BRUE

Objectives:

1. Know the definition and differential diagnosis of BRUE
2. Know red flags and determine which patients warrant admission
3. Understand the evaluation and mangement plan options

Articles:

• Must read: AAP 2016 guidelines
• Peds in Review article 2019
• See the CHOP Clinical Pathways algorithm for BRUE 

Additional Resources:

• Great short video by OPENPediatrics on how to approach diagnosing and managing BRUE as a pediatric provider
• Full hour long lecture - like a grand rounds lecture. Great, intricately explains guidelines and data/research, but not quick, good cases.
• Check out the PHM from Pittsburgh podcast episode about BRUEs

Self-Assessment:

1. A previously healthy 2-month old boy is brought to the ED by his mother. Approx. 15 min after a feed, he had an episode in which he suddenly started choking, gagging, arching his back, his skin color turned red, then dusky. He then appeared to stop breathing for 10 seconds, after which his color returned to normal and he was appropriately responsive. The boy has no history of similar episodes. He was born at 35 weeks gestation to G1P0 mother. There were no illness or infections during pregnancy, no concerns in the perinatal period. The boy has not had any recent illnesses, fever, or difficulty breathing. He does not breathe noisily or snore. He has been gaining weight appropriately, and takes 4 oz of formula every 3 hours, requiring 5 min to finish a feed. When he is burped after every feed, a small amount of formula dribbles pout of his mouth. The boy’s VS are: temp 37C, BP (r arm) 80/45 mm HG and (L leg) 75/40 mm HG, resp rate 25, HR 130; PE reveals a well-nourished infant w/ no external signs of trauma. While sleeping, the boy has occasional periods of apnea lasting 6 seconds, which are followed by a few seconds long periods of rapid, shallow breathing. He then resumes a normal breathing pattern. He arouses appropriately with exam. His lungs are clear, pulses are equal and strong, and heart has a normal S1 and S2, which is variably split with breathing, with no rubs, gallops, or murmurs. His abdomen is soft, non tender, and non distended, with no masses or organomegaly. Of the following, the MOST likely explanation for this event is:

1. Anomalous left coronary artery
2. BRUE
3. Periodic breathing
4. Seizure

2. Which of the following scenarios is most likely to meet criteria for a Brief Resolved Unexplained Event (BRUE)? 

1. A previously healthy 6-month-old male who presents to a walk-in clinic after he seemed to stop breathing and turned blue when crying. He recovered after mom patted him on the back a few times and his is currently awake and alert
2. A previously healthy 10-month-old female brought in by EMS after loss of consciousness and hypertonia. The episode lasted a few minutes. When you examine her, she is almost back to herself, but is still somewhat sleepy
3. A previously healthy 12-week-old male presents with an episode where his parents say he seemed to stop breathing and turned blue around the lips. He has a few day history of nasal congestion and cough. On exam, vitals are normal for age other than mild tachypnea, and he is otherwise back to normal
4. A previously healthy 11-month-old male brought to the Emergency Department after he stopped breathing. Prior to the event, he bumped his leg and was very upset, then stopped breathing and became limp. Currently, he is awake and alert, and his vital signs are normal

3. Which of the following features would lead an infant with a possible BRUE to be considered at higher risk of having a serious undiagnosed condition or experiencing recurrent events or adverse outcomes? Select all that apply

1. EMS was called and did chest compressions
2. This is the infant’s second episode of turning blue around the lips
3. Infant was born at 35 weeks gestation
4. Family history of sudden cardiac death in childhood
5. Infant is 1 month old

4. You are assessing Caleb, a 4-month-old male in an outpatient clinic. His mom brought him in after he had an episode where he seemed unresponsive and floppy.  She was not sure if he was breathing or not. This is the first time something like this has happened, so she was worried when he didn’t respond to her. She isn’t exactly sure how long it lasted, but thinks it was less than a minute. She picked him up and he seemed to recover on his own, and was acting normally before and afterwards. Caleb was born at 39 weeks gestation and has been a healthy baby since. The only thing his mom can think of for family history is hypertension in his paternal grandfather. On exam, Caleb is awake and alert.  All his vital signs are normal for age, and his height and weight and head circumference are within the accepted ranges on the growth charts. You perform a full physical exam, and everything seems normal. At this point, you tell Caleb's mom that you think he had a BRUE, and explain to her what this means. She wonders if there are any test that should be done. Which of the following investigations would you order? Select as many as are appropriate:

1. Arterial or venous blood gas
2. Chest x-ray
3. Echocardiogram
4. Electroencephalogram (EEG)
5. Serum electrolytes
6. White blood cell count and blood culture
7. None of the above

5. Now that their questions about diagnostic tests have been answered, Caleb’s parents want to what will happen next. Before responding to the parents, your preceptor asks what your ideal management plan would be. What do you recommend?

1. Admit Caleb for cardiorespiratory monitoring for a few days
2. Suggest his parents purchase a home apnea monitor
3. Prescribe antibiotics in case he has as subclinical infection
4. Discharge him home and arrange for follow-up and caregiver support

6. Caleb’s parents are comfortable with the plan to discharge him home at this time. As they are getting ready to leave, they realize they have one more question. They can’t find your preceptor, so they ask you instead. They want to know what the relationship is between BRUEs and sudden infant death syndrome (SIDS). How should you respond?

1. Say that BRUEs used to be called “near-miss SIDS” or “aborted crib deaths” and that there is a known link between the conditions
2. Say that current research indicates that some BRUEs lead to SIDS, but not all
3. Say there is no clear association between BRUEs and SIDS- BRUEs aren’t thought increase the risk for or lead to SIDS
4. Say that this is a current area of research, and that the two diagnoses need to be studied more before you can answer

Find the answers here.