Brief Resolved Unexplained Event In The Infant and Apparent Life Threatening Event Concern
Clinical Assessment Checklist
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History
Event description
BRUE event features
Age younger than 12 months
Sudden brief now resolved episode
Caregiver report of one or more core features
Cyanosis or pallor
Absent decreased or irregular breathing
Marked change in tone
Hypertonia
Hypotonia
Altered level of responsiveness
Duration estimate in seconds
Number of episodes in last 24 hours
Similar prior episodes
Witness description and video available
Circumstances and triggers
Context of event
Position
Supine
Prone
Seated
Car seat swing bouncer
Activity
Feeding
Sleeping
Crying
Bathing
Choking gagging coughing noted
Color change description and progression
Breathing sounds
Stridor
Wheeze
Silence
Stimulation required for recovery
None
Gentle stimulation
Vigorous stimulation
CPR performed by trained provider
Feeding and reflux history
Feeding around event
Last feed timing relative to event
Feed type
Breast milk
Formula
Solids
Volume per feed and pace
Spit up or emesis
Arching irritability with feeds
Aspiration symptoms
Cough with feeds
Wet voice
Recurrent choking
Infectious and exposure context
Recent illness context
Fever
Cough
Coryza
Vomiting
Diarrhea
Sick contacts
Immunization status
Baseline and development
Baseline status
Usual color and breathing pattern
Baseline tone and activity
Baseline feeding and urine output
Weight gain concerns
Developmental milestones concerns
Perinatal history
Birth and NICU history
Gestational age at birth
Prematurity complications
Apnea of prematurity
Chronic lung disease
Birth weight
NICU length of stay
Prior apnea monitor use
Alarm Features
Immediate instability
Unstable features
Current apnea
Persistent cyanosis or pallor
Persistent altered mental status
Ongoing seizure activity
Respiratory distress
Retractions
Grunting
Shock features
Poor perfusion
Hypotension
High risk BRUE features
High risk features
Age younger than 60 days
Gestational age at birth less than 32 weeks
Postconceptional age less than 45 weeks
Event duration 60 seconds or longer
More than one event
CPR by trained provider
Concerning history
Child maltreatment concern
Ingestion exposure concern
Infection risk
Concerning exam
Abnormal vital signs
Focal neurologic findings
Vital sign danger thresholds
Vital sign red flags
Hypoxia on room air for age and altitude
Marked tachypnea for age
Bradycardia for age
Fever in young infant
Age 0 to 28 days any fever
Age 29 to 60 days fever with ill appearance
Event characteristics not consistent with BRUE
Not a BRUE if explained or ongoing
Choking with feeds suggesting aspiration
Clear seizure semiology
Trauma evidence
Toxic exposure
Persistent respiratory symptoms
Medications
Current and recent medications
Medication exposure
Prescribed medications
Recent antibiotics
Acid suppression
H2 blocker
Proton pump inhibitor
Bronchodilators
Sedating medications in household
OTC and supplements
Non prescribed exposures
Acetaminophen
Ibuprofen
Cough and cold products
Herbal products
Toxin and ingestion risk
Potential ingestions
Opioids
Benzodiazepines
Cannabis edibles
Clonidine
Ethanol
Nicotine products
Contraindications relevant to ED care
Treatment cautions
Allergy history
QT prolonging medications in infant
Methemoglobinemia risk drugs
Diet
Feeding pattern and hydration
Intake pattern
Feeding frequency
Typical volume per feed
Latching and suck strength
Wet diapers in last 24 hours
Stool pattern changes
Formula preparation and changes
Formula details
Recent brand change
Concentration errors concern
Water source
Maternal and infant exposures
Exposure through feeds
Maternal medications while breastfeeding
Caffeine exposure
Honey exposure risk
Recent new foods
Review of Systems
Respiratory
Respiratory symptoms
Cough
Stridor
Wheeze
Apnea episodes
Noisy breathing
Cardiovascular
Cardiac symptoms
Poor feeding with sweating
Cyanosis with crying or feeds
Lethargy
Neurologic
Neurologic symptoms
Abnormal movements
Staring spells
Post event sleepiness
Irritability
Gastrointestinal
GI symptoms
Vomiting
Bilious emesis
Blood in stool
Reflux symptoms
Infectious and systemic
Systemic symptoms
Fever
Poor oral intake
Decreased urine output
Rash
Collateral History and Family History
Collateral source
Source and reliability
Primary caregiver witness
Secondary witness
EMS report
Video available
Family history
Heritable risks
Sudden unexplained death in young family member
Known arrhythmia syndromes
Long QT syndrome
Brugada syndrome
Cardiomyopathy
Inborn errors of metabolism
Seizure disorders
Social context and safety
Home environment
Safe sleep practices
Tobacco smoke exposure
Substance use in household
Supervision reliability
Risk Factors
Infant specific risk factors
Patient risk features
Prematurity
Chronic lung disease
Congenital heart disease
Neurologic disorder
Failure to thrive
Infection risks
Infectious risk
Incomplete immunizations
Pertussis exposure
RSV exposure
Fever in young infant
Aspiration and airway risks
Aspiration risk
Feeding difficulty
Recurrent choking
Craniofacial abnormalities
Non accidental trauma risk
Maltreatment risk
Inconsistent history
Delay in seeking care
Prior CPS involvement
Differential Diagnosis
Life threatening
Cannot miss causes
Sepsis or meningitis
Fever
Ill appearance
Serious bacterial infection in young infant
Age younger than 60 days
Poor perfusion
Arrhythmia
Pallor
Sudden limp episode
Congenital heart disease decompensation
Feeding fatigue
Hepatomegaly
Seizure (G40.909)
Abnormal movements
Postictal period
Airway obstruction foreign body
Sudden cough or choking
Persistent stridor
Child maltreatment including abusive head trauma
Bruising
Bulging fontanelle
Toxic ingestion or poisoning (T50.901A)
Somnolence
Miosis
Common
Common explanations
Gastroesophageal reflux with choking
Event during or after feeding
Regurgitation
Viral URI with mucus plugging
Congestion
Cough
Pertussis
Paroxysmal cough
Posttussive emesis
Breath holding spell
Triggered by crying
Older infant
Laryngospasm
Reflux association
Brief stridor
Less common
Less common causes
Inborn error of metabolism (E88.9)
Poor feeding
Recurrent episodes
Anemia (D64.9)
Pallor
Poor feeding
Obstructive sleep apnea
Snoring
Craniofacial risk
Methemoglobinemia (D74.9)
Cyanosis with normal PaO2
Oxidant exposure
Infantile spasms (G40.822)
Clusters of brief flexion movements
Developmental regression
Past Medical History
Medical problems and baseline
Relevant conditions
Prior apnea episodes
Prior hospitalizations
Prior ICU care
Chronic lung disease
Congenital heart disease
Surgical and procedural history
Procedures and devices
Airway procedures
Cardiac surgery
Gastrostomy tube
VP shunt
Growth and development
Growth trajectory
Weight percentile trend
Feeding therapy involvement
Physical Exam
General and vitals
Initial assessment
General appearance
Well appearing
Ill appearing
Hydration status
Mucous membranes
Capillary refill
Vital signs trend
Heart rate
Respiratory rate
Temperature
Oxygen saturation
Airway and respiratory
Respiratory exam
Work of breathing
Retractions
Nasal flaring
Breath sounds
Wheeze
Crackles
Asymmetry
Upper airway sounds
Stridor
Stertor
Cardiovascular
Cardiovascular exam
Perfusion
Pulses
Capillary refill
Murmur
Hepatomegaly
Neurologic
Neurologic exam
Mental status and consolability
Tone
Fontanelle
Flat
Bulging
Focal deficits
Skin and trauma screen
Skin and injury findings
Bruising pattern concerning locations
Petechiae or purpura
Oral injuries
Skeletal tenderness
ENT
ENT exam
Nasal congestion
Oral secretions
Frenulum injuries
Lab Studies
Point of care and targeted labs
Low risk BRUE testing avoidance
Routine labs not indicated in low risk BRUE
Testing guided by history and exam only
Targeted labs when indicated
Glucose
Hypoglycemia threshold local protocol dependent
Repeat if symptoms recur
Venous or capillary blood gas if respiratory concern
CBC if anemia or infection concern
Electrolytes if dehydration or metabolic concern
Infection evaluation
Infectious workup when indicated
Urinalysis and urine culture in febrile young infant local protocol dependent
Blood culture in ill appearing infant
Lumbar puncture in neonate with fever or ill appearance local protocol dependent
Toxicology
Toxin evaluation when indicated
Acetaminophen level if exposure concern
Salicylate level if exposure concern
Urine drug screen if ingestion concern
Limitations and pitfalls
Interpretation pitfalls
Normal labs do not exclude seizure or arrhythmia
Early infection may have normal CBC
Viral testing rarely changes disposition in well appearing infant
Imaging
Scoring Systems
BRUE risk stratification framework
BRUE definition requires no explanation after history and exam
Low risk criteria all required
Age older than 60 days
Gestational age at birth 32 weeks or more
Postconceptional age 45 weeks or more
First event
Duration less than 60 seconds
No CPR by trained provider
No concerning history
Normal exam
High risk if any low risk criterion not met
MRI
Neuroimaging considerations
MRI brain
Focal neurologic deficits
Concern for abusive head trauma with stable patient
Contraindications
Unstable airway or hemodynamics without MRI safe monitoring
Non compatible implanted devices
CT
CT indications
CT head without contrast
Signs of intracranial injury
Bulging fontanelle with concerning course
Abusive head trauma concern with urgent need
Radiation risk discussion
Use only when benefits outweigh risks
Prefer MRI when feasible and stable
Ultrasound
POCUS and targeted ultrasound
Cardiac POCUS
Poor perfusion
Suspected cardiomyopathy or effusion
Pyloric ultrasound when vomiting pattern suggests
Progressive non bilious vomiting
Weight loss or dehydration
Special Tests
Cardiorespiratory monitoring
Observation monitoring
Continuous pulse oximetry during ED observation
Cardiac monitor during ED observation
Documented feeding trial observation when event associated with feeds
Infectious tests
Pathogen testing when indicated
Pertussis PCR or NAAT
RSV influenza SARS CoV 2 testing local protocol dependent
Neurologic tests
Neurologic evaluation when indicated
EEG
Recurrent events suspicious for seizure
Abnormal neurologic exam
Neurology consult triggers
Infantile spasms concern
Developmental regression
Swallow and airway evaluation
Feeding related testing
Speech language pathology evaluation
Videofluoroscopic swallow study outpatient pathway
ENT evaluation for suspected airway abnormality
ECG
Indications and key findings
ECG role
Consider in BRUE evaluation especially if pallor or family history
Evaluate for rhythm and conduction abnormalities
High risk ECG patterns
Prolonged QT interval
Preexcitation
Brugada pattern
Heart block
Serial and follow up
ECG follow up strategy
Repeat ECG if initial abnormal or artifact
Cardiology referral if QT prolongation or concerning history
Assessment
Determine if event meets BRUE definition
BRUE classification (R68.13)
Meets BRUE definition
Resolved and infant back to baseline
No explanation after history and exam
Not BRUE
Explanation identified
Ongoing symptoms
Risk stratification
Risk category
Low risk BRUE
Meets all low risk criteria
Low probability of serious underlying disorder
High risk BRUE
Any low risk criterion not met
Increased likelihood of targeted testing or admission
Complications to exclude
Immediate concerns
Infection in young infant
Seizure
Arrhythmia
Airway or aspiration event
Diagnostic uncertainty
Alternative diagnoses considered
Reflux associated choking
Viral respiratory illness
Breath holding spell
Child maltreatment concern
Plan
First 5 minutes workflow
Initial stabilization
Airway positioning and suction as needed
Oxygen if hypoxic
Cardiorespiratory monitor
Glucose check if altered or recurrent events
Targeted diagnostics
Testing strategy
Low risk BRUE
Avoid routine labs and imaging
ECG consideration
High risk BRUE
Testing guided by suspected etiology
Febrile young infant pathway local protocol dependent
Therapeutic actions
Interventions based on suspected cause
Nasal suction for congestion
Treat seizure if active
Treat hypoglycemia per local protocol
Antibiotics after cultures if sepsis suspected local protocol dependent
Reassessment loop
Reassessment
Repeat vitals during observation
Repeat focused exam after feeding trial
Escalate if recurrent event in ED
Caregiver education and skills
Caregiver support
CPR resources referral
Safe sleep counseling referral to standard discharge materials
Disposition
ICU and admission criteria
Higher level of care
Ongoing apnea or recurrent events in ED
Need for respiratory support
Hemodynamic instability
Sepsis concern
Significant abnormal neurologic findings
Inpatient admission
High risk BRUE with concerning features
Abnormal ECG
Feeding related events with aspiration concern
Social safety concerns
Observation pathway
ED or short stay observation
High risk features but well appearing
Single brief event with unclear trigger
Need for monitored feeding trial
Discharge criteria
Discharge for low risk BRUE
Meets low risk criteria
Normal vitals during observation
No recurrent events during observation
Caregiver comfortable with plan
Reliable follow up available
Follow up timing
Follow up plan
Primary care within 24 to 48 hours
Cardiology within 1 to 2 weeks if ECG abnormal
Neurology timing based on suspicion
Discharge Instructions
Copy discharge instructions
Summary
Today your infant had a brief event that has fully resolved and the exam is reassuring
No clear cause was found today and this type of event is called a BRUE
What to watch for
Trouble breathing
Blue or very pale color
Unusual sleepiness or hard to wake
Repeated vomiting
Poor feeding or fewer wet diapers
Any shaking or abnormal movements
What to do
Call emergency services right away if any of the warning signs happen
Place your infant on their back to sleep on a firm flat surface
Follow up
See your primary care clinician within 24 to 48 hours
Return to the emergency department sooner if another event happens
Medications
No new medications were started today unless discussed with you
Do not use cough and cold medicines in infants unless prescribed
References
Guidelines and key sources
Evidence based sources
American Academy of Pediatrics Clinical Practice Guideline Brief Resolved Unexplained Events 2016
American Academy of Pediatrics Technical Report Brief Resolved Unexplained Events 2016
American Academy of Pediatrics Clinical Practice Guideline Febrile Infant 8 to 60 Days 2021 local protocol dependent
National Institute for Health and Care Excellence Suspected Child Maltreatment guideline updated regularly local protocol dependent
Heart Rhythm Society and partner societies guidance on inherited arrhythmia evaluation updated regularly local protocol dependent
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