BRUE: What Is It? How Is It Treated?

BRUE –brief resolved unexplained event – whether you pronounce it brew-EE or brOO, it might be a term you haven’t run across since medical school. In a recent resident-led episode of PediaCast CME, Meghan Fennell, MD, and Vanessa Thiel, MD, break down everything you need to know about BRUE.

Events that are classified as a BRUE must meet the following qualifications:

1. Occurs in an infant less than one year old.
2. They are brief. They last less than one minute.
3. Symptoms include cyanosis or pallor; absent, decreased or irregular breathing; significant change in muscle tone (going limp or ridged); and/or altered responsiveness.
4. Emergency responders do not need to perform CPR either at the scene or when the family arrives in the emergency department.
5. They are unexplained by family history, physical exam and routine work up.
6. They are resolved. The infant appears completely normal following the event, as if nothing had happened.

In 2016, the American Academy of Pediatrics published the first clinical guidelines providing a framework for evaluation, risk assessment and management of infants who present with symptoms indicating a possible BRUE. These guidelines are an important tool for physicians diagnosing or caring for patients who have had a BRUE.

Included in the clinical guidelines was the introduction of the term BRUE. Previously, the term commonly used to describe such events was ALTE (apparent life-threatening event). While these events are very frightening for caregivers, they are generally not life-threatening. The term ALTE can invoke even more fear in caregivers.

Drs. Fennell and Thiel say that obtaining a detailed family history can offer important clues about whether the event is a BRUE or related to an undiagnosed condition, such as epilepsy or congenital heart disease (CHD). A physical examination of the infant can provide important clues that would point toward a neurodevelopmental condition.

It is also important to consider nonaccidental trauma when reviewing your diagnostic differential. Talking with the family, observing interactions between the family and the baby, and considering the patient’s medical history can help you identify or rule out nonaccidental trauma.

Once other diagnoses have been ruled out, families may need reassurance to be comfortable with the diagnosis of a BRUE. Teaching them CPR can empower caregivers to feel better equipped and more confident taking their child home.

A BRUE can be frightening for parents and present a mystery for providers to solve. By following the clinical practice guidelines and taking thorough histories, physicians can help each child and family achieve the best possible outcome.