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.