Brief resolved unexplained event (BRUE)

What is a BRUE?

A BRUE is a term used to describe a brief resolved unexplained event in infants under 1 year of age. Similar events used to be called apparent life-threatening events, or ALTE. BRUE has replaced that term since most events are not life-threatening and do not recur. BRUE is used to describe an event that does not appear to have an explanation after a health-care provider has reviewed the history and examined the child.

What is the definition of a BRUE?

A BRUE is an event that:

• occurs in infants younger than 1 year of age
• has a sudden onset
• is brief, lasting less than 1 minute
• is seen in a child with a normal physical examination and normal vital signs
• may involve a change in colour (blue, purple or pale face or trunk)
• may involve a change in breathing (usually apnea, or a pause in breathing)
• may involve a change in muscle tone (either floppier or more tense)
• may involve a change in responsiveness (such as loss of consciousness, sleepiness or lethargy)
• resolves completely (all changes noted during the event resolve)
• is unexplained by an identifiable medical condition

A BRUE can be very scary to witness. Most parents and caregivers want to know why it happened, whether it will happen again and what they can do to prevent another event.

What causes a BRUE?

The cause of a BRUE is unknown. However, there are conditions that can cause changes in colour, breathing, tone and responsiveness of an infant. If an explanation is found based on the history and physical examination, then the event is not a BRUE.

How is a BRUE diagnosed?

A BRUE is often referred to as a diagnosis of exclusion.  The health-care team will gather information from a child’s medical history, the description of the event and the physical examination to help:

• identify a cause of the event
• assess a child’s risk of the event recurring
• assess a child’s risk of a serious underlying medical condition

If all other diagnoses are excluded and no other explanation is found, then a BRUE may be diagnosed.

What is the risk of a child having another BRUE?

Low-risk infants who experience a BRUE are unlikely to have another event. An infant with a normal physical exam and no other diagnosed condition or explanation for the event may be considered low risk if:

• they are more than 60 days old
• they were born at 32 weeks or more and have a corrected age of at least 45 weeks
• no CPR was performed by a health-care provider
• it was the first time an event happened
• the event lasted less than 1 minute

How can another BRUE be prevented?

Since the risk of recurrence is low and the cause is unknown, it is difficult to prevent a BRUE. However, parents and caregivers can keep infants safe with safe sleep practices and maintaining a smoke-free environment.

Testing and treatment for BRUE

Infants who have experienced a BRUE and are considered low risk do not need admission to hospital, or specific testing or treatment. Blood tests, X-rays, viral swabs, urine tests, EEG, heart testing and admission to hospital are not recommended. Sometimes, brief monitoring using pulse oximetry, ECG and/or testing for pertussis (whooping cough) is performed.

Infants who are not considered low risk or who have another explanation for the event may have other individualized investigations and treatment.

Caring for your child at home

Infants who are felt to be at lower risk following a BRUE do not need special monitoring of their breathing or heart at home.

Caregivers and parents of an infant who has experienced a BRUE, like all parents, are encouraged to complete CPR training.

When to see a health-care provider

Regular well-baby visits are recommended. If an infant experiences another BRUE, it is important to discuss both events with their health-care provider. Seek emergency assistance (by calling 911 or going to the nearest emergency department) if:

• your child’s event is not brief (lasts more than a minute)
• the symptoms have not resolved
• you have provided CPR

Resources

To learn more about BRUE read this article written for parents and published by the American Academy of Pediatrics. Brief resolved Unexplained Events: What Parents and Caregivers Need to Know. https://doi.org/10.1542/ppe_document103