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A concerned parent witnessed a brief episode of young baby (1mo to 12mo) being unwell. Baby is completely back to normal, but they came in to ED for a checkup. This is not an uncommon situation – very often, nothing will be found, but you need to be reasonably certain that there are no red flags that are being missed. Here is a stepwise approach.

If there are any red flags or positive findings on assessment below, a paediatrics admission is indicated. Book a paediatrics bed and handover to the paediatrics registrar – if they request to review the patient, it could happen in ED or the wards – “Awaiting paeds reg review” does not delay transfer to the paediatrics ward.

Step 0: Reply to triage nurse. Reassure Parent. Request the following early:
– ECG
– VBG (glucose / lactate)
– WCC CRP
– U&E CMP (electrolyte abnormalities

“We will need to make sure bub is ok, and I will be doing some rather specific investigations. Blood pressure, oxygen levels, heart rate, ECG and blood sugar for a start. I will also be examining bub for some specific things. If everything checks out, then we could safely say there is very low risk of anything sinister happening. These episodes are usually caused by a heightened airway reflex when feeding or having upper airway secretions.”

Step 1: Is it actually a BRUE?
baby is < 12 months old.
sudden onset. Quick return to baseline.
Had one of the following:
cyanosis/pallor
absent, decreased, or irregular breathing.
change in tone (hypertonia or hypotonia)
altered level of responsiveness

*document as much details of the event as possible. where? who witnessed? preceeding events? temporal relationship to feeds? any choking or gagging? change in skin color? working hard to breathe? movement of limbs? eyes open/closed? how long did it last? how did it stop?

Step 2: Are there any high risk criteria?
age > 60 days
not premature: born >32/40, with corrected gestational age > 45 weeks
no CPR by trained professional
first event (ie. Not recurrent)
event lasted < 1 minute

Step 3: Check it is not explainable by any medical conditions
Airway:
– No noisy breathing, congenital issues (laryngomalacia), suspicion of inhaled FB
Breathing:
– Saturating well on room air
– No grunting, rib retractions, wheeze, tachypnoea, nasal flaring.
Circulation:
– Normal ECG, with normal QT, no sx brugadas or WPW. No malignant arrhythmia suspected.
– Normal blood pressure.
Infection
– No tense fontanelle. Normal limb movements. Equal pupils. Moving neck freely.
– Chest clear
– No rash.
– ENT exam unremarkable (throat / ears)
Metabolic/Endocrine
– BSL normal
– Hypokalaemia/Hypocalcaemia: No U waves on ECG. No tetany or hyperreflexia.
No suspicion of NAI:
– No injury to (TEN4FACES) – Torso, Ear, Neck <4yo. Frenulum. Angle of jaw. Cheek. Eyelid. Sclera at any age.
– No growth issues / Failure to thrive: Meeting targets on growth chart.

Step 3: Discharge Planning
– Check in with mother (post natal depression screen): Laugh? Enjoyment? Self blame? Anxious? Scared? Unhappy? Miserable?
– Letter to GP for review in 1-2 days.
– Handout provided (of your choice – choose one from a reputable government agency or hospital)