PEM Currents: The Pediatric Emergency Medicine Podcast

BRUE: Brief Resolved Unexplained Events

Oct 22, 2025

Dive into the world of BRUE, or Brief Resolved Unexplained Events, a perplexing condition frequently seen in the ER. Learn how it differs from the outdated ALTE and explore effective risk stratification methods. Discover the critical components of taking a focused history and the importance of clinical exams. Hear about the latest prediction models and evidence-based discharge criteria that ensure safer outcomes. Get essential guidelines for counseling families and significant insights into the role of home monitors. It's a vital listen for anyone in pediatric emergency medicine.

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INSIGHT

BRUE Definition And Diagnostic Shift

BRUE is a precise term replacing ALTE and requires sudden, brief, resolved events in infants under one year with no explanation after history and exam.
Most BRUE infants look well on arrival, so the diagnosis relies heavily on detailed history rather than exam findings.

ADVICE

Use A Focused History To Guide Evaluation

Take a detailed, structured history focusing on timing, context, duration, interventions, recurrence, and family history.
Prioritize history because most infants have normal exams and the details determine further workup.

INSIGHT

AAP 2016 Risk-Stratification Framework

The 2016 AAP guideline stratified BRUE into low- and high-risk groups to limit unnecessary testing and admissions.
Low-risk infants meeting strict criteria generally require no labs, imaging, or ECG and can be observed with shared decision-making.

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BRUE, Brief Resolved Unexplained Events, are a common and anxiety-provoking condition that presents to the Emergency Department. In this episode we explore the definition of BRUE, contrast it with ALTE, and walk through evidence-based approaches to risk stratification. We’ll explore the original AAP framework and two subsequent prediction models to see where the recommendations stand today. This is a classic example of scary event / well child that you will see in the Emergency Department.

Learning Objectives

By the end of this episode, you will be able to:

Define BRUE and contrast it with the older concept of ALTE.
Recognize evolving risk stratification criteria
Apply evidence-based strategies for evaluation and counseling of infants with BRUE, including safe discharge decisions and the role of home monitoring.

References

Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants: Executive summary. Pediatrics. 2016;137(5):e20160591. doi:10.1542/peds.2016-0591
Carroll AE, Bonkowsky JL. Acute events in infancy including brief resolved unexplained event (BRUE). In: McMillan JA, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025).
Carroll AE, Bonkowsky JL. Use of home cardiorespiratory monitors in infants. In: McMillan JA, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025).
Carroll AE, Bonkowsky JL. Sudden infant death syndrome: Risk factors and risk reduction strategies. In: McMillan JA, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025).
Carroll AE. Patient education: Brief resolved unexplained event (BRUE) in babies (The Basics). In: UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com (Accessed October 2025).
Nama N, Neuman MI, Finkel MA, et al. Risk prediction after a brief resolved unexplained event. JAMA Pediatr. 2023;177(12):1263–1272. doi:10.1001/jamapediatrics.2023.4197
Nama N, Neuman MI, Finkel MA, et al. External validation of brief resolved unexplained events prediction rules for serious underlying diagnosis. JAMA Pediatr. 2024;178(4):398–407. doi:10.1001/jamapediatrics.2024.0114