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BRUE is the new ALTE



The term ALTE in
pediatrics had previously referred to apparent life-threatening event. This event was characterized by some combination of apnea, color change, change in muscle tone, choking or gagging and was also witnessed by and distressing to a caregiver. This was the definition from the National Institute of Health (NIH) in 1986. 
Because an ALTE was a diagnosis based on symptomatology rather than pathophysiology, the differential diagnosis was broad.


In 2016, the American Academy of Pediatrics (AAP) released a new clinical practice guideline that recommended the replacement of the term ALTE with the new term BRUE (pronounced ‘brew’) which stands for brief resolved unexplained event


“This is the first AAP guideline that specifically addresses these events. The new guideline and change in terminology are based on a literature review of ALTEs from 1970 through 2014. The new term “better reflects the transient nature and lack of clear cause of such events, which are rarely life-threatening under the BRUE definition.” New guidance around the term is meant to help reduce costly and unnecessary interventions and better inform care.”


BRUE definition:

  • Occurs in an infant < 1 year of age
  • Includes > 1 of the following:
    • Cyanosis or pallor
    • Absent, decreased, or irregular breathing
    • Marked change in tone, either hypertonia or hypotonia
    • Changed level of responsiveness
  • No explanation after a thorough, appropriate history and physical exam



Lower risk infants:

  • Age > 60 days
  • Gestational age > 32 weeks
  • One event only with no prior BRUE
  • BRUE lasted < than 1 minute
  • No CPR was required by trained medical personnel
  • No concerning history findings (e.g., possible child abuse, family history of sudden unexplained death, toxic exposures)
  • No concerning physical exam findings (e.g., bruising, cardiac murmurs, organomegaly).

High-risk infants:

  • Those not meeting age or time criteria
  • Concerning findings on history or physical exam
  • Family history of sudden cardiac death, or subtle, non-diagnostic social, feeding or respiratory problem


The approach to the child with a suspected BRUE includes a thorough history of the event and a careful physical examination.


  1. Who observed the event?
  2. What was the description of the event?
  3. Was the infant limp, or was muscle tone increased during or after the event?
  4. Were any seizure like movements observed?
  5. Was any resuscitation required, or did the event spontaneously resolve?
  6. Was the infant born at term, or was the infant premature?
  7. Does the infant have any other significant health issues?
  8. Were any pregnancy or labor and delivery complications reported?
  9. Are any factors that predispose to neonatal sepsis?
  10. Has the infant previously exhibited symptoms of gastroesophageal reflux or aspiration of thin liquids?
  11. Are the newborn metabolic screening findings normal?
  12. Does the family have a history of seizures, metabolic disorders, previous sudden infant death syndrome (SIDS), or unexplained death in infancy or childhood?


A complete physical examination begins by obtaining a full set of vital signs, including pulse oximetry. A full head-to-toe examination of the skin should be performed to look for skin lesions or signs of trauma.



The guideline also provides a strategy to assess whether the patient is at high or low risk of a serious underlying problem or a repeat event and suggests management options for the lower-risk group. The guideline does not apply to infants deemed high risk.

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






Guideline Link: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Clinical Practice Guideline. American Academy of Pediatrics. April 2016.




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