID: PMC5728046 DOI: 10.1186/s13052-017-0429-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 08/22/2017] [Indexed: 02/07/2023] Open
Abstract
Five years after the first edition, we have revised and updated the guidelines, re-examining the queries and relative recommendations, expanding the issues addressed with the introduction of a new entity, recently proposed by the American Academy of Pediatrics: BRUE, an acronym for Brief Resolved Unexplained Events. In this manuscript we will use the term BRUE only to refer to mild, idiopathic cases rather than simply replace the acronym ALTE per se.In our guidelines the acronym ALTE is used for severe cases that are unexplainable after the first and second level examinations.Although the term ALTE can be used to describe the common symptoms at the onset, whenever the aetiology is ascertained, the final diagnosis may be better specified as seizures, gastroesophageal reflux, infection, arrhythmia, etc. Lastly, we have addressed the emerging problem of the so-called Sudden Unexpected Postnatal Collapse (SUPC), that might be considered as a severe ALTE occurring in the first week of life.
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Affiliation(s)
- Raffaele Piumelli
- Sleep Breathing Disorders and SIDS Center, Meyer Children's Hospital, Firenze, Italy.
| | - Riccardo Davanzo
- Department of Perinatal Medicine, Institute for Maternal and Child Health-IRCCS Burlo Garofolo, Trieste, Italy
| | - Niccolò Nassi
- Sleep Breathing Disorders and SIDS Center, Meyer Children's Hospital, Firenze, Italy
| | | | - Cinzia Arzilli
- Department of Neuroscience, Psychology, Drug Research and Child Health, University of Florence, Firenze, Italy
| | - Marta Peruzzi
- Sleep Breathing Disorders and SIDS Center, Meyer Children's Hospital, Firenze, Italy
| | - Massimo Agosti
- Neonatal Intensive Care Unit, Del Ponte Hospital, Varese, Italy
| | - Antonella Palmieri
- SIDS Center, Pediatric Emergency Department, "G. Gaslini" Children's Hospital, Genova, Italy
| | - Maria Giovanna Paglietti
- Pneumology Unit - University Hospital Pediatric Department, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
| | - Luana Nosetti
- Paediatric Department, University of Insubria, Varese, Italy
| | - Raffaele Pomo
- SIDS/ALTE Center, Buccheri la Ferla Hospital, Palermo, Italy
| | | | | | | | - Simona Costabel
- Emergency Department of Paediatrics, G. Gaslini Children's Hospital, Genova, Italy
| | | | - Anna Cremante
- National Neurological Institute IRCCS C, Mondino, Pavia, Italy
| | | | - Renato Cutrera
- Pneumology Unit - University Hospital Pediatric Department, Bambino Gesù Children Hospital, IRCCS, Rome, Italy
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Martínez Monseny A, Bobillo Pérez S, Martínez Planas A, García García JJ. [The role of complementary examinations and home monitoring in patient at risk from apparent life threatening event, apneas and sudden infant death syndrome]. An Pediatr (Barc) 2015; 83:104-8. [PMID: 25801068 DOI: 10.1016/j.anpedi.2014.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2014] [Revised: 11/12/2014] [Accepted: 11/14/2014] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Home apnea monitors detect abnormalities in cardiac and respiratory frequency, but their use in the diagnosis of respiratory -related sleep disturbances in children has not been demonstrated, as was originally thought. OBJECTIVE To describe the type of patients being monitored, for how long and their outcome. MATERIAL AND METHODS A retrospective descriptive study was conducted on patients with controlled home cardiorespiratory monitoring from October 2008 to September 2012 in the Outpatient department of a Maternity tertiary hospital. RESULTS During the study period 88 patients were included, 58% of them were male, with a median age of 15.5 days, and followed up for a period of 4.7 months. The reason for monitoring was in a 20.5% due to a history of sudden death without finding underlying pathology in 20.5%, 25% due to apnea of prematurity, 20.5% due to apparent life-threatening event, and 14.8% due to choking. Other causes accounted for 19.3% (apnea/hypopnea, desaturation and periodic breathing). Of these last three groups, pathological events were observed in 50% of them: reflux disease (9), apnea of prematurity (2), neurological causes (3), and apnea of unknown cause (10). CONCLUSIONS Suspected infant apnea is a cause for consultation that creates a great deal of concern to the family and the pediatrician. Home monitoring is useful in detecting changes in cardiac and respiratory frequency, but is necessary to limit its indications and ensure proper monitoring of these patients, avoiding the abuse of other tests or treatments.
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Affiliation(s)
- A Martínez Monseny
- Servicio de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | - S Bobillo Pérez
- Servicio de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
| | - A Martínez Planas
- Servicio de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España.
| | - J J García García
- Servicio de Pediatría, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona, España
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Monasterio V, Burgess F, Clifford GD. Robust classification of neonatal apnoea-related desaturations. Physiol Meas 2012; 33:1503-16. [PMID: 22902971 DOI: 10.1088/0967-3334/33/9/1503] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Respiratory signals monitored in the neonatal intensive care units are usually ignored due to the high prevalence of noise and false alarms (FA). Apneic events are generally therefore indicated by a pulse oximeter alarm reacting to the subsequent desaturation. However, the high FA rate in the photoplethysmogram may desensitize staff, reducing the reaction speed. The main reason for the high FA rates of critical care monitors is the unimodal analysis behaviour. In this work, we propose a multimodal analysis framework to reduce the FA rate in neonatal apnoea monitoring. Information about oxygen saturation, heart rate, respiratory rate and signal quality was extracted from electrocardiogram, impedance pneumogram and photoplethysmographic signals for a total of 20 features in the 5 min interval before a desaturation event. 1616 desaturation events from 27 neonatal admissions were annotated by two independent reviewers as true (physiologically relevant) or false (noise-related). Patients were divided into two independent groups for training and validation, and a support vector machine was trained to classify the events as true or false. The best classification performance was achieved on a combination of 13 features with sensitivity, specificity and accuracy of 100% in the training set, and a sensitivity of 86%, a specificity of 91% and an accuracy of 90% in the validation set.
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Affiliation(s)
- Violeta Monasterio
- CIBER de Bioingenieria, Biomateriales y Nanomedicina (CIBER-BBN), Zaragoza, Spain.
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