identify if they did not witness the episode and the neurologic examination is normal in the postictal period Apnea may be a symptom of several systemic disease processes, including sepsis and metabolic abnormalities that result in hypoglycemia Congenital abnormalities must always be considered in newborns and in young infants Prolongation of the QT interval can cause a dysrhythmia that manifests as a BRUE or ALTE Finally, there have been well-substantiated reports of apnea as the result of life-threatening child abuse such as Munchhausen syndrome by proxy or inflicted head injury Frequently, no cause for the apneic episode is identified The risk of sudden infant death syndrome (SIDS) for an infant who has a BRUE or ALTE is of great concern to both parents and physicians Multiple studies have identified no causal relationship between BRUE/ALTE and SIDS Furthermore, although the rate of SIDS in the United States has dropped dramatically since 1992 when the American Academy of Pediatrics recommended that infants be placed supine or on the side during sleep, there has been no change in the incidence of ALTEs In addition, the vast majority of SIDS events occur at night, whereas infants typically experience BRUEs or ALTEs during the day The peak incidence of ALTEs is during the first months of life while SIDS occurs most frequently in older infants between and months of life TABLE 14.1 COMPARISON BRUE VERSUS ALTE BRUE Definition Inclusion criteria (any finding) ALTE Diagnosis of exclusion—no Chief complaint and other explanation for diagnosis event based on history and physical examination Based on clinician’s Based on caregiver’s characterization of the perception of the event event Cyanosis or pallor Any color change (cyanosis, pallor, plethora, erythema) Absent, decreased, or Apnea (central or irregular respirations obstructive) Hyper or hypotonia Change in muscle tone Altered level of Frightening to the caregiver responsiveness Choking or gagging TABLE 14.2 CRITERIA FOR LOWER RISK INFANT WITH BRUE Age >60 days Gestational age ≥32 wks and postconceptional age ≥45 wks First BRUE episode Episode lasted