What is Brief Resolved Unexplained Event?
In 2016, the American Academy of Pediatrics suggested replacing an old term “apparent life-threatening event” (ALTE) with a fresh term “brief resolved unexplained event” (BRUE). The older term was used to describe any event that looked scary to someone watching and involved symptoms like sudden stopping of breathing, changes in skin color, changes in muscle tone, and instances of choking or gagging. This term, which was originally created to replace the term “near-miss sudden infant death syndrome” in 1986, was thought to be too vague for practical use and research because its symptoms and causes varied widely.
Rather than focusing on the observer’s personal, potentially biased, report, the new term BRUE is aimed to move away from the “life-threatening” tag and to illustrate better the short-lived nature of this event and the lack of any definite cause. A BRUE is defined as an observed instance in an infant younger than one year old, where the observer recounts an unexpected, brief, but now resolved, event with symptoms like unusual skin color (blue or pale), irregular or absent breathing, significant change in muscle tone (hard or soft), and an altered level of consciousness.
The diagnosis of BRUE can only be made after a thorough medical checkup and history taking to ensure there are no other factors causing the reported symptoms.
A closer look at previous ALTE studies shows that a minor number of babies with symptoms matching BRUE could actually have a serious hidden disease or may repeat these symptoms. High-risk children are those younger than two months old, those born prematurely (especially, if before 32 weeks of pregnancy), and those who had more than one such event.
Low-risk infants, on the other hand, are those aged over 60 days, born after 32 weeks of pregnancy, first-time experiencing BRUE, the event lasted for less than a minute, didn’t require CPR by a professional medical provider, and do not have any concerning symptoms or physical findings from the examination. Those who can’t be classified as low risk are, by nature, considered high risk.
What Causes Brief Resolved Unexplained Event?
The term ‘brief resolved unexplained event’ implies that the event has no clear cause. However, infants who are considered high-risk could have underlying reasons similar to those often found in literature discussing serious health scares in babies. These potential causes might include acid reflux, seizures, bronchiolitis, whooping cough, and child abuse.
Some less common causes can include genetic metabolic disorders, irregular heart rhythms, increased pressure in the brain, the ingestion of toxic substances, and certain genetic conditions, particularly those that involve abnormalities in the structure of the face or skull.
Risk Factors and Frequency for Brief Resolved Unexplained Event
The term “brief resolved unexplained event” was only coined in 2016, so there’s limited data on how often it occurs. However, this term does cover some instances of what used to be called “apparent life-threatening events.” These events are responsible for about 0.6% to 0.8% of all visits to the emergency department and occur in between 0.6 to 2.6 out of 1000 live births. A study in Lombardy, Italy, recorded an occurrence rate of 4.1 cases per 1000 live births.
Signs and Symptoms of Brief Resolved Unexplained Event
A thorough medical history and physical exam are crucial in determining whether a baby has experienced a brief, resolved unexplained event (also known as a BRUE), or if another diagnosis is more appropriate. It’s important to gather information about what was happening before, during, and after the event. You might want to consider where the event took place, what position the infant was in, and what they were doing at the time. You should also aim to get a detailed description of the incident, noting any changes to the baby’s behavior or appearance.
After the event, some useful details to collect might include how long the incident lasted, whether it ended suddenly or gradually, and if any interventions were necessary (like picking the baby up or administering CPR). Also note any changes in the baby’s behavior before they returned to their normal state. It’s helpful to know about any recent illnesses, as well as any family history of early deaths or cardiac arrhythmias. Finally, information about the family’s social support systems and access to resources can provide valuable context.
Infants who have experienced a BRUE will usually seem normal and have normal vital signs upon examination. However, performing a comprehensive physical exam can help identify babies who are at high risk of future events or who might have another underlying condition.
The key aspects of the event are:
- Date and place of the incident
- Baby’s position and activity before the event
- Description of the baby’s appearance and behavior during the event
- Duration and end of the event
- Any interventions used
- Baby’s behavior before returning to normal
- Past and family medical history
- Social support and resources
Testing for Brief Resolved Unexplained Event
If a baby has an unexplained event filled with symptoms that seem serious but quickly go away, and they are a low-risk baby, providing a short period of constant observation (between one to four hours) with a focus on pulse monitoring is sufficient; we don’t need to perform any tests. However, the American Academy of Pediatrics doesn’t provide recommendations for higher-risk babies faced with the same situation. In this case, the sensible approach is to consider specific tests that match whatever concerns have been raised during an examination or from the baby’s medical history.
Using a 12-lead EKG (a test that checks how your heart is functioning by measuring the electrical activity of the heart) is something to think about. It can be very valuable, as it can point out some heart disorders that might lead to a sudden and unexpected death. For babies who could be at risk of a disease called pertussis (whooping cough), testing for this disease might be useful, especially if symptoms suggest it’s likely or if the baby hasn’t been immunized.
However, other tests such as those that monitor how the blood is working (complete blood count, electrolytes, blood glucose, lactic acid, bicarbonate levels, blood gas, and blood cultures), a urine check, imaging, brain wave tests (electroencephalogram or EEG), acidity test (pH probe), and sleep study test (polysomnography) aren’t recommended as a regular thing in these situations.
Treatment Options for Brief Resolved Unexplained Event
The crucial part of managing this health issue involves educating caregivers about the condition, ensuring there are regular check-ups after they leave the hospital, and providing resources for training in emergency breathing and heartbeat restoration techniques. It is generally not routine to have someone admitted to the hospital for constant heart and breathing monitoring. There is also no need for medication, tests, talking to specialist doctors, or monitoring at home. Care for babies who are not considered low-risk should be based on their overall health condition and any abnormalities found in their medical history and physical examination.
The criteria for hospital admission for patients that suffered from an ALTE (a sudden frightening spell that resembles a life-threatening event) include situations where the person required emergency breathing and heartbeat restoration, had more than one frightening event in a 24-hour period, or if a significant underlying disease is associated with the event. The American Academy of Pediatrics guideline does not give any recommendations for managing high-risk BRUE, a brief period when a baby under a year old stops breathing, becomes pale or blue, and becomes unresponsive or limp.
What else can Brief Resolved Unexplained Event be?
Several health issues can cause a baby to briefly stop breathing, but they wouldn’t be classified under the umbrella term BRUE (Brief Resolved Unexplained Event) if they could be more specifically diagnosed. Some examples include:
- Upper and lower respiratory infections like Bronchiolitis, whooping cough (pertussis), and pneumonia – these conditions can cause a baby to stop breathing temporarily.
- Serious infections such as sepsis or meningitis.
- Gastroesophageal reflux, which is when stomach acid backs up into the esophagus.
- Seizures or infant botulism.
- Prolonged QT syndrome, a heart rhythm condition that can cause fast, chaotic heartbeats.
- Metabolic disorders, which are genetic conditions that affect a baby’s metabolism.
- Child abuse, unfortunately, can also lead to a baby temporarily stopping breathing.
Therefore, multiple other conditions should be taken into account before concluding that a brief hiccup in a baby’s breathing falls under the category of a BRUE.
What to expect with Brief Resolved Unexplained Event
BRUE is a fairly new area, so we don’t have a lot of information about how it might progress in the long term. However, we can get some ideas from previous studies that looked at ALTE, especially for patients facing a high risk of BRUE.
According to one study, the death rate within a year of an ALTE condition was under 1%. In terms of hospital readmissions, around 2.5% of patients had to be admitted into the hospital again within 30 days after an ALTE episode.
Possible Complications When Diagnosed with Brief Resolved Unexplained Event
There are no known complications.
