We review BRUEs (Brief Resolved Unexplained Events).

Hosts:

Cyanosis or pallor

Irregular, absent, or decreased breathing

Marked change in tone (hypertonia or hypotonia)

Risk stratification is the most important step in management. While only 6-15% of cases meet strict “Low Risk” criteria, identifying these patients allows us to avoid unnecessary invasive testing.

Low Risk Criteria

To be considered Low Risk, the infant must meet ALL of the following:

Age: > 60 days old

Gestational Age: GA > 32 weeks (and Post-Conceptional Age > 45 weeks)

Frequency: This is the first episode

Duration: Lasted < 1 minute

Intervention: No CPR performed by a trained professional

Clinical Picture: Reassuring history and physical exam

Management for Low Risk:

Generally do not require extensive testing or admission.

Prioritize safety education/anticipatory guidance.

Ensure strict return precautions and close outpatient follow-up (within 24 hours).

High Risk Criteria

Any infant not meeting the low-risk criteria is automatically High Risk.

Additional red flags include:

Suspicion of child abuse

History of toxin exposure

Family history of sudden cardiac death

Abnormal physical exam findings (trauma, neuro deficits)

Management for High Risk:

Requires a more thorough evaluation.

Often requires hospital admission.

Differential Diagnosis: “THE MISFITS” Mnemonic

Step 1: Stabilization

ABCs (Airway, Breathing, Circulation)

Point-of-care Glucose

Cardiorespiratory monitoring

Step 2: Diagnostic Testing (For High Risk/Symptomatic Patients)

Labs: VBG, CBC, Electrolytes.

Imaging:

CXR: Evaluate for infection and cardiothymic silhouette.

EKG: Evaluate for QT prolongation or dysrhythmias.

Clinical Pearl: Only ~6% of diagnostic tests contribute meaningfully to the diagnosis. Be judicious—avoid “shotgunning” tests in low-risk patients.

Recurrence: Approximately 10% (lower than historical ALTE rates of 10-25%).

Mortality: < 1%. Nearly always linked to an identifiable cause (abuse, metabolic disorder, severe infection).

BRUE vs. SIDS: These are not the same.

BRUE: Peaks < 2 months; occurs mostly during the day.

SIDS: Peaks 2–4 months; occurs mostly midnight to 6:00 AM.

Diagnosis of Exclusion: You cannot call it a BRUE until you have ruled out obvious causes via history and physical.

Strict Criteria: Stick strictly to the Low Risk criteria guidelines. If they miss even one (e.g., age < 60 days), they are High Risk.

Education: For low-risk families, the most valuable intervention is reassurance, education, and arranging close follow-up.

Systematic Approach: For high-risk infants, use a structured approach (like THE MISFITS) to ensure you don’t miss rare but reversible causes.