Tia Dickson, RN, BSN

Primary Children's Hospital

Very few calls will impact your life like a call for an unresponsive infant. Unfortunately, many of you will get that call at least once during your career. Babies aren't supposed to die but they sometimes do. We discussed this topic in great detail last month at PETOS and the presentation will be in our archive soon but let us cover the main points now. This is a tough topic but understanding may smooth your way.

Chari Larsen MD, Assistant Professor, University of Utah School of Medicine

Medical Director, Rapid Treatment Unit, Primary Children's Hospital

Excerpts from April 11, 2022 PETOS—BRUE & Safe Sleep: Babies like to make life stressful!

A 10-week old term male infant at home with family. Mom placed infant in pack-n-play and walked out of the room for just a few seconds. When she walked back in, the infant was blue and didn’t seem to be breathing. She picked him up and he was limp. She immediately called 911. After “what felt like an eternity” but was likely less than 30 seconds, he was back to normal without any residual symptoms.

• No shaking. No spit up or vomit present. No sudden death or heart issues in the family. Baby hasn’t been sick at all.
• EMS crew arrives and finds a very normal appearing infant with normal vital signs

These types of events are not uncommon pediatric calls. The estimated incidence is 0.6-5 per 1000 live births. In fact these are common enough that since 1986 they have been labeled Apparent Life-Threatening Events or ALTEs. Before that, these kinds of calls were considered "near-miss SIDS." Both of those terms have become outdated.

Brief Resolved Unexplained Event or BRUE is a term used since 2016. It offers a more precise definition of what occurred. BRUE is a diagnosis of exclusion with added risk stratification and recommendations on what to do with the low-risk infants. EMS crews should be familiar with a BRUE since you are often the first responder to these events.

• Sudden event in an infant <1 year old
• Brief, under 1 minute, usually <20-30 seconds
• Resolved (back to baseline) at time of evaluation, normal exam/vitals
• Not explained by a medical condition
• Event with 1 or more specific characteristics (see table)

-Color change (cyanosis or pallor)
-Absent, decreased or irregular breathing
-Marked change in tone (increased or decreased)
-Altered level of consciousness

1. Follow your protocols. Assess vitals.

• If by time of arrival, the patient still has abnormal vital signs or still has altered tone/LOC or recurring events, they must be seen in an emergency department.

2. Even though events are usually benign in nature, it is recommended all of these infants be evaluated.

• Ideally by a provider with pediatric expertise (locally or via telehealth).
  
• A detailed history and exam is important to make sure we don't miss anything.
  
• There is a hard balance between making sure the family gets care but not scaring them.
  

3. Take a careful history looking for potential causes, screen for:

• GERD
• Seizure
• Respiratory tract infections
• Congenital cardiac defects
• Arrhythmia
• Child abuse

If there are no clear clues in the history, the examining MD will group the infant into a low or high risk group and treatment is recommended based on that stratification.

Historically it was thought that an infant who has had an ALTE or BRUE was at increased risk for Sudden Infant Death Syndrome (SIDS) but it turns out that there is no association between the two.

SUID and SIDS definitions

SUID (Sudden Unexpected Infant Death)

• Inclusive term used to characterize any sudden and unexpected death (whether explained or unexplained) in the first year of life

• Does not have an obvious cause of death before further investigation
• Examples: suffocation, asphyxia, entrapment, infection, ingestions, metabolic diseases, arrhythmias, trauma (NAT-abuse and accidental)
• SIDS is also considered a SUID

SIDS (Sudden Infant Death Syndrome)

• Sudden and unexpected death before 12mo of age that occurs in a previously healthy infant in which the cause of death remains unknown despite a thorough case investigation (Investigation includes: autopsy, death scene investigation, and analysis of the clinical history)

• Not completely preventable

Epidemiology

SUID

• Percentage of SUID events due to accidental/mechanical suffocation and strangulation in bed has increased over time
• 2-4% in 1999 to 23-25% in 2014
• This increase may be related to improved death scene investigations

SIDS

• ~2300 infants die of SIDS each year in the US
• 2nd leading cause of post-neonatal death
• 4th most common cause of death in infancy
• Numbers were declining after the back to sleep initiative but have plateaued in recent years

The most well-known risk factor for SIDS has to do with how an infant sleeps. In 1994 a campaign launched known as "Back to Sleep" and it resulted in a 40% reduction in infant sleep-related deaths.

Research (https://safetosleep.nichd.nih.gov/) has shown that babies are at higher risk of sudden death if they:

• Sleep on their stomachs
• Sleep on soft surfaces or under soft coverings
• Sleep on or under soft or loose bedding
• Get too hot during sleep
• Sleep in an adult bed with parents, other children, or pets. Especially if:
  

-The adult smokes, has recently had alcohol, or is tired

-The baby is covered by a blanket or quilt

-The baby sleeps with more than one bed-sharer

-The baby is younger than 11 to 14 weeks of age

ABC’s of Safe Sleep

• Alone: Infant sleeps alone (not with other people, pillows, crib bumpers, toys, or loose blankets)
• Back: Back to sleep (not on side or stomach)
• Crib: In a crib or other safe infant sleeping location (not on the couch, chair, swing, or other soft surfaces)
• Drug-free home

EMSC is proud to honor Kris Shields as our EMSC Person of the Year 2022!

EMS Awards will be at 10:00am at This is the Place Heritage Park on May 18th.

Despite being a longtime advocate for Utah's EMS as well as an engaged EMSC Coordinator for 30 years, Kris Shields kicked her EMSC involvement into high gear during 2021. Kris is well known throughout Utah County as the Director of EMS Relations for HCA Healthcare, but it is her tireless efforts, strong support, and training of EMSC in Utah County that we want to recognize today. Kris was instrumental in rolling out the Handtevy app, a tool that will improve first responder care of children throughout the state. Kris became one of the first instructors for the tool and sponsored many classes. She organized meetings to introduce the app to important EMS contacts in Utah Valley. She encouraged EMS leaders, and may have twisted a few of their arms, to give the app a chance. She facilitated collecting feedback and making process improvements. With the distractions of COVID and management changes within the EMSC program in 2021 it is wonderful to have a PECC like Kris. Someone willing to take an idea and run with it. She gets the job done and we cannot thank her enough!

West Valley City Fire coordinated efforts to collect and send resources to Ivano-Frankivsk Regional Children's Clinical Hospital in Ukraine. If you want to help, reach out to Brandon Howard, NRP, FP-C at (801)232-0604

Save the Date!

Our 2nd annual PECC Conference is planned for September 16th

PECCs, our annual EMSC Day is always the Wednesday of EMS week so this year it is May 18th. It is a great reason to focus on pediatrics during that week of celebration. Here are some celebration ideas.

For You:

National EMS Week is our annual chance to thank the incredible prehospital practitioners who serve on the front lines of health care every day. On Emergency Medical Services for Children (EMSC) Day, which falls on the Wednesday of EMS Week (May 18 this year), we draw special attention to prehospital practitioners’ commitment to caring for acutely ill and injured children.

In honor of EMSC Day, and in recognition of both the rising incidence of behavioral health emergencies in children and the need to recognize and mitigate secondary trauma in the EMS professional, the EMSC Innovation and Improvement Center is hosting a free, 1-hour webinar, “COPE-ing with the Challenges of Behavioral and Mental Health Emergencies” on May 18 at 1:00 pm ET. This webinar, led by Drs. Nicolaus Glomb, Kenshata Watkins, and Mary Fallat, will explore both prehospital behavioral health emergency management and introduce the Compassionate Options for Pediatric EMS (COPE) program that provides debriefing tools for EMS after responding to challenging pediatric calls. Registration is free and open to all. CE for EMS professionals through Prodigy EMS is available and will meet requirements in either Psychiatric/Mental Health Emergencies or Pediatric Care.

There are many ways to get involved during EMS Week and EMSC Day. The top five ways to recognize EMS practitioners and the important role they play in providing emergency care to children include: organize an EMSC Day proclamation, share information about EMS Week/EMSC Day on your social media channels, deliver thank-you cards to your local EMS agency, and share injury prevention activity sheets. These and other resources can be downloaded by visiting the EIIC’s EMSC Day promotional materials webpage.

To learn more about EMS week, visit the EIIC EMS Week webpage.

Have you attended a home birth transfer of an infant or a mother to a hospital and saw ways the process could be improved? Have you seen midwives who have really great systems and communication and wish they all did? Help us learn how to improve the collaboration and communication about birth transfers by giving feedback to the Utah Women's and Newborns Quality Collaborative!

Find out more about our work and the improvement tools we have created here: https://mihp.utah.gov/uwnqc/out-of-hospital-births

Do you have a question for our EMSC Medical Director, Hilary Hewes, MD, PCH, ER Attending Physician about this newsletter topic or anything related to pediatrics? Shoot an email to the following address tdickson@utah.gov.

Pediatric Education for the Prehospital Provider

Register online at www.peppsite.com. Look up classes in Utah and find the one that works for you. Once you find the class, go to jblearning.com, and look up pepp als in the search tool. Purchase the number ($21.95). Return to peppsite.org to register for the class and follow the prompts.

If you have any questions, please email Erik Andersen at erikandersen@utah.gov or text/call 435-597-7098. Continue to watch the website for additional classes.

The Emergency Medical Services for Children (EMSC) Program aims to ensure that emergency medical care for the ill and injured child or adolescent is well integrated into an emergency medical service system. We work to ensure that the system is backed by optimal resources and that the entire spectrum of emergency services (prevention, acute care, and rehabilitation) is provided to children and adolescents, no matter where they live, attend school, or travel.

Email: tdickson@utah.gov
Website: https://bemsp.utah.gov/
Phone: 801-707-3763
Facebook: facebook.com/Chirp-UtahDepartmentofHealth