Brief Resolved Unexplained Events

Introduction

• Marked change in tone, colour, breathing or level of consciousness followed by full resolution that cannot be explained by a medical cause
• Diagnosis of exclusion
• Can stratify into higher or lower risk
• Replaces ALTE (Apparent Life Threatening Event) as described events that were both benign and life-threatening with no use in diagnosis, treatment or prognosis

• Episode in infants <12 mo which is:
  • Less than 1 minute duration (usually 20-30 seconds)
  • Return to baseline
  • Not explained by medical condition
  • 1 or more of:
    • Central cyanosis or pallor
    • Absent, decreased or irregular breathing
    • Marked change in tone (hyper- or hypotonic)
    • Altered LOC

• DDx
  • Normal larngospasm/gagging response
  • Inflicted injury: Shaken baby, drug overdose, fictitious, suffocation
  • Infection: Pertussis, RSV, septicaemia, meningitis
  • Airway obstruction: Congenital, choking, infection, hypotonia
  • Abdominal: Intussusception, strangulated hernia, testicular torsion
  • Metabolic: Hypoglycaemia, hypocalcaemia, hypokalaema, inborn errors of metabolism
  • Cardiac: Congenital, long QT, arrhythmias, vascular ring
  • Respiratory: Inhaled FB
  • Toxin/drugs: intentional or accidental
  • Neurological: Head injury, seizures, infections, cerebral malformations

History

• Description of event
  • Choking or gagging
  • Breathing: Yes/No/Attempted
  • Colour and distribution
  • Distress
  • Conscious state: Responsive
  • Tone: stiff, floppy, normal
  • Movements including eyes: Purposeful, repetitive or flaccid

• Events prior
  • Awake or asleep
  • Positioning
  • Relationship to feeding or vomiting
  • Sleeping arrangement, bedding, temperature
  • Availability of suffocation risks
  • Illness in preceding days

• End of event
  • Duration
  • Circumstances of cessation: Self-resolved, CPR, repositioned, stimulation
  • Rapid or gradual recovery
  • Residual symptoms/signs
• Other history
  • PMHx, previous events, sick contacts, FHx of SIDS or sudden cardiac death/CHD
• Most commonly thought to be exaggerated airway reflexes in setting of airway secretions, feeding or reflux

Risk stratification

• Low risk
  • No concerning features AND
    • Age >60 days
    • Born >32 weeks and corrected gestational age >45 weeks
    • No CPR by trained personnel
    • First event
    • Event lasted <1 minute (defines BRUE anyway)

Management

• Low risk BRUE
  • Does not need any Ix necessarily
  • Can consider ECG and pertussis swab
  • Discharge if parents happy with early follow-up from GP in 24 hours
  • In practice, many admitted for observation
• Non low-risk BRUE
  • Consider FBC, U&E, BSL, NPA and ECG
  • Always admit for observation and further Ix as warranted by differential

SUDI/SIDS

• SUDI is sudden unexpected death in infancy
• Most commonly due to SIDS (when no cause can be found) or a fatal sleep accident
• Mostly in first 3 months of life
• Risk factors
  • Premature
  • Low birth weight
  • Baby boys
  • Maternal smoking when pregnant or after baby is born
  • Non-back sleeping
  • Co-sleeping
  • Plush bedding
  • Covered head

Last Updated on November 11, 2021 by Andrew Crofton