You are currently viewing BRUE, the New ALTE: AAP Issues First Clinical Practice Guideline for Apparent Life-Threatening Events

Katherine Bakes, MD, associate editor with NEJM Journal Watch Emergency Medicine

A multidisciplinary group reviewed the evidence from 1970 to 2014 to develop the first recommendations for management of infants with a brief resolved unexplained event (BRUE; formerly apparent life-threatening event [ALTE]) who are at lower risk for a subsequent event or serious underlying disorder.

Key Points

  • Definition of BRUE:
    • Event lasting <1 minute in an infant <1 year of age that is associated with at least one of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in muscle tone (hypertonia or hypotonia); altered level of responsiveness
    • Patient must otherwise be well­appearing and back to baseline health at the time of presentation, and, on evaluation, have no condition that could explain the event.
  • Criteria for designating lower risk:
    • Age >60 days
    • Gestational age ≥32 weeks and postconceptional age ≥45 weeks
    • First BRUE
    • No cardiopulmonary resuscitation (CPR) required by trained medical provider
    • No features in the history of concern (e.g., possible child abuse, family history of sudden unexplained death, toxic exposures)
    • No worrisome physical exam findings (e.g., bruising, cardiac murmurs, organomegaly).
  • Recommendations for management of lower-risk infants (almost all are grades B or C, weak or moderate recommendations):
    • Use shared decision-making with the family and offer resources for caregiver CPR training.
    • Providers may obtain pertussis testing, 12-lead electrocardiogram, and a brief period of continuous pulse oximetry monitoring with serial observations.
    • Providers should not order other testing or monitoring for cardiopulmonary, child abuse, neurologic, infectious disease, gastrointestinal, inborn errors of metabolism, or anemia evaluation, including home cardiorespiratory monitoring and admission solely for cardiorespiratory monitoring.
    • Providers should not prescribe acid suppression therapy or antiepileptic medications.


These are commonsense guidelines for a frequent diagnosis with many etiologies. Providers finally have evidence-based guidance on how to identify and manage lower-risk infants presenting after a BRUE. The key to evaluation is the history and physical exam: If these are without red flags, get an electrocardiogram and, if normal, discharge with close primary care follow-up. Otherwise, evaluate further based on the clinical suspicion of underlying causes.

Personal comment: BRUEs are frightening for parent and doctor alike. Whenever clear recommendations are published, these should be turned into a programmable module that can be added to an EMR and accessed quickly and easily.


Tieder JS et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants. Pediatrics ; :e20160590. (­0590)