Brief Resolved Unexplained Events (BRUE) Criteria for Infants

Why Use

Replaces the term ALTE, which is broader and does not identify patients who are lower risk. May give providers comfort in discharging lower risk BRUE patients home. May reduce the need for unnecessary diagnostic testing which may be invasive and expensive.

When to Use

Infants <1 year old presenting for evaluation after a brief, unexplained, and now resolved event consisting of ≥1 of the following: Cyanosis or pallor. Absent, decreased, or irregular breathing. Marked change in tone. Altered level of responsiveness.

Formula

Pearls / Pitfalls

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).

Critical Actions

Evidence-based guidelines for evaluation and management should only be applied to patients categorized as having had a lower risk BRUE. An appropriate social history and examination is critical to screen for potential child abuse and neglect. BRUE Criteria and evidence-based recommendations are not a substitute for individual physician judgment.

Advice

Key action statements from AAP for lower risk infants (adapted from Tieder 2016 ): Recommendation Level of Evidence Strength of Recommendation Should do Assess social risk factors to detect child abuse C Moderate Offer CPR training resources C Moderate Educate about BRUEs C Moderate Use shared decision-making C Moderate Should NOT do Chest x-ray B Moderate VBG or ABG B Moderate Overnight sleep study B Moderate Echo C Moderate Home cardiorespiratory monitoring B Moderate Neuroimaging (CT, MRI, or ultrasonography) to detect neurologic disorders C Moderate EEG to detect neurologic disorders C Moderate Antiepileptic medication C Moderate WBC count, blood culture, or CSF analysis or culture to detect occult bacterial infection B Strong Chest x-ray to assess for pulmonary infection B Moderate Investigations for GER (e.g. upper GI series, pH probe, endoscopy, barium contrast study, nuclear scintigraphy, ultrasound) C Moderate Prescribe acid suppression therapy C Moderate Serum Na, K, Cl, BUN, Cr, calcium, or ammonia C Weak VBG or ABG C Moderate Urine organic acids, plasma amino acids, or plasma acylcarnitines C Moderate Laboratory evaluation for anemia C Moderate May do Briefly monitor with pulse oximetry and serial observation D Weak 12-lead EKG C Weak Pertussis testing B Weak Not needed Admission solely for cardiorespiratory monitoring B Weak Neuroimaging (CT, MRI, or ultrasonography) to detect child abuse C Weak Urinalysis (bag or catheter) C Weak Respiratory viral testing C Weak Serum lactic acid or bicarbonate C Weak Blood glucose C Moderate Level A Intervention: well-designed and well-conducted trials, meta-analyses. Diagnosis: Independent gold standard studies. Level B Trials or diagnostic studies with minor limitations. Consistent findings from multiple observational studies. Level C Single or few observational studies, or Multiple studies with inconsistent findings or major limitations. Level D Expert opinion. Case reports. Reasoning from first principles. Level X Exceptional situations where validating studies cannot be performed and there is a clear preponderance of benefit/harm. Levels of evidence, from Tieder 2016 :