For the very few things they actually do, babies can be very complicated. Breathing irregularities especially can pose a challenge to providers. Knowing the difference between a benign and a dangerous cause for apnea/cyanosis/loss of muscle tone or choking is difficult and underlies the diagnosis of BRUE.

BRUE (brief, resolved, unexplained event) usually occurs in the first 2 months of life and is defined as a combination of apnea, color change, loss of muscle tone, choking or gagging. Risk of subsequent death is 0%-6% driven in large part by those BRUE cases requiring CPR.

Underlying causes (https://www.ncbi.nlm.nih.gov/pubmed/15499062)

  • Unknown (41%)
  • GERD/Choking/Laryngospasm (31%)
  • Seizure (11%)
  • URI/Respiratory infection (8%)
  • ENT infections (3.6%)
  • Other (5%)
  • Non-accidental trauma (1%)

Workup: if the child appears and well in your care and symptoms are not reoccurring, how do you determine if this is a dangerous or benign event?

  • Detailed history including surrounding events, recent illness, sleeping/eating habits, family history, possible exposures and tobacco/alcohol/drugs in the house
  • Watch the child in the ED for reoccurrence
    • Remember that healthy newborns can have non-pathologic respiratory pauses up to 30s and runs of bradycardia for up to 10s during sleep (tricky babies)
    • Labs are typically not useful if the child appears well in your care

Disposition: Traditionally BRUE cases are admitted for observation. https://www.ncbi.nlm.nih.gov/pubmed/22743742 attempted to develop a decision rule for discharging a patient home. Those who can be safely discharged are:

  • Premature with URI sx
  • Full-term with non-cyanotic color change
  • Full-term with cyanotic color change and a history of choking during the episode

This method will drastically decrease admission rates, but misses 3.8% of patients with serious events. Thus clinical gestalt is still important when considering a child with an unexplained apnea event.