From the Guidelines
Management of an infant with a Brief Resolved Unexplained Event (BRUE) requires risk stratification to guide appropriate interventions, with a focus on minimizing unnecessary testing and interventions while ensuring the infant's safety and well-being. For low-risk BRUE infants (those older than 60 days, born at term with no significant medical history, event lasting less than 1 minute with no CPR required, and normal physical exam), minimal intervention is recommended, as supported by the American Academy of Pediatrics guideline 1. These infants typically need only education and reassurance for caregivers, with no hospitalization or extensive testing necessary.
Key Considerations
- The definition of BRUE is crucial, and clinicians should use the term to describe an event occurring in an infant <1 year of age with sudden, brief, and now resolved episodes of cyanosis or pallor, absent, decreased, or irregular breathing, marked change in tone, or altered level of responsiveness, with no explanation after conducting an appropriate history and physical examination 1.
- The approach to evaluation and management should be based on the risk that the infant will have a repeat event or has a serious underlying disorder, with a focus on patient- and family-centered care, reducing unnecessary medical interventions, and improving patient outcomes 1.
- For higher-risk BRUE infants, hospital admission for observation and targeted evaluation is appropriate, which may include cardiorespiratory monitoring for 24 hours, consideration of EKG, pertussis testing if symptomatic, and possibly a brief period of pulse oximetry monitoring, as well as assessment for social risk factors and child abuse 1.
- Additional testing should be guided by specific clinical concerns rather than performed routinely, and continuous home monitoring is generally not recommended except in specific circumstances like premature infants with ongoing apnea 1.
- Close follow-up with the primary care provider is important for all BRUE patients regardless of risk category, to ensure timely identification and management of any underlying conditions and to provide ongoing support and reassurance to caregivers.
From the Research
Management Approach for Brief Resolved Unexplained Events (BRUE)
The management approach for an infant who has experienced a Brief Resolved Unexplained Event (BRUE) is based on the risk classification of the event, which can be either lower-risk or higher-risk 2, 3.
- Lower-Risk BRUE: For lower-risk BRUEs, the American Academy of Pediatrics (AAP) clinical practice guideline recommends against routine admission, blood testing, and imaging for infants with these events 2, 3.
- Higher-Risk BRUE: For higher-risk BRUEs, more data are required to better identify proportions and risk factors for serious outcomes among these patients 2.
Key Considerations
- BRUE is a diagnosis of exclusion to be applied when there is no apparent etiology after performing an appropriate history and physical examination 3, 4.
- Lower-risk infants should not undergo routine diagnostic testing and should not be admitted solely for cardiorespiratory monitoring 3.
- Higher-risk infants are more likely to benefit from diagnostic testing and admission; however, routine screening testing is unnecessary, and the history and physical should guide the clinician's approach 3.
- The AAP clinical practice guideline provides recommendations for the management of lower-risk BRUEs, advocating for a short period of observation and/or an electrocardiogram may be advisable 2.
Epidemiology and Impact of Clinical Practice Guidelines
- The incidence of BRUEs remains stable, with a population incidence rate of 4.28 per 1000 live births 5.
- The impact of the BRUE clinical practice guideline on admission rates was limited to pediatric EDs, with a significant decrease in admission rates 5.
- The use of electrocardiograms increased in pediatric EDs after the publication of the clinical practice guideline 5.