Definition

BRUEs are a scary event for any parent, characterised by the following:

• At least one of:
  • Central colour change (cyanosis/pallor)
  • Abnormal tone (hyper-/hypotonic)
  • Abnormal breathing (irregular/reduced/apnoea)
  • Altered level of consciousness
• Occurring in infants (<12 months of age)
• Lasting for <1 minute
• Resolves without intervention, typically prior to assessment
• No apparent medical cause

BRUE is a description of the event, not a diagnosis. It also requires exclusion; even though the child in front of you appears well they still need a thorough history and examination to make sure there isn’t something more concerning going on. An event cannot be said to be unexplained unless you have tried to explain it.

Some important causes to consider include reflux (very common), seizures, and maltreatment/NAI.

BRUEs have previously been known as Apparent Life Threatening Events (ALTEs) – your local policies may still use this terminology, though it has largely fallen out of favour because it is too non-specific and widely interpreted, as well as sounding a lot scarier for parents .

Assessment

A standard thorough history should be taken, as well as a typical A-E assessment. Take a general history of the event, enough that you would be able to describe the events before, during, and after the event to a colleague. Feeding history and family histories are important as they may point toward other causes. Key points to look out for in the history include:

• Triggers for the episode, including:
  • Feeds
  • Vomits/choking
  • Temperatures
• Anything raising suspicion of maltreatment/NAI
• Features concerning of other pathology eg
  • Seizure history
  • Cyanotic episodes

An ABCDE approach to examination is always a good approach to take. A full set of observations will also be important, with ongoing sats monitoring and repeat observations.

Risk

When assessing a child presenting with a BRUE, if no other diagnosis seems likely, it is important to stratify the risk of a significant pathological cause. The American Academy of Paediatrics presents features to assess for high vs low risk. If all of the following are present, a child can be considered low risk, and managed with a brief period of observation prior to discharge.

• Age >60 days
• Prematurity: gestational age ≥32 weeks and postconceptional age ≥45 weeks
• First BRUE (no previous BRUE ever and not occurring in clusters)
• Duration of event <1 minute
• No CPR required by trained medical provider
• No concerning historical features
  • A broad history is important here with a good systems review
• No concerning physical examination findings
  • A full examination is necessary

A useful tool which collates the AAP guidance can be found at MDCalc, providing a quick tick list that will allow you to see if criteria are fulfilled.

Management

The mainstay of management of BRUEs includes reassurance for parents and a period of observation. High risk patients should be managed in concert with paediatric services, with investigations and treatment as required in view of the likely pathological cause.

Reassurance: When reassuring parents/carers of low risk children, care should be taken to explain what we mean by BRUEs and why we stratify risk in the way that we do. Education around basic life support should be given to caregivers too. It is reasonable to recommend follow up with their General Practitioner in the next couple of days.

Admission: Low risk patients should not be admitted to hospital for prolonged periods of observation.

Invasive tests & imaging: blood tests (including gas), lumbar punctures, neuroimaging are all generally unnecessary in low risk patients.

Other tests: At most, guidelines suggest that an ECG and pertussis test may be undertaken.

Observation: a brief period of monitoring with continuous pulse oximetry and serial observations is reasonable. As mentioned above, admission is not necessary for low risk patients.

Paediatrics referral: generally unnecessary in low risk BRUEs. That said, it may be useful to discuss with a senior colleague if the history doesn’t quite add up, or if you aren’t sure. High risk patients should be referred for ongoing observation and investigation.

It is worth noting that as of the time of writing there are no NICE clinical guidelines for BRUE, with the predominant guideline in use being the AAP one, linked above.

Written by Dr Joseph Wood, Paediatrics ST2 Trainee

Edited by Dr Bex Evans, Paediatric ST3 Trainee