#54: BRUE’s Clues: Understanding Brief Resolved Unexplained Events with Dr. Tieder

June 29, 2022 | By Sam Masur

Summary

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.

Credits

• Producer, Writer, Infographic: Joan Park MD
• Executive Producer: Max Cruz MD
• Showrunner: Sam Masur MD
• Cover Art: Chris Chiu MD MD
• Hosts: Christ Chiu MD, Max Cruz MD, Joan Park MD
• Editor: Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Joel Tieder MD

Brief Resolved Unresolved Events (BRUE) Pearls

1. If you can explain the events (i.e. reflux, seizure, abuse), it is a brief resolved explained event (BREE) NOT a BRUE. 
2. In order to be categorized as lower risk, an infant must meet all criteria. 
3. 96% of BRUEs aren’t found to have an underlying etiology. Avoid blanket evaluations; be intentional and specific with what you order.

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BRUE Notes

BRU-E or BREW?

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. 

The Evolution of SIDS, ALTE, and BRUE. 

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. 

BRUE Definition 

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:

• central cyanosis or pallor (does not include acrocyanosis)
• absent, decreased, or irregular breathing 
• marked change in tone (hyper- or hypotonia)
• altered level of responsiveness

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).

Determining the Risk 

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.

Criteria for Lower Risk

• > 60 days
• Gestational age ≥32 weeks and postconceptional age ≥45 weeks
• First BRUE
• Duration < 1 minute
• No CPR by trained medical provider 
• No concerning historical features or physical exam findings

It’s notable that 87% of children who present with BRUE don’t meet clinical low risk criteria (Tieder, 2020). 

Evaluation Beyond Risk Stratification

History 

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.

Higher Risk Evaluation

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. 

Some tips from Dr. Tieder: 

• Brief period of cardiorespiratory monitoring. You will observe most serious conditions if you observe the infant for 4 hours (expert opinion). Most BRUE are either self-limiting or normal infant behavior. Therefore, observing the infant can allow for reassurance or solutions.
• No Admission. Even for the 4% of BRUEs with underlying diagnosis, remember about half are diagnosed after the initial presentation.
• Consider Speech Language Pathology evaluation for oropharyngeal dysphagia 
• Consider ENT consult if concern for obstructive lesion. Airway abnormalities were the second most common cause of BRUE (Tieder, 2020).  
• CBC, BMP, Mag, P, CXR, EKG. These tests are unlikely to show anything without an index of concern, even with a positive family cardiac history. 
• If you are concerned for seizures, an outpatient evaluation can be appropriate. You don’t need to get the EEG or head imaging in the hospital because they often don’t lead to inpatient diagnose (Tieder, 2020).

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. 

Counseling Caregivers 

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. 

• Check in. Start by asking how the caregivers are doing: How are you doing? What’s life like with the new baby?
• Set the Agenda. Elicit the caregiver’s concerns.
• Provide Reassurance. No underlying etiology is found for 96% of BRUEs (Tieder, 2020). The other 4% are often diagnosed safely (seizures, infantile spasms, laryngomalacia) without significant morbidity (Tieder, 2021). These can be diagnosed in a non-pressured timeline.
• Give Anticipatory Guidance. 1 in 5 children with BRUEs will have reoccurring event. However, this does not change the severity of the underlying diagnosis (Mittal, 2012). 

Socioeconomic Racial Disparities

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. 

Take Home Points from Dr. Tieder 

1. BRUE is pronounced “BREW”
2. Remember that there are BREE. If you can explain the event, it is NOT a BRUE 
3. If it is a BRUE, evaluation and care should be guided by shared decision making with the family. 
4. Provide reassurance! 96% of BRUEs are self-limiting. 
5. Not all the work-up has to be done in the initial presentation. Schedule close follow-up!

Goal

Listeners will explain the diagnosis, difference between lower and higher risk evaluation of BRUE to improve both care and counseling. 

Learning objectives

After listening to this episode listeners will…  

1. Be familiar with the diagnostic criteria of BRUEs
2. Distinguish between lower and higher risk BRUE presentations
3. Explain importance of tailored evaluation for higher risk BRUE 
4. Feel comfortable counseling caregivers on risk of recurrence and etiologies of BRUEs

Disclosures

Dr. Tieder reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

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.