Brief Resolved Unexplained Event (BRUE) (Previously known as Apparent Life-Threatening Event [ALTE]) - 104-1
Life-threatening events involving infants are devastating to parents, caregivers and health care workers alike. Brief resolved unexplained events (BRUE) are characterized by a non-specific, resolved and episodic presentation, including any of the following: cyanosis or pallor; absent, decreased or irregular breathing; marked change in tone (hypertonia or hypotonia; and/or altered responsiveness). The etiology of these events is heterogeneous for a majority of infants; a specific cause may be identified following a focused history, physical examination and targeted investigations.
An underlying etiology may be found in over half of infants presenting with BRUE. For those infants where a cause cannot be identified through a focused clinical evaluation and/or initial investigations, stratification for risk/probability of an occult pathology should guide further investigations and monitoring interventions. Possible causes of BRUE include:
- Misinterpretation of normal physiology in an infant (e.g., transient choking with rapid feeding or with coughing during feeding, periodic breathing/ respiratory pauses of 5-15 seconds)
- Infectious disease (e.g., respiratory infection, sepsis, meningitis, encephalitis)
- Cardiopulmonary abnormalities (e.g., central or obstructive sleep apnea, arrhythmia)
- Neurologic disease (e.g., epilepsy)
- Child abuse (e.g., intentional suffocation, non-accidental head injury)
- Metabolic disease (e.g., inborn error of metabolism)
- Other (e.g., toxic ingestion, poisoning)
Given the presentation of an infant with a BRUE, the candidate will evaluate possible risk factors and/or causes and initiate an appropriate management plan including investigations, interventions and follow-up. If an etiology is not identified through the initial evaluation, the candidate will determine whether the severity of the BRUE warrants more extensive investigation through the process of risk categorization .
The candidate will also counsel the infant's parents/caregivers and family.
Given an infant presenting with a BRUE, the candidate will
- list and interpret critical clinical findings, including those derived from
- a detailed history of the event;
- an evaluation of maternal, infant and environmental risk factors;
- the physical examination and/or direct observation;
- list and interpret critical investigations based upon the clinical features (e.g., viral studies, chest radiograph)
- construct an effective initial management plan, including
- admitting the patient for observation;
- counselling and supporting the parents' emotional needs, clarifying the difference between BRUE and sudden infant death syndrome (SIDS);
- referring the parents if further investigations or interventions are required (e.g., high-risk BRUE, cardiopulmonary resuscitation training for recurrent events);
- referring the patient for specialized care/investigations, if required (e.g., metabolic testing, cardiac evaluation).