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BRUE

BRUE: What’s new? Admittedly, this is my humble opinion (feel free to gently disagree with me… my feelings are fragile). Essentially, I do not see this change in terminology as a huge alteration in my current practice. I like the term BRUE as it accentuates the Brief and Resolved nature, but fear that that may also diminish provider’s vigilance. “BRUE” should not equate to no concern, even though it does offer a pathway to actually discharge some. Remember, being vigilant most often only requires a thorough H+P. First and foremost: NEVER TRUST A NEONATE! Similar to what we worried about with ALTE, BRUE in a neonate is concerning for badness! Neonates are, by definition, High Risk kids in BRUE…

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 Apparent Life Threatening Events in Babies – Trouble BRUEing

Whenever I start to think about teaching on a paediatric subject, I feel like I should open with a reminder that being a parent is HARD. It’s REALLY HARD. Especially for first-time parents with newborn babies, lives for whom they are completely responsible and yet their “bundle of joy” is a totally unknown quantity, a law unto itself. Then imagine that the baby does something WEIRD. Like, properly weird – maybe it seems to stop breathing. Imagine that for a moment – imagine the panic, the terror, the paralysing fear that your tiny, helpless baby might be about to die. What would you do? You’d call an ambulance, of course. By the time these babies arrive in the ED many are completely fine and sleeping like tiny angels.

 Brief Resolved Unexplained Event (BRUE) Guidelines

A BRUE is diagnosed after a thorough history and examination when there is no explanation for the event. An exaggerated physiological airway protection reflex is the most common explanation. In young infants the laryngeal chemoreceptor cough reflex is immature and ingestion of saliva/feed/refluxed gastric contents into the larynx can sometimes trigger apnoea. This reflex appears to be more sensitive during upper respiratory tract infections.

 Brief Resolved Unexplained Events (BRUE) Criteria for Infants

Developed via expert consensus by the American Academy of Pediatrics (AAP). The criteria require that an extensive history and physical examination have failed to reveal a cause of the episode. Can be used in inpatient, outpatient, and emergency department settings. Note that choking, gagging, and red color change, which were part of the ALTE definition, are not part of the BRUE Criteria. Risk is defined by the likelihood of adverse recurrent events or eventual diagnosis of a serious underlying disorder. BRUEs represent a separate entity from sudden infant death syndrome (SIDS).

 Small Talk – Finding the Right Clues to Manage BRUEs

Since 2016, a defined BRUE criteria among infants has had a profound impact on reducing invasive diagnostic testing, ED length of stay, and admission rate without negatively impacting any clinical outcomes. A detailed and complete clinical history and physical exam remain the most important aspects of early evaluation. A BRUE should be diagnosed only if there remains no explanation for the event. If there are any concerning features discovered, the patient is not lower risk and warrants further workup. Infants with lower risk BRUE exhibit a transient and benign event that has an extremely low risk of recurrence and/or underlying serious condition. In the ED, these patients may undergo a screening 12-lead ECG and/or observation of 1 to 4 hours, but no other interventions are warranted. Clinical guidelines among higher risk BRUE remain less clear, and thus the ED clinician should consider wide differential diagnoses, pursuing an initial workup based on clinical index of suspicion while erring on the side of caution. Whether lower or higher risk criteria are met, it is essential the clinician clearly communicate their findings and appropriately counsel caregivers, while remaining empathic to their concerns.

Articles of Interest

Is It A Brief Resolved Unexplained Event (BRUE) In The Infant Or Something More Serious?

What it boils down to is: If the patient has a completely normal family history, a completely normal pregnancy and labor and delivery history, a completely normal pediatric growth chart, a completely normal pediatric developmental history a completely normal pediatric social history with no concern for the possibility of child abuse a completely normal age appropriate pediatric review of systems a completely normal pediatric physical exam and had no need for professional CPR during the episode only then can the infant be said to have had a low risk Brief Resolved Unexplained Event (BRUE) which does not require extensive workup according to the 2016 AAP guidelines.

PEM Pearls: Brief Resolved Unexplained Events (BRUE)

Goodbye ALTE and hello BRUE! The new AAP definition of BRUE shifts the definition from a caregiver to a clinician-based perspective. This hopefully reduces the confusion amongst families (and providers). A note of caution, the BRUE definition excludes cases where the infant is still symptomatic or when there is an explanation for the event. This shift in focus allows providers to identify lower-risk BRUE patients, who do not warrant a broad diagnostic workup and prolonged observation period.

Acute events in infancy including brief resolved unexplained event (BRUE)

Infants who present with a history of an acute event (an unexpected change in an infant's breathing, appearance, or behavior), reported by their parent or caregiver, represent a heterogeneous group of patients of varying ages with diverse pathophysiology. It is not a specific diagnosis, but rather a "chief complaint" that brings an infant to medical attention. The clinical challenge is to identify the infants who may benefit from further testing and prolonged observation, based on factors that suggest an identifiable underlying diagnosis or risk for subsequent events, while avoiding unnecessary testing, monitoring, and hospital admission for the many other infants without these characteristics.

Acute events in infancy including brief resolved unexplained event (BRUE)

Infants who present with a history of an acute event (an unexpected change in an infant's breathing, appearance, or behavior), reported by their parent or caregiver, represent a heterogeneous group of patients of varying ages with diverse pathophysiology. It is not a specific diagnosis, but rather a "chief complaint" that brings an infant to medical attention. The clinical challenge is to identify the infants who may benefit from further testing and prolonged observation, based on factors that suggest an identifiable underlying diagnosis or risk for subsequent events, while avoiding unnecessary testing, monitoring, and hospital admission for the many other infants without these characteristics.

ALTE in Neonate

So, in the end, when evaluating the neonate for an ALTE, don’t just resort to the common approach of “that’s an easy admission” and admit for “obs.” Rather, be a little fearful… and start looking for those needles in the haystack of disease.

Brief Resolved Unexplained Event: What Parents and Caregivers Need to Know

Though we can never say that a baby who has had a brief resolved unexplained event is at no risk for future problems, we can say that babies are at lower risk if They are older than 60 days. They were born on time (not premature). They did not need CPR (cardiopulmonary resuscitation) by a health care professional. The brief resolved unexplained event lasted less than 1 minute. This was their only such event.

Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants

The transition in nomenclature from the term ALTE to BRUE after 30 years reflects the expanded understanding of the etiology and consequences of this entity. Previous research has been largely retrospective or observational in nature, with little long-term follow-up data available.

Brief resolved unexplained events: a new diagnosis, with implications for evaluation and management

Brief resolved unexplained events (BRUE) are concerning episodes of short duration (typically < 1 min) characterized by a change in breathing, consciousness, muscle tone (hyper- or hypotonia), and/or skin color (cyanosis or pallor). The episodes occur in a normal-appearing infant in the first year of life, self-resolve, and have no readily identifiable explanation for the cause of the event. Previously called apparent life-threatening events (ALTE), the term BRUE was first defined by the American Academy of Pediatrics (AAP) in 2016.

Brief Resolved Unexplained Events: Practical Evaluation and Management in the Emergency Department

The 2016 American Academy of Pediatrics Brief Resolved Unexplained Event (BRUE) guideline provides new terminology and a framework for identifying and managing infants who are at lower risk for a repeat event or for having a serious underlying disorder. This issue reviews the definition of a BRUE, summarizes the risk-stratification criteria for infants who experience a BRUE, and provides management recommendations for patients with a lower-risk BRUE. It also discusses literature published since 2016 that expands on that guidance to include the higher-risk group.

Brief, Resolved, Unexplained Events and Sudden Infant Death Syndrome

When to Admit •Admit infants who have recurrent episodes without an explanation. •Admit infants with a clear diagnosis who are unstable—that is, infants who require ventilation or intravenous antibiotics. •Admit infants without a clear diagnosis but with an abnormal history or physical examination findings that require further inpatient evaluation. •Admit infants with clinically significant compromise (a prolonged event that requires CPR).

BRUE – Brief Resolved Unexplained Events

Changing practice is challenging; changing a definition is a little easier. This study is an excellent example of how to review the impact of guideline change and determine whether patient outcomes have improved without unintended consequences. At face value, the BRUE approach has had a beneficial clinical impact. We see an overall decline in admissions and investigations with no apparent harm (returns don’t increase). There are a few caveats that are important to consider, though. First, this study was from a chain of hospitals likely working with similar cultures and convergent working practices. A random selection of children’s hospitals may have interpreted the AAP guideline with more significant variance (and, therefore, application). With this in mind, the relevance of quite a profound change in coding should be highlighted.

Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments

BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

Episode 49 – The AAP BRUE (formerly ALTE) Guidelines

Some have voiced concerns that these guidelines potentially downplay the event. The concern is that the yield of these workups and admissions may be low, but possibly worthwhile. At FOAMcast, we are not qualified to critique these guidelines but there are helpful tables and charts in them to realize that these recommendations really are only for specific events and children AFTER thorough history and physical.

Management of Infants with Brief Resolved Unexplained Events (BRUE) and Apparent Life-Threatening Events (ALTE): A RAND/UCLA Appropriateness Approach

By combining previous recommendations with expert opinion, the RAND/UCLA appropriateness method permitted to drive pediatricians to reasoned and informed decisions in terms of evaluation, treatment, and follow-up of BRUE and ALTE, by reducing inappropriate exams and hospitalization and highlighting priorities for educational interventions.

Resources

Anesthesia Key

Lower-risk BRUE infants generally do not require clinical investigations and can be discharged home from the emergency department (ED). Most higher-risk patients, particularly those under 2 months of age, typically benefit from hospitalization for further monitoring for recurrent events, diagnostic evaluation, or treatment. In some cases, close outpatient follow-up may be reasonable. BRUE is a diagnosis of exclusion just like another acute idiopathic condition of infancy, the febrile seizure. Both have lower- and higher-risk categories. The lower-risk groups of both of these conditions require few if any investigations and can be discharged from the ED.

EM:RAP

By definition, a brief resolved unexplained event (BRUE) implies an abnormality that is resolved and should require no immediate intervention. Positive findings on any assessment dictate that the condition is not a BRUE.

StatPearls

In 2016, the American Academy of Pediatrics recommended replacing the term apparent life-threatening event (ALTE) with brief resolved unexplained event (BRUE) to better reflect the non life-threatening, transient nature of these events. A BRUE is a transient event with no clear cause that is frightening to the observer and consists of a combination of apnea, color change, muscle tone change, and choking, or gagging in an infant.

The Royal Children's Hospital Melbourne

A low risk BRUE occurs when there are no concerning features on history or examination AND all of the following: age >60 days born ≥32 weeks gestation and corrected gestational age ≥45 weeks no CPR by trained healthcare professional first event event lasted <1 minute A low risk BRUE is unlikely to represent a presentation of a severe underlying disorder and is unlikely to recur