Written by Joshua Belfer
Spoon Feed
Most infants with a brief resolved unexplained event (BRUE) are low risk and do not benefit from extensive testing or admission; careful risk stratification, focused evaluation, and shared decision-making can safely reduce unnecessary workup and hospitalization.
When a scary event (typically) isn’t a dangerous one
Brief resolved unexplained events (BRUE) replaced the term apparent life-threatening event (ALTE) to better reflect the transient nature of these episodes and to emphasize clinician assessment over caregiver perception. BRUE is defined as a sudden, brief (<1 minute), now-resolved episode in an infant less than 1 year of age with no identifiable cause. It is accompanied by abnormal breathing, color change (pallor or cyanosis), tone change, and/or altered responsiveness. Importantly, BRUE is a diagnosis of exclusion—if a cause is identified on history or exam, the event no longer qualifies. The most common conditions associated with episodes that resemble BRUE include gastrointestinal disease (reflux, dysphagia, laryngospasm) and respiratory causes (viruses, periodic breathing, breath-holding spells).
Although BRUEs account for less than 1% of ED visits, they frequently lead to extensive testing and hospital admission despite a low rate (<5%) of serious underlying disease. Routine lab testing and imaging have low diagnostic yield and high false-positive rates. The AAP low-risk criteria are highly sensitive but not specific, meaning many infants are labeled higher-risk despite favorable outcomes. For low-risk infants, brief observation, caregiver reassurance, and close outpatient follow-up are generally sufficient, while higher-risk features should prompt a targeted, focused evaluation, and consideration of admission for prolonged observation.
How will this change my practice?
Infants presenting with an event consistent with BRUE can be difficult to manage, both from a risk stratification standpoint (scary episode, looks great on exam) and a reassurance perspective (“We don’t know exactly what happened, but it’s probably OK”). This review reinforces that managing BRUEs is often about restraint, and that a routine workup should not be done just to do something. For infants meeting low-risk criteria with a reassuring exam, relying on the evidence will allow you to limit workup and avoid costly, likely unnecessary testing. One of the biggest parts of our job is communication, and this diagnosis provides a challenge; taking the time to sit with families and explain your approach can help reduce caregiver anxiety and build a therapeutic alliance.
Source
Emergency medicine updates: Pediatric brief resolved unexplained event. Am J Emerg Med. 2026 Jan 3;101:141-146. doi: 10.1016/j.ajem.2025.12.036. Epub ahead of print. PMID: 41518722.
