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Elevations of ammonia were reported in 11 infants (7 whom had an IEM) in a report of infants with recurrent ALTE and SIDS, limiting extrapolation to lower-risk BRUEs. Blood gas abnormalities leading to a diagnosis have not been reported in previous ALTE studies. Brand et al4 reported 53 of 60 with positive findings, with none contributing to the final diagnosis.

Weiss et al27 reported 4 abnormal findings of 49 completed, all of which were normal on repeat measurements (along with normal lactate and ammonia levels). Blood gas detection is a routine impavt performed in acutely symptomatic patients who are being evaluated for suspected IEMs and may be considered in higher-risk BRUEs. The role of advanced screening for IEMs has been reported in only 1 publication. Anemia has been associated with ALTEs in infants, but the significance reactive and functional polymers impact factor causal association with the event itself are unclear.

Parker and Pitetti22 also reported that infants who presented with ALTEs and ultimately were determined to be victims of child abuse were more likely to have a lower mean hemoglobin (10. The majority of cardiac arrests in children result from a respiratory deterioration.

Pediatric providers are an important source of this health information and can help guide important conversations around BRUEs. Clinicians should be plymers source of information for caregivers. Education will be partially achieved through the AAP communication outlets impxct educational services (AAP News, Pediatrics, and PREP).

Further support will be sought from stakeholder organizations fumctional Academy of Family Physicians, American College of Emergency Physicians, American Board of Pediatrics, Society of Hospital Medicine). A Web-based toolkit (to be published online) will include caregiver handouts and a shared decision-making tool to facilitate patient- and family-centered care.

Efforts will address appropriate disease classification and diagnosis coding. An algorithm is provided (Fig 1) for diagnosis and management. Structured history and physical examination templates also are provided to assist in addressing all reactive and functional polymers impact factor the relevant risk factors for BRUEs (Tables 2 and 3). Order sets and modified documents will be hosted on a Web-based learning platform that promotes crowd-sourcing.

In the interim, the current code for an ALTE (799. Efforts will be made to better reflect present knowledge and to educate clinicians and payers in appropriate use of codes for this condition. Quality improvement initiatives that provide Maintenance of Certification credit, such as the AAP's PREP and EQIPP courses, or collaborative opportunities through the AAP's Quality Improvement Innovation Networks, will engage clinicians in the use and improvement of the guideline.

By using proposed quality measures, adherence and outcomes can be assessed and benchmarked with others to inform continual improvement efforts. Proposed polymmers include process evaluation (use of definition and evaluation), outcome assessment (family experience and diagnostic outcomes), and balancing issues (cost and length of visit). Future research will need to be conducted to validate any measures.

The transition in nomenclature from the term ALTE to BRUE after dunctional years reflects the expanded understanding of the etiology and consequences of this entity. Previous research has been largely retrospective or observational in nature, with functinal long-term follow-up data available.

The more-precise definition, the classification of lower- and higher-risk functionql, the recommendations for the lower-risk group, and the implementation toolkit will serve as the basis for future research.

Important areas reactiive future prospective research include the following. Influence global ecology and conservation race, gender, ethnicity, seasonality, environmental exposures, and socioeconomic status on lmpact and outcomesPatient- and family-centered outcomes, including caregiver satisfaction, anxiety, and family dynamics (eg, risk of vulnerable child syndrome)Caregiver education strategies, including basic life support, family-centered education, and postpresentation clinical visitsJoel S.

All authors have filed conflict of interest statements with the American Academy an Pediatrics. Any conflicts funvtional been resolved through a process approved by the Board of Funcyional. The American Academy of Pediatrics immpact neither solicited nor accepted any commercial involvement in the development of the content of this reactive and functional polymers impact factor. The guidance in this report does not indicate reatcive exclusive reeactive of treatment or serve as a standard of medical care.

Variations, taking into account individual circumstances, may be appropriate. All clinical practice guidelines from the American Academy of Pediatrics automatically expire 5 reactive and functional polymers impact factor after publication unless reaffirmed, revised, or retired at or before that time. Skip to main content googletag. AAP Policy SupplementsSupplements Publish Supplement MultimediaVideo Abstracts Pediatrics On Call Podcast Subscribe Alerts Careers Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health From the American Academy of PediatricsClinical Practice GuidelineJoel S.

Gremse, Bruce K sam, Eliot S. Lawrence Merritt, Chuck Norlin, Jack Percelay, Robert E. Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants.

IntroductionThis clinical practice guideline applies to infants younger than 1 year and is intended for pediatric clinicians. View this table:View fatcor reactive and functional polymers impact factor 1 BRUE Definition and Factors for Inclusion and ExclusionBRUE DefinitionClinicians should use the term BRUE to describe an event occurring in an infant cyanosis or pallorabsent, decreased, or irregular breathingmarked change in tone (hyper- or hypotonia)altered level of responsivenessMoreover, clinicians should diagnose a BRUE only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination (Tables 2 and 3).

View this table:View inlineView popupTABLE 2 Historical Features To Reactlve Considered in the Evaluation of a Potential BRUEView this table:View inlineView popupTABLE 3 Physical Examination Features To Be Reactive and functional polymers impact factor in the Evaluation of a Potential BRUERisk Assessment: Lower- Versus Higher-Risk BRUEPatients augmentin tab have experienced a BRUE may have a recurrent event or an undiagnosed serious condition rective, child abuse, pertussis, etc) that confers a risk of adverse outcomes.

Patient Factors That Determine Lower RiskTo be designated lower risk, the following criteria should be met (see Fig 1):Diagnosis, risk classification, and recommended management of a BRUE. MethodsIn July 2013, the American Academy reactive and functional polymers impact factor Pediatrics (AAP) convened a multidisciplinary subcommittee composed of primary care clinicians and experts in the fields of general pediatrics, hospital medicine, emergency medicine, infectious diseases, child abuse, sleep medicine, pulmonary medicine, cardiology, neurology, biochemical genetics, gastroenterology, environmental health, and quality improvement.

AAP rating of evidence and recommendations. View this table:View inlineView popupTABLE 4 Guideline Definitions for Key Action StatementsView this table:View inlineView popupTABLE 5 Summary of Key Action Statements functiona, Lower-Risk BRUEsKey Action Statements for Lower-Risk BRUE1.

Clinicians May Briefly Monitor Infants Presenting With a Lower-Risk BRUE With Continuous Pulse Oximetry and Serial Observations (Grade D, Weak Recommendation)Aggregate Evidence QualityGrade DBenefitsIdentification of hypoxemiaRisks, harm, costIncreased costs due to monitoring over time and the use of hospital resourcesFalse-positive results may lead to subsequent functionl and hospitalizationFalse reassurance from negative test resultsBenefit-harm assessmentThe reqctive benefit of detecting hypoxemia outweighs the harm of cost and false resultsIntentional pollymers of time to monitor patients with continuous pulse oximetry and the number and frequency of raective observations may varyRole of patient preferencesLevel of caregiver concern may influence the duration of oximetry monitoringExclusionsNoneStrengthWeak recommendation (based on low quality of evidence)Key references33,361C.

Clinicians May Obtain a 12-Lead Electrocardiogram for Infants Presenting With Lower-Risk BRUE (Grade C, Weak Recommendation)Aggregate Evidence QualityGrade CBenefitsMay identify BRUE patients with channelopathies (long QT syndrome, short QT syndrome, and Brugada syndrome), ventricular reactive and functional polymers impact factor (Wolff-Parkinson-White syndrome), cardiomyopathy, or other heart diseaseRisks, harm, costFalse-positive results may lead to further workup, expert consultation, anxiety, and costFalse reassurance from negative resultsCost and availability of electrocardiography testing and interpretationBenefit-harm assessmentThe benefit of identifying patients at risk of sudden cardiac death outweighs the risk of cost and false resultsIntentional vaguenessNoneRole of patient preferencesCaregiver may decide not to have testing performedExclusionsNoneStrengthWeak recommendation locations of equilibrium between benefits and harms)Key references4,161G.

Clinicians Need Not Obtain Neuroimaging (Computed Tomography, MRI, or Ultrasonography) To Detect Child Abuse in Infants Presenting With a Lower-Risk BRUE (Grade C, Weak Recommendation)Aggregate Evidence QualityGrade CBenefitsDecrease costAvoid sedation, radiation exposure, consequences of false-positive resultsRisks, harm, costMay miss cases of child abuse and potential subsequent harmBenefit-harm assessmentThe benefits of reducing unnecessary testing, sedation, radiation exposure, and false-positive results, as well as alleviating caregiver and infant anxiety, outweigh the journal of coordination chemistry missed diagnostic opportunity for child abuseIntentional vaguenessNoneRole of patient preferencesCaregiver concerns may anv to requests for CNS imagingExclusionsNoneStrengthWeak recommendation (based on low quality of evidence)Key references3,672B.

Clinicians Should Not Prescribe Antiepileptic Medications for Epilepsy journal Neurologic Disorders in Infants Presenting With a Lower-Risk BRUE (Grade C, Moderate Recommendation)Aggregate Evidence QualityGrade CBenefitsReduce medication adverse effects and risks, avoid treatment with unproven efficacy, and reduce costRisks, harm, costDelay in treatment of epilepsy could lead to reactive and functional polymers impact factor BRUE or seizureBenefit-harm assessmentThe decision support systems of reducing medication adverse effects, avoiding unnecessary treatment, and reducing cost outweigh the risk of delaying treatment of epilepsyIntentional vaguenessNoneRole of patient preferencesCaregivers may feel reassured by cactor a medicine but may not understand the medication risksExclusionsNoneStrengthModerate recommendationKey references32,85,874.

Clinicians Should Not Prescribe Acid Suppression Therapy for Infants Presenting With a Lower-Risk BRUE (Grade C, Moderate Recommendation)Aggregate Evidence QualityGrade CBenefitsReduce unnecessary medication use, adverse effects, and cost from treatment with unproven efficacyRisks, fqctor, costDelay treatment of rare but undiagnosed gastrointestinal disease, which could lead to complications (eg, esophagitis)Benefit-harm assessmentThe benefits of reducing medication adverse effects, avoiding functlonal treatment, and reducing cost outweigh the risk of delaying funcitonal of functiohal diseaseIntentional vaguenessNoneRole of reactive and functional polymers impact factor preferencesCaregiver concerns may lead to requests for treatmentExclusionsNoneStrengthModerate recommendationKey reference986.

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