Practice Guidelines

AAP Releases Guideline on Brief Resolved Unexplained Events (BRUEs) and Evaluation of Lower-Risk Infants


Am Fam Physician. 2017 Mar 1;95(5):330-331.

Author disclosure: No relevant financial affiliations.

Key Points for Practice

• BRUEs occur in infants younger than one year and last less than one minute, usually less than 20 to 30 seconds.

• A BRUE includes one or more of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked hypertonia or hypotonia; and altered level of responsiveness.

• If a cause for the event can be determined based on the history or examination, then it is not a BRUE.

• A white blood cell count, blood culture, and cerebrospinal fluid analysis or culture should not be performed to identify an occult bacterial infection in lower-risk patients with BRUE.

From the AFP Editors

This guideline from the American Academy of Pediatrics (AAP) addresses apparent life-threatening events (ALTEs), a term recommended to be replaced by brief resolved unexplained events (BRUEs). Based on the results of a history and physical examination, infants who present with a BRUE can be considered lower risk or higher risk, the latter of which should have additional assessment and treatment. This guideline discusses patient evaluation, and, for infants at lower risk, provides management recommendations.


The definition of ALTE is inexact, resulting in difficulties in treatment, as well as performing research. With this definition, infants often have no symptoms when presenting to the office, and the treatment and evaluation of those infants need to be distinct from those with symptoms. Additionally, symptoms listed in the current ALTE definition are not inherently life-threatening, nor are they necessarily a sign of a more serious condition. With a more clear-cut definition, physicians could make their decisions based on events identified as abnormal on history and examination (e.g., symptoms of central apnea need to be differentiated from gastroesophageal reflux, which is more common and of less concern).

Physicians and caregivers may be concerned by the possibility of the event happening again or it being a sign of a serious problem. This can prompt testing or hospital admission, creating stress and additional

Author disclosure: No relevant financial affiliations.

Coverage of guidelines from other organizations does not imply endorsement by AFP or the AAFP.

This series is coordinated by Sumi Sexton, MD, Associate Deputy Editor.

A collection of Practice Guidelines published in AFP is available at



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Feb 15, 2018

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