MDCalc

Brief Resolved Unexplained Events (BRUE) Criteria for Infants

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

BRUE has been updated. BRUE 2.0 has been recommended as a replacement for the older tool. Click here to view.

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.

Entry criteria

Must fulfill all 4 to evaluate for BRUE

E.g. no URI symptoms, no fever
E.g. GER, feeding difficulties

Diagnostic Result

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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.
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