Brief, resolved, unexplained event (BRUE): Clinical sciences

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Introduction 0:00–0:54

Brief Resolved Unexplained Events, or BRUEs, are witnessed episodes during infancy, lasting less than one minute, that are characterized by cyanosis or pallor; absent, decreased, or irregular breathing; a marked change in muscle tone; or altered responsiveness; followed by a return to the infant’s baseline state of health.
BRUE is diagnosed when no underlying cause for these symptoms can be identified after a thorough history and physical examination.
Based on historical features and exam findings, infants who meet the criteria for BRUE can be classified into higher or lower-risk categories.
When a pediatric patient presents with a chief concern suggesting BRUE you should start by obtaining a focused history and physical exam.

History and Physical examination 0:54–2:15

These patients are under 1 year of age, and caregivers typically describe a witnessed episode lasting less than 1 minute, during which the infant’s skin appeared blue, dusky, or pale for no clear reason.
They may also report that the infant had an irregular or shallow pattern of breathing during this episode, or that they stopped breathing altogether.
Caregivers might also describe the infant’s tone as stiff or floppy, or report that the child was less responsive and excessively sleepy.
Further history usually reveals no obvious symptoms suggesting an identifiable precipitant or an acute illness. As far as the exam goes, your patient will be well-appearing and afebrile, with normal vital signs.
Keep in mind that, by definition, patients with BRUE present after the resolution of the episode and have returned to their baseline level of functioning, so an unstable child will not have the diagnosis of BRUE.
Based on these findings, you should suspect a BRUE. Next, you’ll need to assess the event criteria to determine if the event was really a BRUE.

Event criteria 2:15–4:03

The criteria include one or more of the following: cyanosis or pallor; absent, decreased, or irregular breathing; a marked change in muscle tone; and altered responsiveness.
Additional criteria include a lack of history or exam findings that could provide a medical explanation for the event; and a return to the infant’s baseline state of health following the event.
If these criteria are not met, consider an alternative diagnosis. For example, symptoms like nasal congestion or cough suggest a respiratory tract infection, while repetitive focal or generalized motor activity followed by unresponsiveness suggests a seizure.
Here’s a clinical pearl to keep in mind! Always consider the possibility of non-accidental trauma when an infant presents with a suspected BRUE.
Some clues to look for include changes or inconsistencies in the caregiver’s history, recurrence of similar episodes, or delays in seeking medical care.
On exam, look for alarm signs that suggest abuse, such as oropharyngeal or frenulum damage, an unusual pattern of bruising, or retinal hemorrhages.
Now let’s see what to do once we diagnosed BRUE. Alright, if your patient meets event criteria, go ahead and diagnose BRUE.

Risk classification 4:03–4:38

Then, assess your patient for the presence of higher-risk BRUE characteristics. These include an age of 60 days or less; a gestational age at birth of less than 32 weeks with a corrected chronological age of 45 weeks or less; the need for cardiopulmonary resuscitation during the event; and a history of recurrent events.
Now, if any of these characteristics are identified, your patient is higher-risk. A higher-risk classification suggests that the patient might have a higher likelihood of a recurrent event, an adverse outcome, or a serious underlying condition.

Higher-risk 4:38–5:22

In this case, they require additional medical evaluation, even though the initial history and exam findings did not uncover a clear medical explanation for the episode.
Keep in mind that further investigation or monitoring should be tailored to any subtle history or exam findings, such as a history of feeding problems; and extensive testing is not needed.
On the other hand, if you don’t find any higher-risk BRUE characteristics, your patient is lower-risk. In this case, you don’t need to do extensive diagnostic testing.

Lower-risk 5:22–7:35

Instead, you should use shared decision-making to provide education to the patient's caregivers and have them follow up in the outpatient setting.
Be sure to offer the family resources for CPR training. Now, depending on the circumstances, you can consider obtaining pertussis testing.
It’s important to identify pertussis early since young infants can develop severe manifestations such as apnea. You could also obtain a 12-lead electrocardiogram, which can be used to identify channelopathies, such as a long QT syndrome; or ventricular pre-excitation, such as Wolff-Parkinson-White syndrome.
Finally, consider a brief period of pulse oximetry monitoring, which is a non-invasive way to identify episodes of hypoxemia.
Here’s one final clinical pearl! The term “apparent life-threatening event”, or ALTE, was once used to describe any event that frightens the observer and is characterized by apnea, color change, marked change in muscle tone, and choking or gagging.
Because the vague definition of ALTE makes its practical application to clinical care challenging, the term ALTE has been replaced with BRUE, which requires more specific criteria for diagnosis and allows providers to avoid unnecessary interventions.
Even though BRUE episodes can be alarming and appear life-threatening, there is no evidence to suggest that a BRUE or ALTE places an infant at higher risk for sudden infant death syndrome or SIDS.
Despite the lack of connection between these episodes and SIDS, it’s still important to endorse safe sleep practices, especially during every infant’s first year of life.
Alright, as a quick recap… When a pediatric patient presents with a chief concern suggesting a BRUE, assess the event criteria.

Review 7:35–8:31

If criteria are absent, consider an alternative diagnosis, and if sufficient criteria are present, diagnose BRUE. Next, assess for higher-risk characteristics.
The presence of 1 or more characteristics indicates a higher-risk patient, while no characteristics indicate lower-risk.
For higher-risk cases, you should tailor further investigation to the specific history and physical exam findings. But in lower-risk cases, you should provide caregivers with education and follow-up.
Additionally, offer CPR training, and consider pertussis testing, a 12-lead ECG,