Definition
The term BRUE is an event occurring in an infant (<1 year) when the observer reports a sudden, brief and now resolved episode of ≥1 of:
- cyanosis or pallor
- absent, decreased, or irregular breathing
- marked change in tone (hyper- or hypotonia)
- altered level of responsiveness
A BRUE is diagnosed only when there is no explanation for a qualifying event after conducting an appropriate history and physical examination.
Using the above definition, and after history and examination you should categorise the patient into A) High risk - need further investigations or B) Low risk - no further intervention at this time.
| Includes | Excudes | |
|---|---|---|
| Brief | Duration <1 min | Duration ≥1 min |
| Resolved | Back to baseline health Normal vitals Normal appearance |
Recent fever ↑ or ↓ resp rate ↑ or ↓ HR or BP Somnolence/Δ mentation Hyper/Hypotonia Vomiting ANY sign injury Abnormal Wt, growth, head circumference Noisy breathing Recurrent events |
| Unexplained | Event consistent with GOR, swallow dysfunction, nasal congestion etc ANY concern child abuse |
|
| Cyanosis/pallor | Central colour changes | Acrocyanosis or perioral cyanosis Rubor |
| Absent, ↓ or irreg. breathing | Central apnoea Obstructive apnoea |
Periodic breathing of newborn Breath-holding spell |
| Marked Δ tone | Hypertonia hypotonia |
Hypertonia assoc. with crying, choking, gagging or problems Δ tone assoc. with breath-holding Tonic eye deviation or nystagmus Tonic-clonic activity Infantile spasms |
| Δ responsiveness | LOC Mental status Δ Lethargy Somnolence Post ictal phase |
LOC assoc. with breath-holding spell |
Clinical
A careful history and physical examination are necessary to characterise the event, assess the risk of recurrence, and determine the presence of an underlying disorder.
History
Consider NAI:
- Inconsistent Hx
- Hx inconsistent with developmental stage
- Unexplained bruising
- Unexplained attitude to child
History of the event:
- Who reported the event?
- Witness of the event?
- State immediately before the event
- Location of event
- Awake or asleep?
- Position: supine, prone, upright, sitting, moving?
- Feeding?
- Possibility FB ingestion/inhalation
State during the event:
- Choking or gagging noise?
- Active/moving or flaccid?
- Conscious? Able to see you or respond to voice?
- Muscle tone increased or decreased?
- Repetitive movements?
- Appeared distressed or alarmed?
- Breathing: yes/no, struggling to breathe?
- Skin color: normal, pale, red, or blue?
- Bleeding from nose or mouth?
- Color of lips: normal, pale, or blue?
End of event:
- Approximate duration of the event?
- How did it stop: with no intervention, picking up, positioning, rubbing or clapping back, mouth-tomouth, chest compressions, etc?
- End abruptly or gradually?
- Treatment provided by parent/caregiver (eg, glucose-containing drink, call 112/999)?
State after event:
- Back to normal immediately/gradually/still not there?
- Before back to normal, was quiet, dazed, fussy, irritable, crying?
Recent history
- Illness in preceding days?
- If yes, detail signs/symptoms (fussiness, decreased activity, fever, congestion, rhinorrhea, cough, vomiting, diarrhea, decreased intake, poor sleep)
- Injuries, falls, previous unexplained bruising?
Past medical history
- Pre-/perinatal history
- Gestational age
- Newborn screen normal (for inborn errors of metabolism, congenital heart disease)?
- Previous episodes/BRUE?
- Reflux? If yes, obtain details, including Mx
- Breathing problems? Noisy ever? Snoring?
- Growth patterns normal?
- Development normal? Assess a few major milestones across categories, any concerns about development or behavior?
- Illnesses, injuries, emergencies?
- Previous hospitalization, surgery?
- Recent immunization?
- Use of over-the-counter medications?
Family history
- Sudden unexplained death (including unexplained car accident or drowning) in first- or second degree family members before age 35, and particularly as an infant?
- Apparent life-threatening event in sibling?
- Long QT syndrome?
- Inborn error of metabolism or genetic disease?
- Developmental delay?
Environmental history
- Housing: general, water damage, or mold problems?
- Exposure to tobacco smoke, toxic substances, drugs?
Social history
- Family structure, individuals living in home?
- Housing: general, mold?
- Recent changes, stressors, or strife?
- Exposure to smoke, toxic substances, drugs?
- Recent exposure to infectious illness, particularly upper respiratory illness, paroxysmal cough, pertussis?
- Support system(s)/access to needed resources?
- Current level of concern/anxiety; how family manages adverse situations?
- Potential impact of event/admission on work/family?
- Previous child protective services or law enforcement involvement (eg, domestic violence, animal abuse), alerts/reports for this child or others in the family (when available)?
- Exposure of child to adults with history of mental illness or substance abuse?
Examination
| Appearance | Craniofacial abnormalities Age appropriate response to environment |
|---|---|
| Growth variables | Length, weight occipitofrontal circumference |
| Vitals | Temp, pulse, RR, BP, O2 sats |
| Skin | Colour, perfusion evidence of injury |
| Head | Shape, fontanelles bruising or injury |
| Eyes | General, movements pupillary responses Conj. haemorrhage Retinal exam |
| Ears | TMs |
| Nose & mouth | Congestion/coryza Blood in nares/oropharynx Trauma or obstruction Torn frenulum |
| Neck | Mobility |
| Chest | Auscultation rib tenderness crepitus, irregularity |
| Heart | Rhythm, rate, auscultation |
| Abdomen | Organomegaly, masses tenderness |
| Genitalia | Any abnormality |
| Extremities | Muscle one, injuries Deformity (?#) |
| Neurological | Alertness, responsiveness Response to sound/visual stimuli General tone Pupilary response Symmetrycal reflexes Symmetrical move/tone/power |
Algorithm
Risk assessment
High risk
- infants <2 months of age
- Hx of prematurity
- More than 1 event
- CPR instigated by trained person
Lower risk
- Age >60 days (congenital or infection less likely)
- Prematurity: gestational age ≥32 weeks and postconceptional age >45 weeks
- First BRUE (no previous BRUE ever and not occurring in clusters)
- Duration of event <1 minute
- No CPR required by trained medical provider
- No concerning historical features (see table above)
- No concerning physical examination findings (see table above)