Brief Resolved Unexplained Event

A brief resolved unexplained event (BRUE) is defined as a reported, sudden, brief (< 1 minute) event in a child < 1 year of age, which is resolved at the time of presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor. The definition includes ≥ 1 finding of either change in color ( cyanosis Cyanosis A bluish or purplish discoloration of the skin and mucous membranes due to an increase in the amount of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule. Pulmonary Examination or pallor), breathing pattern (absent, decreased, or irregular), muscle tone Muscle tone The state of activity or tension of a muscle beyond that related to its physical properties, that is, its active resistance to stretch. In skeletal muscle, tonus is dependent upon efferent innervation. Skeletal Muscle Contraction ( hypertonia Hypertonia Abnormal increase in skeletal or smooth muscle tone. Skeletal muscle hypertonicity may be associated with pyramidal tract lesions or basal ganglia diseases. Neurological Examination or hypotonia Hypotonia Duchenne Muscular Dystrophy), or level of consciousness. The findings are based on a report given by a parent or caregiver. Adopted by the American Academy of Pediatrics in 2016, the new term was to replace the previously used terms “apparent life-threatening event” (ALTE) and “near sudden infant death syndrome Sudden Infant Death Syndrome Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS)”. The change in terminology was to better define an unexplained event after a thorough evaluation, stratify high- and low-risk groups, identify those needing further evaluation, and avoid unnecessary testing and admissions. Importantly, BRUE can be diagnosed only if there is no other explanation for the episode after a careful history and physical examination.

Last updated: Mar 22, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

A brief resolved unexplained event (BRUE) is defined as a sudden and unexplained change in an infant’s breathing, appearance, or behavior that was brief (< 1 minute, average 20–30 sec) and is fully resolved.

  • A thorough history and physical exam do not identify another cause to explain the event. 
  • Further criteria to meet the diagnosis include:
    • The child is < 1-year-old.
    • 1 or more of the following is described:
      • Cyanosis Cyanosis A bluish or purplish discoloration of the skin and mucous membranes due to an increase in the amount of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule. Pulmonary Examination or pallor (but no redness Redness Inflammation or rubor Rubor Inflammation, which can be normal)
      • Absent, decreased, or irregular breathing during the brief event
      • A marked change in tone (hyper- or hypotonia Hypotonia Duchenne Muscular Dystrophy)
      • An altered level of responsiveness

Change in terminology

An “apparent life-threatening event” (ALTE) is no longer current but was defined as:

  • “An episode that is frightening to the observer and is characterized by some combination of apnea, color change, a marked change in muscle tone, and choking or gagging”
  • The term “life-threatening” was removed due to a lack of causal relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship between ALTE and SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS):
    • The majority of SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS) deaths occur 12 AM-6 AM; the majority of ALTE episodes occur 8 AM-8 PM.
    • Peak incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS) is between 2–4 months of age; ALTE events are < 2 months of age.
    • “Back to sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep” initiatives for supine sleeping, which led to a dramatic decrease in the incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS), have not changed the incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency of ALTE events.

BRUE specifies “there is no other explanation on a thorough history and physical examination” and it removes “choking or gagging.”

Epidemiology

  • Data is not yet fully known in part due to a change in the terms and definition.
  • Current estimates of occurrence: 0.5%–0.6% of healthy infants to term
  • 0.6%–0.8% of all emergency room visits for children under 1 year of age
  • May be reported more in infants with:

Etiology

By definition, there is no explanation or cause for BRUE, but common and important non-BRUE causes need to be identified.

Common conditions leading to an event and exclude BRUE:

  • Neonatal gastroesophageal reflux
  • Feeding or swallowing Swallowing The act of taking solids and liquids into the gastrointestinal tract through the mouth and throat. Gastrointestinal Motility difficulty leading to laryngospasm Laryngospasm Hypoparathyroidism or aspiration
  • Neurologic:
    • Brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification tumor Tumor Inflammation
    • Seizure
    • Breath-holding behavior
  • Conditions affecting brainstem respiratory regulation Respiratory regulation Human cells are reliant on aerobic metabolism. Chemoreceptors in the lungs and tissues sense changes in the concentration of respiratory gasses and send messages to the CNS, which, in turn, modifies breathing parameters such as the respiratory rate or tidal volume to compensate for any imbalance. Disruption of this control mechanism can be caused by severe disease and also result in severe disease. Respiratory Regulation:
    • Hydrocephalus Hydrocephalus Excessive accumulation of cerebrospinal fluid within the cranium which may be associated with dilation of cerebral ventricles, intracranial. Subarachnoid Hemorrhage
    • Brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification malformations
  • Respiratory infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease:
    • Respiratory syncytial virus Respiratory Syncytial Virus Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus ( RSV RSV Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus)
    • Influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza
    • Pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough)
  • Other infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease:
    • Meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis
    • Sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock 

Less common conditions leading to an event and exclude BRUE:

  • Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR):
    • Critical cyanotic heart disease often screened for in the newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn nursery
    • Undiagnosed ductal-dependent lesion when patent ductus arteriosus Patent ductus arteriosus The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA) ( PDA PDA The ductus arteriosus (DA) allows blood to bypass pulmonary circulation. After birth, the DA remains open for up to 72 hours and then constricts and involutes, becoming the ligamentum arteriosum. Failure of this process to occur results in patent ductus arteriosus (PDA), a condition that causes up to 10% of congenital heart defects. Patent Ductus Arteriosus (PDA)) closes
    • Arrhythmia 
  • Metabolic disorders:
    • Diseases screened for via newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn metabolic screening Screening Preoperative Care (varies between states)
    • Can present with hypoglycemia Hypoglycemia Hypoglycemia is an emergency condition defined as a serum glucose level ≤ 70 mg/dL (≤ 3.9 mmol/L) in diabetic patients. In nondiabetic patients, there is no specific or defined limit for normal serum glucose levels, and hypoglycemia is defined mainly by its clinical features. Hypoglycemia, electrolyte disturbances, or toxic effect of metabolite build up
  • Upper airway obstruction Upper Airway Obstruction Airway Obstruction:
    • Obstructive sleep apnea Obstructive sleep apnea Obstructive sleep apnea (OSA) is a disorder characterized by recurrent obstruction of the upper airway during sleep, causing hypoxia and fragmented sleep. Obstructive sleep apnea is due to a partial or complete collapse of the upper airway and is associated with snoring, restlessness, sleep interruption, and daytime somnolence. Obstructive Sleep Apnea
    • Anatomic abnormalities of head or airways
  • Nonaccidental trauma ( child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse)
  • Other:
    • Toxins including unintentional ingestions and cold medications
    • Anaphylaxis Anaphylaxis An acute hypersensitivity reaction due to exposure to a previously encountered antigen. The reaction may include rapidly progressing urticaria, respiratory distress, vascular collapse, systemic shock, and death. Type I Hypersensitivity Reaction

Pathophysiology

BRUE is “unexplained”, therefore the mechanism producing the event is unknown. Well-defined findings in infants, however, help to determine if an event has an underlying pathology.

Newborn checkup

Normal baby on examination:
Respiratory rate Respiratory rate The number of times an organism breathes with the lungs (respiration) per unit time, usually per minute. Pulmonary Examination is 30–60/min; periodic breathing patterns noted in term and late-preterm babies. Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions is normally pink (indicating adequate oxygenation), both upper and lower extremities have a flexor tone, and the baby arouses on stimulation.

Image: “ Newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn checkup” by Topato. License: CC BY 2.0

Breathing

Normal term infant breathing:

  • The respiratory rate is 30–60/min.
  • Healthy term and late-preterm (> 36 weeks) infants will sometimes exhibit “periodic breathing” patterns:
    • Brief pattern of rapid breathing and pauses (lasting 10–15 sec)
    • Not associated with color change or change in behavior
    • May show modest/brief desaturation and bradycardia Bradycardia Bradyarrhythmia is a rhythm in which the heart rate is less than 60/min. Bradyarrhythmia can be physiologic, without symptoms or hemodynamic change. Pathologic bradyarrhythmia results in reduced cardiac output and hemodynamic instability causing syncope, dizziness, or dyspnea. Bradyarrhythmias if measured but requires no intervention
  • Educate parents on periodic breathing as a normal variant going away outside the newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn period.

Apnea (> 20 sec pause) can result from: 

Tone

Normal infant tone:

  • Normal muscle tone Muscle tone The state of activity or tension of a muscle beyond that related to its physical properties, that is, its active resistance to stretch. In skeletal muscle, tonus is dependent upon efferent innervation. Skeletal Muscle Contraction: both upper and lower extremities are predominantly flexor tone (supine)
  • Compared to term infants, preterm infants exhibit decreased muscle tone Muscle tone The state of activity or tension of a muscle beyond that related to its physical properties, that is, its active resistance to stretch. In skeletal muscle, tonus is dependent upon efferent innervation. Skeletal Muscle Contraction.
  • Flexor tone decreases with decreased gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care (preterm infants).

Hypotonia Hypotonia Duchenne Muscular Dystrophy (decreased muscle tone Muscle tone The state of activity or tension of a muscle beyond that related to its physical properties, that is, its active resistance to stretch. In skeletal muscle, tonus is dependent upon efferent innervation. Skeletal Muscle Contraction): 

  • The infant is “frog-like” in the supine position.
  • The infant has abducted hips and abnormally extended lower limbs.
  • Reduced spontaneous activity

Hypertonia Hypertonia Abnormal increase in skeletal or smooth muscle tone. Skeletal muscle hypertonicity may be associated with pyramidal tract lesions or basal ganglia diseases. Neurological Examination (increased muscle tone Muscle tone The state of activity or tension of a muscle beyond that related to its physical properties, that is, its active resistance to stretch. In skeletal muscle, tonus is dependent upon efferent innervation. Skeletal Muscle Contraction):

Alertness/consciousness

Check for normal response to arousal maneuvers ( tactile stimulation Tactile Stimulation Coma) and noxious stimuli (sternal rub).

Clinical Presentation

Reporting the event

  • At the time of presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor, a baby < 1 year of age will appear at a normal baseline with the parent/caregiver reporting the observed event.
  • The following details are needed to determine if the presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor is a BRUE and whether it is a low- or high-risk event:
    • Witness description of breathing, color, tone, appearance of the eyes, and/or sounds made
    • Duration 
    • Any preceding event/activity
    • Any intervention (e.g., CPR CPR The artificial substitution of heart and lung action as indicated for heart arrest resulting from electric shock, drowning, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation and closed-chest cardiac massage. Cardiac Arrest)
    • Age of gestation when the baby was born and current age (when the event occurred)

Distinguishing other events

Event and historical descriptions pointing to other explanations for the event:

  • Feeding issues:
  • Respiratory issues in the premature Premature Childbirth before 37 weeks of pregnancy (259 days from the first day of the mother’s last menstrual period, or 245 days after fertilization). Necrotizing Enterocolitis: Apnea of prematurity Prematurity Neonatal Respiratory Distress Syndrome is typically found in infants < 37 weeks of age. 
  • Neurologic issues:
    • Seizure:
      • Often the baby will not be back to baseline.
      • Tonic-clonic movements or repeated spasms Spasms An involuntary contraction of a muscle or group of muscles. Spasms may involve skeletal muscle or smooth muscle. Ion Channel Myopathy may be noted.
    • Brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification tumor Tumor Inflammation:
      • The baby may have developmental delays.
      • Poor feeding and vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia may be observed.
    • Breath-holding behavior in some older infants: Often the event is observed when the infant is starting to cry.
    • Brainstem abnormalities or lesions causing central apnea: Cyanosis Cyanosis A bluish or purplish discoloration of the skin and mucous membranes due to an increase in the amount of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule. Pulmonary Examination is noted during sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep.
  • Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) issues:
    • History of a murmur or known lesion
    • Poor feeding and growth
  • Infections Infections Invasion of the host organism by microorganisms or their toxins or by parasites that can cause pathological conditions or diseases. Chronic Granulomatous Disease:
    • Apnea may be more predominant than cough in RSV RSV Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus, pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough), and influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza (especially if < 60 days of age).
    • Altered consciousness in sepsis Sepsis Systemic inflammatory response syndrome with a proven or suspected infectious etiology. When sepsis is associated with organ dysfunction distant from the site of infection, it is called severe sepsis. When sepsis is accompanied by hypotension despite adequate fluid infusion, it is called septic shock. Sepsis and Septic Shock, meningitis Meningitis Meningitis is inflammation of the meninges, the protective membranes of the brain, and spinal cord. The causes of meningitis are varied, with the most common being bacterial or viral infection. The classic presentation of meningitis is a triad of fever, altered mental status, and nuchal rigidity. Meningitis
  • Nonaccidental trauma ( child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse) findings:
    • Unexplained bruises or fractures
    • Subconjunctival or retinal hemorrhages
    • Torn frenulum Torn Frenulum Child Abuse in a young infant
    • Inconsistent history
    • Previous episodes
  • Toxins or medications at home:
    • An older, mobile infant may put a substance in their mouth while exploring.
    • Includes herbal or homeopathic medications and over-the-counter cold remedies
Image of a baby with pertussis

An infant with pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough):
Presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor of the infection is atypical and can include eye-bulging, cyanosis Cyanosis A bluish or purplish discoloration of the skin and mucous membranes due to an increase in the amount of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule. Pulmonary Examination, subcostal/intercostal retractions, gagging, and apnea.

Image: “6379” by CDC. License: Public Domain

Diagnosis

BRUE is diagnosed when there is no other explanation for the event. Therefore, a thorough history and physical is key.

History

  • Was the baby asleep, awake, or crying when the event occurred?
  • Were respirations absent, shallow, or increased?
  • Was the cyanosis Cyanosis A bluish or purplish discoloration of the skin and mucous membranes due to an increase in the amount of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule. Pulmonary Examination or pallor affecting the entire body or localized?
  • Was the baby’s tone decreased ( hypotonia Hypotonia Duchenne Muscular Dystrophy), increased ( hypertonia Hypertonia Abnormal increase in skeletal or smooth muscle tone. Skeletal muscle hypertonicity may be associated with pyramidal tract lesions or basal ganglia diseases. Neurological Examination), or tonic-clonic (possible seizure)?
  • Were the baby’s eyes open? Did the eyes deviate?
  • Did the baby make choking sounds or exhibit stridor Stridor Laryngomalacia and Tracheomalacia? Were objects nearby?
  • Did the baby spit-up or vomit? What was the relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship in time to a feeding?
  • Who witnessed the event? How long did it last? Were any interventions needed for the event to resolve?
  • Was there an intervention by a trained medical provider?
  • Also include:

Physical exam

Management

Babies are stratified as low risk (little evaluation needed) or high risk (may need further evaluation, monitoring, and observation).

Low-risk BRUE

Criteria:

  • Asymptomatic
  • > 60 days old
  • If premature Premature Childbirth before 37 weeks of pregnancy (259 days from the first day of the mother’s last menstrual period, or 245 days after fertilization). Necrotizing Enterocolitis: born ≥ 32 weeks gestational age Gestational age The age of the conceptus, beginning from the time of fertilization. In clinical obstetrics, the gestational age is often estimated as the time from the last day of the last menstruation which is about 2 weeks before ovulation and fertilization. Pregnancy: Diagnosis, Physiology, and Care, now ≥ 45 weeks postconceptional age
  • No more than 1 BRUE 
  • BRUE lasted < 1 minute
  • The infant did not receive CPR CPR The artificial substitution of heart and lung action as indicated for heart arrest resulting from electric shock, drowning, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation and closed-chest cardiac massage. Cardiac Arrest from a trained medical provider.
  • No concerning history to suggest infection, child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse, toxin, or a congenital Congenital Chorioretinitis/metabolic condition 
  • No family history Family History Adult Health Maintenance of sudden and unexplained death Unexplained Death Sudden Infant Death Syndrome (SIDS) of a sibling
  • No concerning findings on physical exam

Minimal management:

  • Briefly observe 1–4 hours on continuous pulse oximetry.
  • Follow-up with primary care provider within 24 hours.
  • Optional:
    • Serial checks
    • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG) to evaluate QT interval QT interval Electrocardiogram (ECG) 
    • Viral test
    • Pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough) test
  • Further labs, imaging, and monitoring are NOT recommended.
  • Educate parents about BRUE: There is no association between BRUE and SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS).
  • Offer resources for CPR CPR The artificial substitution of heart and lung action as indicated for heart arrest resulting from electric shock, drowning, respiratory arrest, or other causes. The two major components of cardiopulmonary resuscitation are artificial ventilation and closed-chest cardiac massage. Cardiac Arrest.

High-risk BRUE

High-risk infants (do not meet low-risk criteria):

  • Pulse oximetry for at least 4 hours
  • Consider admission.
  • Tests may include the following to broaden evaluation for common or targeted conditions based on presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor and suspicion:
    • ECG ECG An electrocardiogram (ECG) is a graphic representation of the electrical activity of the heart plotted against time. Adhesive electrodes are affixed to the skin surface allowing measurement of cardiac impulses from many angles. The ECG provides 3-dimensional information about the conduction system of the heart, the myocardium, and other cardiac structures. Electrocardiogram (ECG)
    • CBC
    • Electrolytes Electrolytes Electrolytes are mineral salts that dissolve in water and dissociate into charged particles called ions, which can be either be positively (cations) or negatively (anions) charged. Electrolytes are distributed in the extracellular and intracellular compartments in different concentrations. Electrolytes are essential for various basic life-sustaining functions. Electrolytes
    • Lactic acid (if considering possible metabolic condition)
    • Venous blood gas
    • Viral panel ( RSV RSV Respiratory syncytial virus (RSV) is an enveloped, single-stranded, linear, negative-sense RNA virus of the family Paramyxoviridae and the genus Orthopneumovirus. Two subtypes (A and B) are present in outbreaks, but type A causes more severe disease. Respiratory syncytial virus causes infections of the lungs and respiratory tract. Respiratory Syncytial Virus, pertussis Pertussis Pertussis, or whooping cough, is a potentially life-threatening highly contagious bacterial infection of the respiratory tract caused by Bordetella pertussis. The disease has 3 clinical stages, the second and third of which are characterized by an intense paroxysmal cough, an inspiratory whoop, and post-tussive vomiting. Pertussis (Whooping Cough), influenza Influenza Influenza viruses are members of the Orthomyxoviridae family and the causative organisms of influenza, a highly contagious febrile respiratory disease. There are 3 primary influenza viruses (A, B, and C) and various subtypes, which are classified based on their virulent surface antigens, hemagglutinin (HA) and neuraminidase (NA). Influenza typically presents with a fever, myalgia, headache, and symptoms of an upper respiratory infection. Influenza Viruses/Influenza)
    • Review newborn Newborn An infant during the first 28 days after birth. Physical Examination of the Newborn screen
    • Toxicology screen
    • EEG EEG Seizures
    • MRI
    • Skeletal survey Skeletal Survey Child Abuse (if child abuse Child abuse Child abuse is an act or failure to act that results in harm to a child’s health or development. The abuse encompasses neglect as well as physical, sexual, and emotional harm. Seen in all subsets of society, child abuse is a cause of significant morbidity and mortality in the pediatric population. Child Abuse suspected)
    • Ophthalmology exam
  • Home monitoring:
    • Limited use
    • Not correlated to reduce SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS)
    • Determine on a case-by-case basis.

Clinical Relevance

  • Apnea of prematurity Prematurity Neonatal Respiratory Distress Syndrome: an episode of apnea (and sometimes associated bradycardia Bradycardia Bradyarrhythmia is a rhythm in which the heart rate is less than 60/min. Bradyarrhythmia can be physiologic, without symptoms or hemodynamic change. Pathologic bradyarrhythmia results in reduced cardiac output and hemodynamic instability causing syncope, dizziness, or dyspnea. Bradyarrhythmias) > 20 sec in infants < 37 weeks of age. Increased incidence Incidence The number of new cases of a given disease during a given period in a specified population. It also is used for the rate at which new events occur in a defined population. It is differentiated from prevalence, which refers to all cases in the population at a given time. Measures of Disease Frequency occurs with the degree of prematurity Prematurity Neonatal Respiratory Distress Syndrome and resolves by 43 weeks postconceptual age. Apnea of prematurity Prematurity Neonatal Respiratory Distress Syndrome is due to respiratory control immaturity. 
  • Sudden infant death syndrome Sudden Infant Death Syndrome Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS) ( SIDS SIDS Sudden infant death syndrome (SIDS) describes the sudden death of an otherwise healthy infant (< 1 year of age) with no identifiable cause. Sudden infant death syndrome is the leading cause of death in children between 1 and 12 months of age in the United States. Sudden Infant Death Syndrome (SIDS)): the sudden and unexpected death of an infant that is unexplained postmortem on autopsy. Peak occurrence is 1–4 months of age. Risk factors include maternal smoking Smoking Willful or deliberate act of inhaling and exhaling smoke from burning substances or agents held by hand. Interstitial Lung Diseases, alcohol, and drug use, low socioeconomic status, boy gender Gender Gender Dysphoria, and prematurity Prematurity Neonatal Respiratory Distress Syndrome. Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep position was identified as a major risk factor. Since the implementation of supine sleeping (back to sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep), the rate has significantly and progressively declined. Co-sleeping is also associated with mortality Mortality All deaths reported in a given population. Measures of Health Status
  • Neonatal gastroesophageal reflux: a common condition in newborns and younger infants. The range of neonatal gastroesophageal reflux may include mild spit-ups, severe vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia, or silent reflux. Symptoms include fussiness with feeds, arching, coughing, or gagging. The mechanism of choking, gagging, and obstructive breath pattern is likely laryngospasm Laryngospasm Hypoparathyroidism and not necessarily related to the severity of reflux. Management includes frequent burping, holding upright 15–20 minutes after feeding, and avoidance of overfeeding (usually bottle-fed babies). Sometimes nondairy milk, thickened feeds, or acid suppression Suppression Defense Mechanisms therapy is indicated. Additional testing is usually not needed and the majority of babies will outgrow the condition.

References

  1. Alhaboob, Ali. “Clinical Characteristics and Outcomes of Patients Admitted with Brief Resolved Unexplained Events to a Tertiary Care Pediatric Intensive Care Unit”. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7370642/#:~:text=According%20to%20a%20previous%20report,have%20experienced%20BRUE%20%5B5%5D
  2. Jilani, N., Hussain, A., et al. (2019). Gastro-oesophageal reflux is not a major cause of brief resolved unexplained events in infants. Breathe (Sheff) 15(2):e32-e39. doi: 10.1183/20734735.0174-2019.
  3. Kliegman, R., St. Geme, J. (2019). Nelson Textbook of Pediatrics. Ed. 21. Pages 2167–2179.
  4. Kondamudi, N., Virji, M. (2020). Brief resolved unexplained event. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK441897/
  5. Raab, Christopher MD.“ALTE and BRUE”. Merck Manuals Professional. Retrieved March 3, 2021, from https://www.merckmanuals.com/professional/pediatrics/miscellaneous-disorders-in-infants-and-children/alte-and-brue?query=brue.
  6. Tieder, Joel, et al. “Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants”. Retrieved March 18, 2021, from https://pediatrics.aappublications.org/content/137/5/e20160590#sec-4

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