Background

Abbreviation: BRUE

BRUE was formerly known as Apparent life-threatening event (ALTE) [1]

BRUE definition has a strict age limit and should only be considered if no other likely explanation.

Peak incidence: 1 wk - 2 mo

BRUE is a symptom and requires evaluation for the actual diagnosis causing the event

Only 10% have repeat events

BRUE is not related to SIDS

Definition

BRUE diagnosis is only made by a clinician based on the features and is not based on the caregiver's perception of what happened. BRUE is an event occurring in an infant <1 year of age when an observer reports a sudden, brief ( <1 minute but typically <20–30 seconds), and now resolved episode of ≥1 of the following:[1]

Cyanosis or pallor

Absent, decreased, or irregular breathing

Marked change in tone (hyper or hypotonia)

Altered level of responsiveness

Must have returned to baseline

A BRUE should only be diagnosed when there is no alternative explanation for a the event after completing full history and physical.

ALTE to BRUE Definiton Changes

BRUE has a strict age limit < 1yo

There must be no other explanation for the event (not something as simple as nasal congestion, choking, viral infection or vomiting)

Caregiver's perception of a BRUE does not make an event a BRUE without clinical suspicion

Altered responsiveness is a new criteria

Risk Factors

RSV infection

Prematurity

Recent anesthesia

GERD

Airway/maxillofacial anomalies

Age < 10 wks

History of apnea

Pallor, cyanosis, feeding difficulties

Clinical Features

See definition above

Past Medical History

The history in an BRUE should focus extensively on the details surrounding the event, need for resuscitation, prior events, possible related medical conditions, or historic findings that may indicate prior events.

Prematurity, history of apnea, prior resp/feeding difficulties

Immunization status (particularly pertussis)

Family History

History of SIDS, cardiac abnormalities, seizures, or metabolic disease

Event

Duration of the BRUE

Was resuscitation with CPR and rescue breaths required?

Temporal relationship with feeding, sleeping, crying, vomiting, or choking

Any episodes concerning for central versus obstructive patterns of apnea

Any progressive or episodic changes in mental status

Differential Diagnosis

The differential diagnosis is extensive, and although a broad workup is often started in the ED including evaluation for sepsis, occult infection, and metabolic disorders, a cause is infrequently found[2]

Idiopathic (~50%)

GERD

Seizure

Respiratory tract infection (e.g. bronchiolitis)

Misinterpretation of benign process (e.g. periodic breathing)

Vomiting/choking episode

Less Common

Uncommon

Evaluation

Work-Up

Low Risk

Individualize testing by history and exam. These are generally not needed for the low risk patients.

Consider: Obtain pertussis ECG Briefly observe on pulse oximetry (e.g. 1-3 hours)



Moderate or Higher Risk

CBC

Chem 10

Urinalysis

CXR

Pertussis nasal swab

RSV nasal swab

Consider: Urine culture /BC ECG LP LFTs MRI Brain



Diagnosis

See Definition in Background section

[1] Low Risk Criteria

Age >60 days

Gestational age > 32 weeks and post-conceptional age >= 45 weeks

First BRUE ever No prior BRUE or BRUE in clusters

BRUE duration <1 minute

No CPR by a medical provider

No concern for child abuse, family history of sudden unexplained death,or toxic exposures

No abnormal physical findings: (bruising, cardiac murmurs, organomegaly)

Management

Low Risk

Low Risk infants can be safely discharged but there should be shared decision making with parents.

Also offer the family CPR training resources

Consider pertussis swab, ECG, and brief monitored observation in the ED.

No other consults, metabolic or hematologic labs or medications are necessary for discharge

Disposition

Low Risk

Discharged with shared parental decision making, CPR instructions, and close outpatient follow-up

Not Low Risk

Admission in most cases

Especially for:

<30 weeks preterm [4]

Ill-appearing or abnormal vitals (including pulse ox) [5]

Bronchiolitis or pertussis with apnea

>1 event in past 24hr or multiple BRUE

Abnormalities in past medical history

Prolonged central apnea >20 seconds

Need for resuscitation

Family history of SIDS

Current Research

Neither of these decision rules have been validated

[6] Mittal ALTE Decision Rule

300 Infants in a single center with 76% admission rate with 37 (12%) required significant intervention

Predictors for requiring intervention

Prematurity

Abnormal physical examination

Color change to cyanosis,

Absence of upper respiratory infection symptoms and the absence of choking

Negative predictive value: 96%

Specificity of 70.5%

7 out of the 184 (3.8%) were incorrectly discharged

[7] Kaji ALTE Decision Rule

832 patients from 4 different study sites, with a 79.2% admission rate

Predictors for requiring admission

See Also

Brue - Don't forget the bubbles

SGEM Xtra: Strange Brue from The Sketics' Guide to EM