Brief resolved unexplained events in early childhood

This transcript has been edited for clarity.

Justin L. Berk, MD, MPH, MBA: Welcome to the Cribsiders. This is a Medscape video recap of one of our most recent podcast episodes.

Jessica Hane, MD, MPH, MBA: For those of you who don’t know us, we’re the Pediatric Medicine Podcast. We interview leading experts in the field to provide clinical pearls, put changing knowledge into practice, and answer lingering questions about fundamental topics in pediatric medicine.

Yuck: All right, Jessica, what topic are we looking at today?

Figure: We’re here today to talk about the important pediatric topic of Brief Resolved Unexplained Events (BRUE), “BRUE Clues: Understanding Brief Resolved Unexplained Events with Dr. Tieder.” We spoke with Dr. Tieder, who is a pediatric hospitalist and associate professor at Seattle Children’s Hospital at the University of Washington, and, more importantly, a leading expert in resolved brief unexplained events. In today’s recap, we’ll talk about definitions, patient risk stratification, and share some clinical gems from Dr. Tieder.

Yuck: So first and maybe most important, I loved when it was called ALT. It was so much easier to say. Is BRUE pronounced brasser? Is it beer? How to talk about these patients?

Figure: This is a great question that we answered on the show with Dr. Tieder. The subcommittee determined that it is pronounced infusion as cold infusion so as not to be confused with the already existing medical term noise.

Yuck: It’s really helpful. I said it wrong. What is a brief resolved unexplained event?

Figure: A BRUE is defined as an event occurring in an infant less than 1 year old. This is when the parent or observer reports a sudden, brief (less than a minute) and now resolved event that exhibits one or more of the following characteristics:

• Color change; this may be central cyanosis or pallor

• Change in breathing pattern, such as absent, decreased, or irregular breathing

• Change in tone (hyper- or hypotonic)

• Reactivity change

It is important to remember that there should be no explanation for the event. If there is an explicit explanation, it will be called a Brief Resolved Explained Event (BREE).

Yuck: I loved learning the term BREE in this episode. One of the big topics a patient with a BRUE goes through is making these patients low risk or stratifying them. What makes a patient low risk?

Figure: Dr. Tieder taught us all the criteria that must be met for an infant to be considered low risk. First, they must be over 60 days old. Gestational age must be greater than 32 weeks and post-conception age must be greater than 45 weeks. This must be the child’s first real event. The duration must be less than one minute. No medical training provider must have performed CPR during the event. And finally, and probably most important, there should be no concerning features on the history or on the physical exam. Some examples would be bruising when doing the physical exam or a family history of something like heart arrhythmias.

Yuck: What about the high risk category? What to do with these high-risk patients?

Figure: Basically, any child who does not fit into the low-risk category is automatically in the high-risk category. One thing that I thought was really great was that Dr. Tieder pointed out that these patients aren’t really high riskthey are fair higher risk than the low-risk group in general. He did not recommend general testing for these infants. It’s not useful or recommended, and there really isn’t a test that everyone in the high-risk group needs to undergo. Depending on the clinical history and examination, several things to consider for high-risk patients would be a 4-hour cardiorespiratory monitoring test, a swallowing evaluation, or perhaps an ENT consultation if the clinical history suggests a problem there. And then finally close the outpatient follow-up.

Yuck: It’s really helpful. Were there any other pearls from the episode that you remember?

Figure: Yes. So one thing that I thought was critical was that 96% of BRUE resolves on its own and there is no underlying etiology. So basically, we should be very careful about making general assessments and be really intentional with our track record. Most children don’t really need exercises. If you can explain the event as, you know, maybe a seizure or GERD, that’s not a BRUE, it’s a BREE. And so this framework that we’re talking about today doesn’t really apply. And then the last thing we learned is that there are new guidelines in the works for BRUE. So stay tuned.

Yuck: Awesome. This was a great recap of BRUE and BREE. Please join us for this Medscape video recap of the Cribsiders pediatric podcast. To listen to this full episode, click on “BRUE’s Clues: Understanding Brief Resolved Unxplained Events with Dr. Tieder” or search for it on any podcast player. Thanks for listening.

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