BRUE: documentation that holds up

A BRUE is a diagnosis of exclusion with a precise definition — and the chart's job is to prove the event actually met the criteria, classify lower- vs higher-risk correctly, and document that abuse and the other can't-miss causes were considered before the reassuring label was applied.

01What's at stake

The BRUE framework (AAP 2016) replaced "ALTE" to curb over-testing — but the safety hinges on two things: the event must truly be resolved and unexplained (any persistent abnormality means it's not a BRUE and needs a workup), and the lower-risk criteria must be applied correctly, including gestational age. Missing those — or missing occult abuse — is the failure.

02The definition

• Infant <1 year, with a sudden, brief (<1 min), now-resolved episode of ≥1 of: central cyanosis/pallor; absent/decreased/irregular breathing; marked tone change; or altered responsiveness — and unexplained after history and exam.
• Excluded (so it's not a BRUE): acrocyanosis/perioral cyanosis, periodic breathing, breath-holding spells, symptoms of GER/feeding, and any persistent abnormality (abnormal vitals, ongoing symptoms).

03Lower-risk vs higher-risk

• Lower-risk (ALL required): age >60 days; gestational age ≥32 weeks and post-conceptual age ≥45 weeks; first event; duration <1 min; no CPR by a trained provider; no concerning history/exam. → minimal testing
• Higher-risk = anyone not meeting all of the above — individualized, often admitted, testing directed by findings.
• Note: bystander/parent CPR does not make a patient higher-risk; only trained-provider CPR does. And account for prematurity (don't use chronologic age alone).

04Can't-miss causes

• Child abuse / abusive head trauma — often subtle, history-only; the most important not-to-miss.
• Cardiac arrhythmia (long QT, WPW) — the role for an ECG.
• Infection — pertussis, RSV, UTI, sepsis/meningitis.
• Seizure, inborn errors of metabolism, toxic exposure; GER (but GER means it isn't a BRUE).

05Workup & management

• Lower-risk: minimal testing — a brief period of pulse-ox/observation (1–4h), an ECG, and pertussis testing if indicated; a social-risk/abuse assessment; CPR-training resources and caregiver education; shared decision-making and 24-hour follow-up. Avoid reflexive labs, CXR, neuroimaging, EEG, and admission for monitoring alone.
• Higher-risk: targeted, individualized workup driven by the specific concern; admission as needed.
• Don't "order basic labs just to be sure" in a lower-risk infant — false positives drive harm.

06What to document

07Where charts fail

• Calling something a BRUE that's actually explained (GER, periodic breathing) or not resolved (a persistent abnormal vital).
• Using chronologic age alone and missing prematurity in the lower-risk classification.
• Counting bystander CPR as a higher-risk factor.
• Not documenting the abuse/social-risk assessment (it can be history-only, diagnosed later).
• Over-testing a lower-risk infant "just to be sure," or not arranging 24-hour follow-up and return precautions.

08Sources

• Austin-Page LR, Cho CS. Brief resolved unexplained events: practical evaluation and management in the emergency department. Pediatric Emergency Medicine Practice (EB Medicine). 2024;21(4).
• Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly ALTE) and evaluation of lower-risk infants. Pediatrics. 2016;137(5):e20160590.
• Merritt JL, Quinonez RA, Bonkowsky JL, et al. A framework for evaluation of the higher-risk infant after a brief resolved unexplained event. Pediatrics. 2019;144(2):e20184101.
• Tieder JS, Sullivan E, Stephans A, et al. Risk factors and outcomes after a brief resolved unexplained event: a multicenter study. Pediatrics. 2021;148(1):e2020036095.

© 2026 Kim Trinh, MD. All rights reserved. Educational only — synthesized from EB Medicine, the AAP guideline, and primary literature. Synthetic examples. Not medical advice — apply local protocol and judgment.