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    Brief Resolved Unexplained Events (BRUE) Criteria for Infants

    Classifies unexplained events and replaces the Apparent Life Threatening Events (ALTE) classification.
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    INSTRUCTIONS

    Use in infants <1 year old who are asymptomatic and in their normal state of health at the time of evaluation. Do not use in symptomatic patients (e.g. fever, respiratory distress) or those with obvious cause for prior symptoms.

    When to Use
    Pearls/Pitfalls
    Why Use

    Infants <1 year old presenting for evaluation after a brief, unexplained, and now resolved event consisting of ≥1 of the following:

    • Cyanosis or pallor.
    • Absent, decreased, or irregular breathing.
    • Marked change in tone.
    • Altered level of responsiveness.
    • Developed via expert consensus by the American Academy of Pediatrics (AAP).
    • The criteria require that an extensive history and physical examination have failed to reveal a cause of the episode.
    • Can be used in inpatient, outpatient, and emergency department settings.
    • Note that choking, gagging, and red color change, which were part of the ALTE definition, are not part of the BRUE Criteria.
    • Risk is defined by the likelihood of adverse recurrent events or eventual diagnosis of a serious underlying disorder.
    • BRUEs represent a separate entity from sudden infant death syndrome (SIDS).
    • Replaces the term ALTE, which is broader and does not identify patients who are lower risk.
    • May give providers comfort in discharging lower risk BRUE patients home.
    • May reduce the need for unnecessary diagnostic testing which may be invasive and expensive.
    Entry criteria

    Must fulfill all 4 to evaluate for BRUE

    Diagnostic Result:

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    Next Steps
    Evidence
    Creator Insights

    Advice

    Key action statements from AAP for lower risk infants (adapted from Tieder 2016):

    Recommendation

    Level of Evidence

    Strength of Recommendation

    Should do

    Assess social risk factors to detect child abuse

    C

    Moderate

    Offer CPR training resources

    C

    Moderate

    Educate about BRUEs

    C

    Moderate

    Use shared decision-making

    C

    Moderate

    Should NOT do

    Chest x-ray

    B

    Moderate

    VBG or ABG

    B

    Moderate

    Overnight sleep study

    B

    Moderate

    Echo

    C

    Moderate

    Home cardiorespiratory monitoring

    B

    Moderate

    Neuroimaging (CT, MRI, or ultrasonography) to detect neurologic disorders

    C

    Moderate

    EEG to detect neurologic disorders

    C

    Moderate

    Antiepileptic medication

    C

    Moderate

    WBC count, blood culture, or CSF analysis or culture to detect occult bacterial infection

    B

    Strong

    Chest x-ray to assess for pulmonary infection

    B

    Moderate

    Investigations for GER (e.g. upper GI series, pH probe, endoscopy, barium contrast study, nuclear scintigraphy, ultrasound)

    C

    Moderate

    Prescribe acid suppression therapy

    C

    Moderate

    Serum Na, K, Cl, BUN, Cr, calcium, or ammonia

    C

    Weak

    VBG or ABG

    C

    Moderate

    Urine organic acids, plasma amino acids, or plasma acylcarnitines

    C

    Moderate

    Laboratory evaluation for anemia

    C

    Moderate

    May do

    Briefly monitor with pulse oximetry and serial observation

    D

    Weak

    12-lead EKG

    C

    Weak

    Pertussis testing

    B

    Weak

    Not needed

    Admission solely for cardiorespiratory monitoring

    B

    Weak

    Neuroimaging (CT, MRI, or ultrasonography) to detect child abuse

    C

    Weak

    Urinalysis (bag or catheter)

    C

    Weak

    Respiratory viral testing

    C

    Weak

    Serum lactic acid or bicarbonate

    C

    Weak

    Blood glucose

    C

    Moderate

    Level A

    • Intervention: well-designed and well-conducted trials, meta-analyses.
    • Diagnosis: Independent gold standard studies.

    Level B

    • Trials or diagnostic studies with minor limitations.
    • Consistent findings from multiple observational studies.

    Level C

    • Single or few observational studies, or
    • Multiple studies with inconsistent findings or major limitations.

    Level D

    • Expert opinion.
    • Case reports.
    • Reasoning from first principles.

    Level X

    • Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit/harm.

    Levels of evidence, from Tieder 2016:

    Critical Actions

    • Evidence-based guidelines for evaluation and management should only be applied to patients categorized as having had a lower risk BRUE.
    • An appropriate social history and examination is critical to screen for potential child abuse and neglect.
    • BRUE Criteria and evidence-based recommendations are not a substitute for individual physician judgment.
    Content Contributors
    • Eric Zwemer, MD
    About the Creator
    Dr. Joel S. Tieder
    Are you Dr. Joel S. Tieder?
    Content Contributors
    • Eric Zwemer, MD