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BRUE - Acute Events of Infancy

Also known as Brief Resolved Unexplained Events

Formerly known as ALTE - Apparent Life-Threatening Events

In the mid-1980's ALTE was used to represent a frightening episode in a pediatric patient. This term has since fallen out of favor and has been replaced by "BRUE"

ALTE was imprecise by nature and difficult to apply to both clinical care and research. The ALTE diagnosis was, as you can imagine very concerning for a caregiver (imagine getting discharged from the ED with ALTE on your paperwork) that would be a little nerve wracking, especially if the parents were not in healthcare. The ALTE nomenclature just didn't fit because the reported symptoms under the ALTE definition, although often concerning to the caregiver, are not intrinsically life-threatening and frequently are a benign manifestation of normal infant physiology or a self-limited condition.

BRUE is now the accepted medical terminology (since 2016)

BRUE is bound by both age and time limits

Brief - the episode lasts < 1 min, typically only about 20-30 secs

Resolved - the event is over and the infant has returned to their baseline (VS + appearance are normal)

Unexplained Event - this is self-explanatory, it is not readily explained by an identifiable medical condition

The child has to be less than 1 year old

The clinical criteria include the following signs/symptoms: (only 1 is necessary, but more can be present simultaneously)

A color change has to occur (usually cyanosis or pallor -- not erythema!!)

A change in muscle tone has to occur - it can be hypotonia or hypertonia (not associated with feeding problems like reflux)

Apneic period of > secs OR, any irregular/diminished breathing

Altered level of responsiveness or consciousness

Choking or gagging does NOT count

Collect a thorough medical history -- does the kid have a seizure history? A congenital heart defect, issues with GERD? This isn't always relevant but keep potential child abuse on your list of differential diagnosis if something with the history just doesn't add up.

Once we establish that a BRUE is likely, we and other clinicians have to determine risks (high risk vs. low risk) The chart below from the American Academy of Pediatrics illustrates this point well.

If any of the above bullet points/criteria are answered NO - then they should be considered high risk. For use, transport for evaluation by an ED physician is always recommended. The low-risk patients will likely get observed for several hours in the ED and go home with discharge instructions (likely no medications, expert consults or specialized test are required) The high-risk group will at minimum likely have a 24 HR hospital admission where further workups can be completed.

Parental reassurance and education is crucial -- that should center around CPR education amongst other things. Hint: your agency can even host them once everything calms down at a later date. This short course will empower them and give them much more confidence in the future. It also helps you promote good will across your community.

March 25, 2024

Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP

Pass with PASS, LLC.

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