Brief Resolved Unexplained Events
BRUE criteria: episode in infants < 12 months of age that are observed to be:
Brief, lasting <1 minute (typically <20–30 seconds)
Resolved, the baby has now returned to baseline state of health
Unexplained, no identifiable medical cause suspected after assessment
Infants are often brought for medical assessment for episodes that frighten their parents; including any one or more features of:
Central cyanosis/pallor
Absent, decreased or irregular breathing
Marked change in tone (hyper or hypotonia)
Altered level of consciousness
The term BRUE can only be used as a diagnosis if there is no other explanation for the event after a thorough history and examination.
So, if the baby has cough-cold, fever, rash etc, then it is not BRUE.
The older term of ‘Acute Life Threatening Event’ (ALTE) has been replaced with ‘BRUE’ that allows risk stratification of infants; and guides further investigation or management for higher risk babies.
Differentials of BRUE are conditions like:
– GIT: Choking on feeds, GORD, Intussusception, gastroenteritis
– Resp: Bronchiolitis, Pertussis, LRTI, Croup, laryngomalacia, inhaled FB
– Cardiac: Cong heart dis, cardiac failure, SVT
– Infection: Sepsis, meningitis, UTI
– CNS: seizures, dystonia, head injury
– Misc- electrolyte abnormality, hypoglycemia, inherited metabolic disorders
– Non Accidental Injuries
History
– Who witnessed, when, where, position of baby
– Duration of whole event
– Any unusual behaviour after the event? Taken any feeds since event?
– Any recent illness – fever, cough-cold, vomiting, rash etc or ill contacts?
– Any falls, injuries or bleeding from nose, ears or mouth?
– Description of event: What was baby doing before event? Awake or asleep?
– Change in colour (pale, blue or red) of lips (also tongue)?
– Change in tone (floppy or tense) or jerking movements?
– Change in breathing pattern – shallow / irregular / paused / distressed?
– Determine whether apnoea was present- whether it appeared to be central or obstructive.
– Distinguish true apnoea (more than 15-20 sec) from periodic breathing.
– Unresponsive to voice / touch?
– How did it stop: spontaneous/ when picked up / back slaps/ mouth to mouth / chest compressions?
– Feeding:Event related to feed? During or after a feed?
– Any vomiting or choking? Any feed or vomitus seen in mouth?
– Is baby overfed (ask volume offered & how many times daily)? Has the infant previously exhibited symptoms of GORD? Excessive irritability, arching, or straining behaviours displayed during or following a feeding?
– Swallowing incoordination? Symptoms of aspirating thin liquids? – coughing, choking, or gagging during or after feeding; frequent or excessive spitting-up; persistent nasal stuffiness; or frequent hiccups.
– PMH of similar episodes or other medical issues?
– Detailed perinatal history & developmental review; Immunisations (any recent?)
– F/H- any sudden deaths in young age (<35y)? Any SUDI / BRUE in siblings?
– Any significant inherited metabolic condition?
– Social issues- who lives in the household; smoking; drugs at home
Examination
Similar to a child with fever or sepsis
Full ABCDE assessment; including vitals – temp, RR, HR, BP and SaO2
Check central capillary refill time; peripheries cold? Skin mottled?
Plot weight, length and head circumference.
Palpate anterior fontanelle open? Sunken or bulging?
Any choanal stenosis or atresia? Cleft palate? Tongue movements? Check ENT, Lymph nodes exam.
Any rashes, bruises or unusual marks? Check frenulum & nappy area
Any signs of neglect?
Full systemic examination: RS, CVS, Abdo, CNS including femorals
Risk Stratification:
Often no specific diagnosis found after a thorough history and examination. A low risk event is unlikely to represent a severe underlying disorder; and is unlikely to recur.
Lower risk BRUE if no concerning feature on history/examination & ALL of following:
– 1st event
– Episode lasted < 1 minute total duration
– Age > 2 months
– Born ≥ 32wks gestation and corrected gestational age ≥ 45 weeks
– No CPR by trained health care professional
Higher risk BRUE is: > 1 episode / lasting > 1 minute / baby < 2 months age / born prematurely < 32 weeks at birth
Investigations & Management:
Lower risk BRUE:
No investigations required; capillary blood glucose and urinalysis may be performed if clinical concern.
Discharge home only if low clinical suspicion of serious underlying disorder; parents agree and reassured
May be offered short-observation, including observing the next feed
Lower risk does not mean ‘no’ risk as this episode may be start of an illness
Offer ‘safety netting’ advice and contact number;
May offer BLS training
Higher risk BRUE:
– Discuss with senior doctor, as risk of serious illness
– Admit for monitoring HR, RR, continuous SaO2; Observe feeds and events
– Consider investigations: FBC, UEC, CRP, glucose, naso-pharyngeal aspirate, blood gas
– Consider ECG, Chest xray or other relevant investigation based on clinical presentation
– If sepsis likely: do full septic screen and initiate broad-spectrum antibiotics as per local policy
– Manage any suspected condition as per local guideline