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This guideline has been developed for the evaluation, risk stratification, investigation and management of patients presenting to hospital with a brief resolved unexplained event (BRUE). This guideline is intended to replace the previous guidance on Apparent life-threatening events (ALTE), due to updated evidence and reclassification of such presentations.
An ALTE is a descriptive term based on an event that is frightening to the observer including a combination of: apnoea, colour change, change in muscle tone, choking or gagging. This definition includes both physiological and pathological causes for events.
It has been recommended that the term ALTE is replaced with the new term “Brief Resolved Unexplained Event” or BRUE. This concept differs from an ALTE both in definition, and in allowing risk stratification of patients, which in turn can guide further management.
BRUE allows for health care professional to categorise event, and stratify infants as lower or higher risk of having a repeated episode or a serious underlying disorder. Higher risk patients require further investigation +/- treatment.
The diagnosis of a BRUE can only be used as a diagnosis if there is no explanation for the event after a thorough history and examination.
BRUE is defined as an episode in an infant less than 12 months old characterized by:
Includes one or more of the following:
Source: American Academy of Pediatrics; Brief resolved unexplained events (formerly Apparent life-threatening events) and evaluation of lower risk infants. Pediatrics 2016, 137(5): e20160590.
Physiological |
Gagging, laryngospasm, neonatal periodic breathing |
Cardiac |
Congenital heart disease, arrhythmias, prolonged QT, vascular ring |
Respiratory |
Inhaled FB, airway obstruction incl. laryngomalacia, congenital malformation. |
Infection |
Pertussis, pneumonia, URTI/LRTI (esp. RSV), meningitis/encephalitis, UTI, septicaemia, gastroenteritis. |
CNS |
Head injury, seizures, cerebral malformations, central hypoventilation syndrome. |
Non-accidental injury |
Inflicted injury incl. drug ingestion, factitious illness (Munchhausen by proxy), suffocation. |
Gastrointestinal |
Gastro-oesophageal reflux |
Surgical |
Intussuception, testicular torsion |
Metabolic/toxins
|
Hypoglycaemia, hypocalaemia, hypokalaemia, inborn error(s) of metabolism, intentional and non-intentional drug overdose. |
General description of event:
During event:
End of event:
After event:
Recent past medical history:
Past medical history:
Family history:
Social & Environmental history:
Full ABCDE assessment; with consideration of differential diagnosis.
Observations including temp, RR, HR, BP, AVPU and oxygen saturations.
Plot weight, length and head circumference.
Consideration for child protection concerns:
If ANY Child Protection concerns then HIGH RISK and needs to be |
Often after history and examination there may be no specific diagnosis found.
Factors which make the event higher risk:
Patients may be classified as lower risk BRUE if they have no concerning feature on history/examination PLUS:
A low risk event is unlikely to represent a severe underlying disorder; and is unlikely to recur. Therefore based on the above risk stratification of patients; it is possible to guide what further investigation of the event, if any, is required.
Please refer to Flow diagram (1) above for guidance
By definition if patient requiring ongoing treatment, episode is NOT a BRUE. Lower risk patients do not routinely need admitted for cardio-respiratory monitoring.
Lower risk: Discharge home only if:
Lower risk does not mean no risk. Lower risk patients could be considered for a period of observation within the ED department if required.
Higher risk: Following discussion with ED Consultant or OOH senior paediatric registrar, consider admission for observation, cardio-respiratory monitoring and further investigations as guided by presentation.
Involve and refer to relevant specialties as appropriate if underlying cause identified:
Last reviewed: 14 December 2018
Next review: 31 October 2025
Author(s): S Farquharson, S Foster.
Version: 2
Approved By: Paediatric Clinical Effectiveness & Risk Committee