Approach to Brief Resolved Unexplained Events, or BRUE, by Jonathan Fried and Dr. Beth Harper.
Learning Objectives.
By the end of this video, the learner will be able to define brief resolved unexplained
events, or BRUEs, recognize the clinical presentation, diagnose and risk stratify a patient, and
understand the principles of management.
Introduction.
As a health care provider working in clinic or in the emergency department, you'll be
confronted with many anxious caregivers who will ask you, "Is my infant OK?" You'll be
called upon to evaluate their baby.
And over time, you'll develop the clinical acumen necessary to determine which patients
are at higher risk of having underlying disease and which patients are at lower risk and can
be reassured.
One diagnosis that will test that clinical acumen in pediatrics is a BRUE, or brief resolved
unexplained event.
Let's begin with a clinical scenario.
It is 11:00 PM in the emergency department, and you are called to evaluate a three-month-old
girl for a chief complaint of apnea and cyanosis.
You rush to the room, where you find two very anxious looking parents and a happy, cooing,
healthy-appearing infant, pink and breathing comfortably.
Seeing your confused look, her parents immediately launch into an explanation.
Without warning, their daughter, the otherwise healthy product of an uncomplicated, spontaneous
vaginal birth at 38 weeks gestational age, suddenly stopped breathing while breastfeeding
and turned blue.
After 30 seconds, she resumed breathing.
This has never happened before.
Terrified by their blue baby, her parents rushed to the emergency room.
Does this infant require admission for observation and workup of her apnea or reassurance that
her parents can care for her at home?
After performing a thorough history and physical exam to characterize the event, assess the
risk of reoccurrence and determine the presence of an underlying disorder.
You've not identified any probable cause for this infant's brief apneic episode.
You should, therefore, ask yourself, was this a BRUE?
Definition.
An episode is defined as a BRUE if and only if all of the following are true.
First, it's brief, lasting under one minute in an infant whose life has been pretty brief,
less than one year old.
Second, it has resolved and the patient is back at their baseline.
Third, it's unexplained with no other symptoms, signs, or explanation derived from the history
and physical.
Fourth, the event is a change in either color, central cyanosis or pallor; breathing, such
as apnea; tone, hyper- or hypotonia; or mental status.
If any of these criteria are not met, then this is not a BRUE and you must investigate
and manage accordingly.
For example, if the symptoms lasted longer than one minute or are ongoing, then it is
not a BRUE.
If you observe abnormal vital signs or additional signs on physical exam such as respiratory
distress, cyanosis, or abnormal movements, that's not a BRUE.
Or if the episode is characterized by choking or gagging with emesis, then it is not a BRUE.
How common are BRUEs?
The term BRUE is new and replaced a previous category of apparent life-threatening events
in 2016.
It is a relatively common complaint among young, otherwise healthy babies, occurring
in up to 1% of all infants.
Diagnosis.
Apnea and cyanosis, along with a change in tone or mental status, may represent a wide
range of underlying problems.
Therefore, the history and physical are of critical importance.
Let's now talk about what to include in the history and physical for a child who presents
with a BRUE.
In general, you should characterize the event and the events that preceded it, including
where the infant was and what they were doing, whether they were feeding or had recently
fed, and what position they were in.
It is important to note who witnessed the event, how long it lasted, and whether an
intervention such as CPR was required to make the event resolve.
You should also thoroughly review past medical, social, developmental, environmental, and
family histories.
There are several do not miss diagnoses that you must consider, which include cardiopulmonary
disease, abuse, and serious infections.
You should also ask about symptoms usually associated with more common conditions that
can present as BRUEs, which include gastroesophageal reflux, respiratory infections, and seizures.
Let's go over a few of these one by one.
To evaluate for cardiac disease, you might ask about failure to thrive, feeding or respiratory
problems, or family history of sudden unexplained death.
And you should listen for murmurs or irregular heart rate.
To evaluate for infections, you should obtain a full immunization history and ask about
recent fevers, sick contacts, or rashes.
Vital sign abnormalities and your physical exam can clue you into this as well.
To evaluate for seizure, you should ask about rhythmic or abnormal eye or limb movements
and inquire about family history of seizure in any first or second degree relatives.
To evaluate for reflex or aspiration, you should ask about feeding habits, including
whether the infant is breast or bottle-fed, how much and how often they drink, and any
difficulties with coughing, gagging, choking, or emesis during or after feeds.
You may suspect this if a story is inconsistent with the clinical picture in front of you.
On exam, you should look for multiple injuries, bruises, a torn frenulum, or a bulging fontanelle.
To evaluate for abuse, you should ask about similar events in siblings, the presence of
a mental illness or drugs in the home.
If any of these red flags are present, you should consider if there has been previous
child protective services or law enforcement involvement.
Let's say you've finished a thorough history and physical and you've found nothing out
of the ordinary, you're ready to diagnose a BRUE.
But you're not done.
Next, You must risk stratify your patient.
How do we know if an infant who has experienced a BRUE is at lower risk for a recurrent event
or for having an underlying disease.
Lower risk BRUEs are defined by five features.
First, the patient's age is greater than 60 days.
Second, the patient's gestational age was at least 32 weeks and post-conceptual age
is at least 45 five weeks.
Third, this was the patient's first and only BRUE.
Fourth, the duration was under one minute.
Fifth, no CPR by a trained medical provider was required.
And, of course, you found no concerning features on history and physical exam, which would
rule out the diagnosis of BRUE in the first place.
On the other hand, a BRUE is considered higher risk if a patient does not meet all of the
above criteria.
There are no current guidelines for how to manage high risk BRUEs.
You should use the evidence that you have at hand to construct a broad differential
diagnosis and manage these patients accordingly.
Management.
If your patient meets these five criteria, then they are at a lower risk of a subsequent
event or serious underlying disorder.
You should reassure these parents.
But that's not all.
The American Academy of Pediatrics provides helpful guidelines on what to do next with
lower risk BRUE patients.
You should provide caregivers with education about BRUEs and CPR training resources and
come to a shared decision with caregivers about a potential safe discharge home.
While there is no known association between lower risk BRUEs and sudden infant death syndrome,
or SIDS, you may take this opportunity to educate caregivers about routine measures
like safe sleep to prevent SIDS.
You don't need to admit these patients for observation nor do you need to order any further
tests or prescribe any treatments.
However, you may briefly monitor patients for one to four hours with serial exams and
pulse oximetry to ensure ongoing stability and to continue the search for an alternative
diagnosis to BRUE such as by observing a breath-holding episode or reflux.
The AAP allows the option of obtaining an EKG or pertussis testing based on your clinical
suspicion and immunization trends in your area, although the evidence for these interventions
is weak at best.
Summary.
When confronted with a healthy-appearing infant with a history of a change in color, tone,
breathing, or mental status, you can diagnose a BRUE if and only if the episode lasted under
one minute and resolved and has no better explanation provided by a thorough history
and physical.
If there's anything that clues you into a possible underlying diagnosis, then it is
not a BRUE, and you should work it up accordingly.
You should then risk stratify the patient and can determine that a patient is at lower
risk for having underlying disease or recurrent episodes if this was their first and only
event, if they are greater than 60 days old, if they were born at gestational age at least
32 weeks, and if no CPR was provided by a trained medical provider.
These patients require no further workup and are at no increased risk for SIDS, and caregivers
can be reassured that it is safe to return home with their precious infant.