What is the immediate management for an infant presenting with a Brief Resolved Unexplained Event (BRUE)?

Immediate Management of Brief Resolved Unexplained Events (BRUE) in Infants

For infants presenting with a Brief Resolved Unexplained Event (BRUE), the immediate management should focus on risk stratification, with minimal testing for lower-risk infants and targeted evaluation for higher-risk infants. 1

Risk Stratification

First, determine if the infant meets criteria for BRUE:

• Event was brief (typically <1 minute) and now resolved
• Includes ≥1 of: cyanosis/pallor, absent/decreased/irregular breathing, marked change in tone, altered responsiveness
• No explanation found after appropriate history and physical examination
• Infant appears well at presentation

Lower-Risk BRUE (all criteria must be met):

• Age >60 days
• Born ≥32 weeks gestation and postconceptional age ≥45 weeks
• First BRUE episode with duration <1 minute
• No CPR required by trained medical provider
• No concerning historical features or physical examination findings

Higher-Risk BRUE (any one criterion):

• Age ≤60 days
• Born <32 weeks gestation or postconceptional age <45 weeks
• Recurrent BRUE episodes
• Event duration ≥1 minute
• CPR required by trained medical provider
• Concerning history or physical examination findings

Immediate Management for Lower-Risk BRUE

1. Brief observation (1-4 hours) with continuous pulse oximetry and serial assessments may be appropriate 1

   • Monitor for recurrent events
   • Assess feeding and vital signs

2. Testing to avoid in lower-risk BRUE 1:

   • Blood tests (CBC, blood culture, blood gases)
   • Chest radiographs
   • CSF analysis/culture
   • Urinalysis/urine culture
   • Neuroimaging (CT, MRI, ultrasound)
   • Prolonged cardiac monitoring

3. Consider obtaining a 12-lead ECG to evaluate for cardiac causes such as channelopathies 1

4. Social risk assessment to evaluate for potential child abuse 1

5. Provide caregiver education about BRUE, including:

   • Nature of the event
   • Low risk of recurrence or serious underlying disorder
   • CPR training if desired
   • When to seek medical attention

Immediate Management for Higher-Risk BRUE

For higher-risk infants, a more comprehensive evaluation is warranted 2:

1. Immediate assessment:

   • Continuous cardiorespiratory monitoring
   • Pulse oximetry
   • Consider hospital admission

2. Tiered diagnostic approach:

   • First tier (time-sensitive conditions):

     • 12-lead ECG
     • Observation of feeding
     • Social assessment for child maltreatment
     • Targeted infectious workup if clinically indicated

   • Second tier (less time-sensitive):

     • Consider video EEG if seizure suspected
     • Consider upper GI evaluation if reflux suspected
     • Consider polysomnography if sleep-related breathing disorder suspected

Important Considerations

• Recent evidence suggests that only about 4% of BRUE cases are caused by serious underlying illness 3, supporting a more selective approach to testing.

• The AAP guidelines have been shown to safely reduce unnecessary testing and hospitalizations, particularly in academic medical centers 4.

• Contrary to previous beliefs, recent data suggests that infants >60 days may actually be more likely to have a serious underlying diagnosis than younger infants (OR: 1.43,95% CI: 1.03-1.98) 3.

• Common pitfalls in BRUE management include:

  • Overdiagnosis of BRUE when another explanation exists
  • Unnecessary extensive testing in lower-risk infants
  • Failure to recognize higher-risk features requiring more thorough evaluation
  • Inadequate caregiver education and follow-up planning

By following this risk-stratified approach, clinicians can provide appropriate care while avoiding unnecessary interventions for infants presenting with BRUE.