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.
|Brief||Duration <1 min||Duration ≥1 min|
|Resolved||Back to baseline health
↑ or ↓ resp rate
↑ or ↓ HR or BP
ANY sign injury
Abnormal Wt, growth, head circumference
|Unexplained||Event consistent with GOR, swallow dysfunction, nasal congestion etc
ANY concern child abuse
|Cyanosis/pallor||Central colour changes||Acrocyanosis or perioral cyanosis
|Absent, ↓ or irreg. breathing||Central apnoea
|Periodic breathing of newborn
|Marked Δ tone||Hypertonia
|Hypertonia assoc. with crying, choking, gagging or problems
Δ tone assoc. with breath-holding
Tonic eye deviation or nystagmus
Mental status Δ
Post ictal phase
|LOC assoc. with breath-holding spell|
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.
- 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?
- 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?
- 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?
- 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?
- Housing: general, water damage, or mold problems?
- Exposure to tobacco smoke, toxic substances, drugs?
- 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?
Age appropriate response to environment
|Growth variables||Length, weight
|Vitals||Temp, pulse, RR, BP, O2 sats|
evidence of injury
bruising or injury
|Nose & mouth||Congestion/coryza
Blood in nares/oropharynx
Trauma or obstruction
|Heart||Rhythm, rate, auscultation|
|Extremities||Muscle one, injuries
Response to sound/visual stimuli
- infants <2 months of age
- Hx of prematurity
- More than 1 event
- CPR instigated by trained person
- 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)