Zeid Kalarikkal, Chief Resident Extraordinaire

Picture this; you have a previously healthy 14-week-old boy who is brought by his very concerned first-time parents. The mother notes that the infant had an episode where he went blue and was not breathing. She quickly picked him up, tapped on his back and maybe 30 seconds later the baby was noted to be awake and breathing comfortably.

You note that the child was born at-term with an uncomplicated birth history. He has been doing well since and they follow up regularly with their pediatrician. Parents deny any history of fever, URI symptoms, cough, vomiting or diarrhea. Vital signs and physical are normal and the baby is noted to feeding from the bottle during your evaluation.

You complete your evaluation and conclude that this child had an Acute Life Threatening Event or ALTE.

ALTE was previously defined as “an episode that is frightening to the observer and that is characterized by some combination of apnea, color change, marked change in muscle tone, choking, or gagging”

You return to the room to explain this to the parents. While your gestalt tells you that the child is and probably will be fine, you start explaining your diagnosis. At the mere mention of the word ‘Life-Threatening’, the father collapses to the ground and the mother starts sobbing. You curse yourself for picking up the chart and start consoling the parents.

In most cases, this case had an obvious disposition – Transfer to a Pediatric hospital.  Previously, there was no data to identify a subset of ALTE patients that could be safely discharged home. While some do get discharged home, it depended heavily on provider gestalt, comfort and degree of risk aversion.

Enter BRUE

Brief Resolved Unexplained Event or BRUE has replaced ALTE in the most recent guidelines from the American Academy of Pediatrics.

BRUE brings some clarity to the definition of ALTE by specifying that:

  • The term only applies to infants less than 1 year old
  • Episode must be less than 1 minute and have resolved
  • Patient must have a reassuring history, physical exam and vitals during evaluation
  • Episode must be unexplained

First thing to do with a child meeting the definition of BRUE is to classify them as low or high risk.

Features that have been defined as low risk are age greater than 60 days, a lack of prematurity (gestational age > 32 weeks and post-conceptual age > 45 weeks), a first and isolated event, duration of less than one minute, no need for CPR provided by a trained medical provider and no concerning historical features or physical exam findings. 

If your patient does not meet all of these criteria, they are now high risk and the guidelines offer no further recommendation.

For low-risk patients, the guidelines offer further recommendations.

  • Parent/caregiver education regarding these events and use shared-decision making for further testing, discharge and follow-up.
  • You may consider pertussis testing, EKG and cardiorespiratory monitoring.
  • You do not need obtain viral panels, CBC, CSF/blood cultures, electrolytes, CXR, EEG or other advanced testing.
  • You DO NOT need to admit these patients for the event alone and they can be discharged home with close outpatient follow-up within 24 hours.

Remember, BRUE is only used when no other condition can be found as the etiology of the event. It only represents a constellation of symptoms and you should use your history and physical examination skills to determine a more precise diagnosis before labeling it a BRUE. The biggest strength of these updated guidelines is that you now have some support for discharging a low risk patient.



Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B, Katz ES, Krilov LR, Merritt JL 2nd, Norlin C, Percelay J, Sapién RE, Shiffman RN, Smith MB; SUBCOMMITTEE ON APPARENT LIFE THREATENING EVENTS. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Pediatrics. 2016 May;137(5). PMID: 27244835.

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