Evaluating pediatric risk after BRUE

A detailed patient history and physical examination inform this diagnosis of exclusion after a brief resolved unexplained event (BRUE)

By ​David Wright, M.S., PA-C, NRP; and Kate Randolph, B.S.

You and your partner are responding to a 911 call. Dispatch informs you that an alarmed new mother has a 6-week-old premature infant who had a 2-minute episode of lethargy.

When you arrive on scene, that mother is now calm and states her baby looks much better at this time. You evaluate the patient and obtain further history. The patient's mother informs you that the patient was born prematurely at 31 weeks and 4 days, and admitted in the NICU for 5 weeks. The patient was just discharged 4 days ago. Today, while holding the patient, she noted that he suddenly stopped breathing and became limp. Even though she was not feeding the child at the time of the episode, she performed some back blows, but nothing changed. She called 911 and noticed that the baby had a bluish color around the lips and in the fingers and toes.

A BRUE is defined as an event in patients younger than 1 year of age, that is an acute, short and now resolved episode of at least one of the associated symptoms.
A BRUE is defined as an event in patients younger than 1 year of age, that is an acute, short and now resolved episode of at least one of the associated symptoms. (Photo/Getty Images)

Your current physical exam shows a very well-appearing infant, with good tone, pink color and normal capillary refill time. You obtain a set of vital signs and note them all to be within normal limits for his age. You start to wonder what happened, when your partner reminds you about brief resolved unexplained events (BRUEs) and their need for transport to the ED.

Brief resolved unexplained event (BRUE)

BRUEs can be very concerning for not only the guardians of a patient, but also the
clinicians involved in the patient's care. A BRUE is defined as an event in patients younger than 1 year of age, that is an acute, short and now resolved episode of at least one of the following symptoms [1]:

It is extremely important to understand that this is classified as a diagnosis of exclusion. This means that this diagnosis should only be applied when the clinician has performed a thorough history and physical exam, and if indicated, diagnostic testing has been performed.

BRUE signs and symptoms

BRUE symptoms include:

  • Cyanosis or pallor
  • Absent, decreased or irregular breathing
  • Marked change in tone (hyper or hypotonia)
  • Altered level of responsiveness

The patient must be <1 year old and have no other explanation for the event for the incident to be considered BRUE.

BRUE epidemiology

First described in 2016, BRUEs are a relatively new diagnosis, making the estimated incidence of BRUEs currently difficult to assess under the new criteria. Prior to 2016, BRUEs were classified under the apparent life-threatening events (ALTE) diagnosis. It should be noted that BRUE is more than just the new term for ALTE [2]. One study revealed only 1 out of 78 reviewed cases that met the criteria for ALTE also met the criteria for BRUE. The other 77 cases had explainable events that had explainable causes [3]. The study of ALTEs is more readily available for evaluation of frequency of occurrence. Such studies indicate that ALTEs occur in 3:10,000-41:10,000 infants [4]. This wide range could be the result of the broad definition of ALTE. It is likely that studies implementing the more narrow definition of BRUE will shift the diagnosis explanation [4].​ The influence of race, gender, ethnicity, environmental factors, and social status associated with BRUEs are also being reviewed [2].

Low vs. high risk BRUE

Using the BRUE definition, infants younger than 1 year of age who present with a brief, sudden and now resolved episode are categorized as a lower risk or higher risk. This is based on history and physical examination [5]. ​Infants defined as lower risk are older than 60 days of age and have no requirement for cardiopulmonary resuscitation by the medical professional.

Lower risk BRUEs last less than one minute with no repeating or previous BRUE events, no concerning medical or family history, as well as no concerning findings during a physical examination. With the lower risk infants, the medical professional may educate the caregiver about BRUE and offer additional resources, but do not need to do any additional medical testing.

Infants defined as higher risk are younger than two months of age, a history of prematurity, and those with repeating events. If the clinical history and/or physical examination of the patient reveals abnormal findings or other concerns that the patient is at higher risk, then the patient should undergo further investigation/treatment. Higher risk infants are more likely to have an underlying cause, recurring events or abnormal outcomes and findings [5].

Table: Signs and symptoms for low vs. high risk BRUE [1]

Differential diagnosis for BRUE

As BRUE is a diagnosis of exclusion, it is important for the clinician to rule out other etiologies. It is important to point out that many causes cannot be ruled out in the current pre-hospital setting.

  • Respiratory​. Upper and lower respiratory infections (bronchiolitis, pertussis and pneumonia can all cause apnic spells)
  • Hematologic. Sepsis
  • Neurological​. Meningitis, seizures, infantile botulism
  • Gastrointestinal. Gastroesophageal reflux
  • Cardiac​. Prolonged QT syndrome, dysrhythmia
  • Endocrine. Metabolic disorders, electrolyte imbalance
  • Trauma​. Child abuse

Immediate BRUE treatment by EMS

Initial EMS treatment is based on how the patient presents on your arrival. As with any patient, it is important for the EMS clinicians to perform a thorough physical assessment. Initial assessment should begin with utilization of the pediatric assessment triage. This helps accurately predict the severity of a child’s illness and your primary assessment [6]. Recall your pediatric assessment triangle (PAT) consists of the three following components [7]:

  • Appearance​. Initially ask yourself “what does the patient look like?” Clinicians should be evaluating the patient’s tone, ability to interact, consolability and their speech/gaze before even touching the patient.
  • Work of breathing. The patient’s respiratory status should be immediately evident to the clinician upon first encounter. A rapid evaluation of the patients’ positioning, retractions, nasal flaring and any apnea/gasping should be assessed, along with any audible breath sounds.
  • Circulation/color. Prior to touching the patient, the clinician should perform a rapid assessment of the skin, looking for cyanosis, mottling or pallor.

After the general (PAT) assessment, the initial assessment should be performed as follows:

  • Airway. Evaluate the patient’s airway for patency. Look for any deformities, foreign bodies or obstructions, including mucous, vomitus or formula.
  • Breathing​. Evaluate the patient’s breathing. Look for quality, rate and rhythm. Place the patient on a pulse ox and/or capnography.
  • Circulation. Evaluate the patient’s circulatory function. Look at the capillary refill, blood pressure, skin color and pulses.
  • Disability. Is the patient alert? Responsive to verbal statements or painful stimulus? Are they unresponsive?
  • Exposure. When you look at the patient, do you see any major deformity, obvious injuries or sources of symptoms?

Any concerns that are uncovered during the PAT or the initial assessment, should be immediately corrected. As with all patients, the presentation and assessment should be used to guide treatment. While many BRUE patients are asymptomatic upon EMS arrival, any who are symptomatic need immediate treatment to correct any life-threatening conditions.

If the patient is asymptomatic upon EMS arrival, the EMS provider should obtain a complete history (include the details below) and physical exam. ​These patients still need full evaluation by an emergency room provider with additional interventions performed as necessary.​ It is important for EMS clinicians to not be fooled by the patient's well initial appearance and perform a detailed history and physical exam.

A complete and thorough patient history should include:

  • Length of event
  • Was the patient limp?
  • Was there a color change of the skin? If so, what color?
  • Was there ever an apneic event?
  • Birth history
    • Weeks of gestation
    • C-Section vs vaginal delivery
    • Any NICU stay?
  • Is the patient currently altered
  • Abnormal vital signs?

Table: Important BRUE history and physical components

General hospital treatment for BRUE

In a recent analysis at a tertiary pediatric care center, the implementation of the 2016 clinical practice guidelines for BRUEs has reduced hospital invasive testing, admission rates, and length of stays, while not increasing readmissions or returning ED visit rates [8].

Patients who experience a BRUE require additional evaluation by a pediatric trained provider. These patients are often well served at a pediatric specialty hospital. Patients who experience a BRUE are often admitted to the hospital for observation and monitoring. In one study, 80% of patients diagnosed with a BRUE were admitted [9].

Although there is some evidence showing there is no increased risk of death in patients who experience a low-risk BRUE​, it is still highly recommended that these patients who present to EMS should be transported to the hospital for additional monitoring and work-up to rule out other causes of the event [10].

Read next: Pediatric patient ABCs: 7 tips for EMTs and paramedics


  1. Kondamudi NP, Virji M. Brief Resolved Unexplained Event (BRUE) [Updated 2020 Jul 10]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: ​www.ncbi.nlm.nih.gov/books/NBK441897/
  2. ​Tieder, J., Bonkowsky, J., Etzel, R., et al. (2016) Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. ​American Academy of Pediatrics​, American Academy of Pediatrics, pediatrics.aappublications.org/content/137/5/e20160590.
  3. Gerber NL, Fawcett KJ, Weber EG, et al. Brief Resolved Unexplained Event: Not Just a New Name for Apparent Life-Threatening Event [published online ahead of print, 2020 May 28]. ​Pediatr Emerg Care​. 2020;10.1097/PEC.0000000000002069. doi:10.1097/PEC.0000000000002069
  4. Corwin, J. Michael. (2020) ​Acute events in infancy including brief resolved unexplained event (BRUE). www.uptodate.com/contents/acute-events-in-infancy-including-brief-resolved-unexplained-event-brue
  5. Merritt, J. Lawrence II, Quinonez, A. Ricardo, Bonkowsky, L. Joshua, et al.(2019) A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event. ​American Academy of Pediatrics​, American Academy of Pediatrics, pediatrics.aappublications.org/content/144/2/e20184101.
  6. Horeczko, T., Enriquez, B., McGrath, N. E., Gausche-Hill, M., & Lewis, R. J. (2013). The Pediatric Assessment Triangle: accuracy of its application by nurses in the triage of children. ​Journal of emergency nursing​, ​39​(2), 182–189. https://doi.org/10.1016/j.jen.2011.12.020
  7. American Heart Association (2018) Pediatric Advanced Life Support.
  8. Sethi A, Baxi K, Cheng D, Laffey S, Hartman N, Heller K. Impact of Guidelines Regarding Brief Resolved Unexplained Events on Care of Patients in a Pediatric Emergency Department [published online ahead of print, 2020 Mar 7]. ​Pediatr Emerg Care​. 2020;10.1097/PEC.0000000000002081. doi:10.1097/PEC.0000000000002081
  9. Duncan DR, Growdon AS, Liu E, et al. The Impact of the American Academy of Pediatrics Brief Resolved Unexplained Event Guidelines on Gastrointestinal Testing and Prescribing Practices. ​J Pediatr​. 2019;211:112-119.e4. doi:10.1016/j.jpeds.2019.04.007
  10. Freedman, M., Burke, M. (2018) BRUE in infancy does not increase risk of death.
    Contemporary Pediatrics. Accessed from: www.contemporarypediatrics.com/view/brue-infancy-does-not-increase-risk-death

About the authors

Kate Randolph, BS, works as a patient care associate and is pursuing an education to become a pediatric physician assistant. 
Kate Randolph, BS, works as a patient care associate and is pursuing an education to become a pediatric physician assistant. 

Kate Randolph, BS

Kate recently graduated in May 2020 from Central Methodist University where she graduated with honors with a Bachelor of Science Degree in Biology. She is highly motivated to continue working to complete the pre-requisites before pursuing admission as a physician assistant student in 2021. She is currently employed at Mercy Hospital in Creve Couer as a patient care associate in the Medical Progressive Care Unit where she is able to provide excellent patient care and follow her passion for medicine, while obtaining valuable experience in the healthcare field. She hopes one day to work as a pediatric physician assistant taking care of infants and children in their time of need.

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