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Summary
Brief resolved unexplained events (BRUE) are sudden, brief, resolved events characterized by transient cyanosis, pallor, change in muscle tone, altered level of responsiveness, and/or absent, decreased, or irregular breathing in an infant less than 1 year of age. If the cause is identified, the event is no longer considered a BRUE. Management is based on risk category. Infants with low-risk BRUE criteria can often be managed as outpatients with minimal early testing. Management for infants with high-risk BRUE criteria includes admission, expert consultation, feeding evaluation, and laboratory studies. Most BRUE remain unexplained even after investigation.
Definitions
Brief resolved unexplained event (BRUE) [1]
- A sudden, brief, and resolved event in a child < 1 year that includes ≥ 1 of the following features:
- No explanation for the event after history and physical examination
BRUE is a diagnosis of exclusion and is no longer applicable once the cause has been identified. [1]
Apparent life-threatening event (ALTE) [1][2]
- An episode of apnea, color or muscle tone change, choking, and/or gagging that is frightening to the observer
- A historical term that is no longer recommended by the American Academy of Pediatrics
Epidemiology
- ∼ 4/1000 live births [3]
- ♂ = ♀
Epidemiological data refers to the US, unless otherwise specified.
Classification
BRUE risk criteria accurately identify patients at low risk for serious underlying pathology, but even high-risk infants are unlikely to have a serious underlying pathology. [4]
Low-risk BRUE criteria [1]
A BRUE is classified as low-risk if it fulfills all of the following criteria:
- Age > 60 days
- Gestational age ≥ 32 weeks at birth and postconceptional age ≥ 45 weeks
- Duration < 1 minute
- First BRUE
- No CPR by a trained medical provider
- No concerning findings on history and physical examination
High-risk BRUE criteria [5]
A BRUE is classified as high-risk if it fulfills any of the following criteria:
- Age ≤ 60 days
- Prematurity (gestational age < 32 weeks, postconceptional age < 45 weeks)
- Duration ≥ 1 minute
- Recurrent events or clusters of events in the first episode
- CPR from trained medical provider
- Concerning findings on history and physical examination, e.g.:
- Feeding and/or respiratory issues
- Family history of sudden death before 35 years of age
- Bruising, choking, and/or coughing
Differential diagnoses
The following conditions may initially present as a BRUE:
- Gastroenterological
- Infectious
-
Neurological
- Seizures and epilepsy
- Neuromuscular disorders
- Respiratory
- Cardiac
- Other
The differential diagnoses listed here are not exhaustive.
Management
Approach [1][5][6]
- Perform a primary survey.
- Monitor the infant with continuous pulse oximetry and serial examinations.
- Complete a thorough pediatric history and physical examination, including:
- Prematurity and postconceptional age < 45 weeks
- Injuries suggesting child maltreatment
- Feeding difficulties, reflux symptoms
- Recent respiratory infection
- Cause identified: Start cause-specific treatment.
- Unknown cause: Assign a diagnosis of BRUE.
- Determine whether the child meets low-risk BRUE criteria or high-risk BRUE criteria.
- Begin management based on risk category.
Maintain a low threshold for admission and specialist consultation in infants with high-risk BRUE, as they have more adverse outcomes, more frequent recurrences, and a higher risk of a serious underlying condition than low-risk patients. [4]
Management of low-risk BRUE [1]
Use shared decision-making with parents and/or guardians when determining management.
Diagnosis
- Consider pertussis testing and 12-lead ECG.
- The following studies are not routinely recommended but may be considered based on clinical suspicion:
- Respiratory viral panel
- Urinalysis
- Serum glucose, lactate, and bicarbonate
- CT or MRI head
Disposition
- Consider access to health care, caregiver anxiety, and shared decision-making concerns when determining disposition.
- Admission solely for cardiorespiratory monitoring is not typically recommended.
- If the patient is discharged, arrange follow-up with a primary care physician or pediatrician.
- Educate caregivers on BRUE and SIDS prevention.
- Recommend CPR training to caregivers.
Home cardio-respiratory monitoring is not recommended for low-risk BRUE. [1]
Management of high-risk BRUE [5]
All patients require further diagnostic testing and continuous pulse oximetry monitoring for ≥ 4 hours.
Diagnosis
-
All patients
- ECG
- Respiratory viral panel
- Pertussis testing
- Hematocrit
- Serum glucose, lactate, and bicarbonate or venous blood gas
- Bedside feeding examination
-
Suspected child maltreatment
- CT or MRI head
- Skeletal survey
-
Advanced testing based on clinical suspicion
- Echocardiogram: to identify congenital heart disease
- Videofluoroscopic swallowing study: to evaluate for swallowing dysfunction
- Polysomnography: to distinguish between obstructive and central sleep apnea
- Endoscopic airway assessment: to evaluate for obstruction
- Prolonged EEG (12–24 hours): to identify seizure activity
Consultations and disposition
- Admit for continuous pulse oximetry and observation.
- Consult social services to:
- Screen for child maltreatment
- Evaluate for social and/or mental health contributors
- Provide caregiver support
- Consult additional specialists based on clinical suspicion, e.g.:
- Gastroenterology for GERD
- Pulmonary for obstructive or central sleep apnea
- Otolaryngology for obstructive sleep apnea
- Neurology for seizures
- Cardiology for congenital heart disease or arrhythmia
- Genetics for inborn errors of metabolism
Acute management checklist
- Begin monitoring with continuous pulse oximetry.
- Perform a primary survey.
- Complete a thorough pediatric history and physical examination.
- Start cause-specific treatment immediately if cause is identified.
- Determine whether the child meets low-risk BRUE criteria or high-risk BRUE criteria.
- Obtain diagnostics based on risk category.
- Consider outpatient management for low-risk individuals.
- Admit high-risk individuals for monitoring and evaluation.