Ever wonder whether it’s called “BREW” or “BRU-E”? Dr. Joel Tieder puts an end to this debate and provides other key pearls in risk stratification and workup for the infant who presents with a brief resolved unexplained event.
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The AAP Subcommittee on ALTE determined that BRUE is pronounced brew. Like cold brew. This way we don’t get it mixed up with a bruit.
Cultural awareness of Sudden Infant Death Syndrome (SIDS) was growing in the 1980s. Understandably, this idea that children could die in their sleep gave caregivers a lot of anxiety. Children were frequently brought in after episodes of presumed apnea. These events were called “near- miss SIDS”. This terminology caused undue panic to caregivers and so in response, the 1986 NIH Consensus Conference on Infantile Apnea coined the term “Apparent Life-Threatening Events (ALTE)”. But the vague definition of ALTE caused difficulty in evaluation and care.
In 2016, AAP released new guidelines that renamed ALTEs to “Brief Resolved Unexplained Events” and offered more well-defined criteria for these episodes. Importantly, the term BRUE removed the label of “life threatening” as studies found that these events were self-limiting and rarely life threatening.
BRUEs are defined as an event occurring in an infant <1 year of age when the observer reports a sudden, brief (< 1 min), and now resolved episode of ≥1 of the following:
Adapted from Tieder, 2016.
Importantly there should be no explanation for the event. If there is an explanation it would be a Brief Resolved EXPLAINED event (BREE).
Leading up to the AAP Clinical Practice Guidelines, there were several systematic reviews of SIDS/ALTE literature that determined risk factors for a serious underlying etiology or recurrence of the event (Tieder, 2013; Kaji 2013; Mittal, 2012). Children without these risk factors are considered lower risk. Lower risk criteria have a 90% NPV of having an event recurrence, readmission or having a serious underlying disease (Tieder, 2020). By default, children who do not fall into the lower risk category are at higher risk. Importantly, they are not at high risk, just at a HIGHER risk.
It’s notable that 87% of children who present with BRUE don’t meet clinical low risk criteria (Tieder, 2020).
Characterize the event. Details of the event are essential to categorize the event as a BRUE or assign alternate diagnosis. What was going on before? During? How did it stop? What happened afterwards? Confirm with the caregivers, “This is what I understand. Tell me if I understood correctly.”
Other past medical history. Dr. Tieder suggests digging into other history about development, weight gain, feeding history, family history of cardiac history, and second-hand smoke. Tobacco exposure is inflammatory to the respiratory system and can cause difficulty with secretions.
If the infant falls into the higher risk category, evaluation must be tailored. Though the event sounds scary, remember that only 4% of infants presenting with BRUEs will likely have a serious underlying diagnosis (Tieder, 2020). Of these, 45% of these diagnoses were identified after the initial presentation (Tieder, 2020). So, blanket screening testing is neither efficient nor effective and all work-up does not have to be done in that first visit. When ordering tests consider likelihood of the diagnosis and risk of harm if falsely positive.
New guidelines on higher risk evaluation are in the works! In the meantime, work-up should be informed by your clinical suspicion and also shared decision making with the family.
BRUEs are scary events for caregivers and establishing a therapeutic relationship with families is important. Dr. Tieder uses the following to help guide his conversations with caregivers.
In a study of 15 research hospitals, African-Americans had different rates of testing, admission, length of stay regardless of risk (Tieder, 2021). Dr. Tieder points out that the disparities in birth, infant mortality, and post-partum care are likely entangled and perpetuated in BRUE care. Unfortunately, research is limited in this area.
Listeners will explain the diagnosis, difference between lower and higher risk evaluation of BRUE to improve both care and counseling.
After listening to this episode listeners will…
Dr. Tieder reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures.
Park J, Tieder J, Cruz M, Masur S, Chiu C, Berk J. “#54 BRUE’s Clues: Brief Resolved Unexplained Events with Dr. Tieder”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ June 29, 2022.
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