Brief Resolved Unexplained Event In The Infant and Apparent Life Threatening Event ConcernAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

509 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Fever In The Neonate And Young Infant Pediatric Fever By Age 0 To 28 Days Pediatric Fever By Age 29 To 60 Days Pediatric Fever By Age 2 To 24 Months Pediatric Respiratory Distress Croup And Stridor In Children Pediatric Dehydration Pediatric Abdominal Pain Febrile Seizure Rash In The Child Poor Feeding And Lethargy In The Infant Vomiting In The Child Diarrhea In The Child Pediatric Trauma Evaluation Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern Lethargy And Altered Mental Status In The Child

Environmental and Exposure4▾

01History/hx71

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

02Alarm Features/alarm38

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

03Medications/meds24

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

04Diet/diet15

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

05Review of Systems/ros25

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

06Collateral History and Family History/chafh18

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

07Risk Factors/rf19

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

08Differential Diagnosis/ddx57

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

09Past Medical History/pmh14

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

10Physical Exam/exam45

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

11Lab Studies/labs22

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

12Imaging/img34

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 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

13Special Tests/spec18

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

14ECG/ecg11

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

15Assessment/ax24

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

16Plan/plan24

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

17Disposition/dispo25

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

18Discharge Instructions/di19

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

19References/r6

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Brief Resolved Unexplained Event In The Infant and Apparent Life Threatening Event ConcernAPPROACH

PEDIATRICS · 19 SECTIONS

⚲

509 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

01History/hx71

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

02Alarm Features/alarm38

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

03Medications/meds24

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

04Diet/diet15

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

05Review of Systems/ros25

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

06Collateral History and Family History/chafh18

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

07Risk Factors/rf19

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

08Differential Diagnosis/ddx57

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

09Past Medical History/pmh14

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

10Physical Exam/exam45

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

11Lab Studies/labs22

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

12Imaging/img34

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 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

13Special Tests/spec18

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

14ECG/ecg11

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

15Assessment/ax24

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

16Plan/plan24

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

17Disposition/dispo25

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

18Discharge Instructions/di19

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

19References/r6

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.