Post Created by: Bill Foo, MD

Case 1



3 week old ex FT baby Bruce is brought the emergency room after “mom says he stopped breathing for about 10 secs. He had associated cyanosis around the lips. His mother witnessed the entire event. He did not require any stimulation for the event to resolve. By the time EMS arrived, baby Bruce is already back to his usual self. Initial vitals and exam in the Emergency room is reassuring.


What should you do with this kid?


The American Academy of Pediatrics (AAP) released new guidelines concerning children presenting with a “Brief Resolved Unexplained Event (BRUE),” formerly referred to as an “Apparent Life Threatening Event (ALTE).” These new guidelines are meant to reduce testing in low risk infants coming in for a BRUE.


The two questions that determine if the new guideline applies to your patient are:

  • Does this event meet criteria for a BRUE?
    • There are narrow criteria for what the AAP defines as a BRUE in this guideline
      • Brief event lasting less than one minute in a child <1 year of age
      • Events can have one or more of:
        • Cyanosis or pallor
        • Absent, decreased, or irregular breathing
        • Marked change in tone (hyper- or hypotonia)
        • Altered responsiveness
      • The patient must return to their baseline after the event without any resuscitation by trained medical provider.


  • Is this the patient low risk?
    • The AAP guideline’s recommendations only apply to patients who they define as low risk!!!
      • Age >60 days
      • Gestational age >/= 32 weeks and post-conceptional age >/= 45 weeks (calculate the corrected gestation age, those NICU/ex-premie will trick you)
      • No previous BRUE episode, and occurrence of only 1 BRUE with this event (not occurring in clusters)
      • No concerning physical exam findings
      • No concerning historical feature that would suggest another diagnosis such as underlying neurological, cardiac, pulmonary or GI disorder.


If you can answer Yes to both of the questions above, you can send the patient home  with reassurance and education, but without further testing. Note, in the case described above, Bruce is 3 weeks old, therefore WOULD NOT be considered low risk. 


BRUE guideline:

“Laboratory studies, imaging studies and other diagnostic procedures (including admission to the hospital solely for cardio-respiratory monitoring as lower risk infants do not have increased risk of cardiovascular events) are unlikely to be useful”

Case 2


6 week old ex-FT baby Sarah is brought the emergency room after developing apnea for 2 minutes. She was unresponsive during this event. She also became limp and her hands and feet turned blue. EMS was called, and by the time of arrival the baby was back to her baseline self. In the ED, she is noted to have vitals appropriate for age and a reassuring exam.


What do you do for this child?


The event described does not meet criteria for BRUE based on the history provided and furthermore, Sarah is not considered “low risk” based on her age. At a minimum, she should be admitted to the floor for at least 24 hours of cardio-respiratory monitoring.


High-risk infants:

  • Age < 60 days (ALTE events may indicate occult bacteremia)
  • History of prematurity
  • Duration of event >1 minutes
  • Clustering of events.
  • History of ALTE or of ALTE or unexplained death in a sibling


Due to a paucity of evidence, the new guideline does not provide any recommendations for evaluation of high-risk BRUEs.  However it does state that some studies suggest that these patients are more likely to have “a serious underlying cause, recurrent event, or an adverse outcome.”


Can’t remember all the specifics? Well there is a smart phrase in EPIC you use: .BRUEVSALTE

Faculty Reviewer: Dan Coghlin, MD


Tieder, J. S., Bonkowsky, J. L., Etzel, R. A., Franklin, W. H., Gremse, D. A., Herman, B., . . . Smith, M. B.  “Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary.” Pediatrics. 2016(5)137. doi:10.1542/peds.2016-0591