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Brief Resolved Unexplained Event (BRUE)

Pathway Background and Objectives

Brief Resolved Unexplained Events (BRUEs) are a common presenting complaint for children under 1 year of age and cause a great deal of anxiety for parents and caregivers. The presentation of BRUEs can be widely variable and involve a constellation of observed, subjective and nonspecific symptoms.

In 2016, the American Academy of Pediatrics replaced the term “Apparent Life Threatening Event (ALTE)” with BRUE, clarified the definition, and made recommendations for lower risk infants. The term BRUE is now defined as an event occurring in infants younger than 1 year of age that is characterized by the observers as brief, sudden and now resolved event with one of more of the following 1) cyanosis or pallor; 2) absent, decreased or irregular breathing; 3) marked change in tone and 4) altered level of responsiveness. The approach to management of a BRUE can vary widely between providers, who may often feel compelled to perform unnecessary testing that rarely leads to a treatable diagnosis.

The AAP recommendations were used as the foundation for the pathway in terms of evaluation and management of the lower risk infants and the decision to admit high risk infants. As evidenced in the pathway, significant routine testing is not recommended for these infants unless indicated based on history and physical exam.

The objectives of this pathway are to:

  • Create a systematic way to manage BRUE in infants at low risk of event recurrence or serious underlying disease
  • Aid in the identification of infants with low risk for event recurrence and diagnosis of serious underlying disease
  • Avoid unnecessary admissions
  • Decrease unnecessary laboratory and radiographic testing

Algorithm

Download Brief Resolved Unexplained Event Pathway Algorithm

Quality Metrics

  • Percentage of eligible patients with use of BRUE order set
  • Percentage of low risk patients that are admitted
  • Percentage of patients with ECGs obtained
  • Percentage of patients with 2 ECGs and/or echocardiogram and/or cardiology consult
  • Number of patients that return to the ED within 30 days
  • Percent of admitted patients who receive a diagnosis other than BRUE (and type of diagnosis)

Educational Module

Download Brief Resolved Unexplained Event Educational Module

Key References

Tieder JS, Bonkowsky JL, Etzel RA, et al. Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. 2016;137 (5):e20160590.

Pathway Contacts

  • Marta Neubauer, MD
  • John Brancato, MD

Disclaimer

The clinical pathways in the above links have been developed specifically for use at Connecticut Children’s and are made available publicly for informational and/or educational purposes only. The clinical pathways are not intended to be, nor are they, a substitute for individualized professional medical judgment, advice, diagnosis, or treatment. Although Connecticut Children’s makes all efforts to ensure the accuracy of the posted content, Connecticut Children’s makes no warranty of any kind as to the accuracy or completeness of the information or its fitness for use at any particular facility or in any individual case.

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