5 Best of 2018: Pediatrics Viewpoints

William T. Basco, Jr, MD, MS


January 11, 2019

In This Article

Mortality in an Infant After a BRUE

In 2016, the American Academy of Pediatrics published a guideline[9] on the evaluation of brief, resolved, unexplained events (BRUEs; formerly known as apparent life-threatening events [ALTEs]) that lack a diagnosis after appropriate evaluation. That guideline offered a way to categorize infants who experience BRUEs into "lower risk" for future harm:

  • Not born prematurely

  • At least 2 months old

  • No previous BRUE episodes

  • An event lasting less than 1 minute and not requiring resuscitation by a medical professional

A recent study[10] sought to define the upper bound of the risk for death in an infant after a BRUE. Investigators pooled data from 12 studies published between 1970 and 2017, with a total of 3005 infants. The follow-up period in these studies ranged from 1 week to 3 years. Any death that occurred more than 4 months after the index BRUE was considered unlikely to be related to the BRUE.

A total of eight deaths occurred among infants 0-4 months old, a mortality rate of 3.1 deaths/month/10,000 BRUEs. However, the 95% CI for this rate was wide (0.3-30.1). This mortality ratio corresponds to a risk for death after a BRUE of approximately 1/800. The baseline mortality rate among all infants during the same time period was approximately 1/500 within the first 4 months of life, or 1/1200 if neonatal deaths (before 28 days of age) were excluded. The conclusion is that the very low rate of death after a BRUE falls within the ranges of all-infant mortality (1/500) and the "non-neonatal" death rate (1/1200), thereby supporting the 2016 recommendation to avoid admitting to the hospital infants who experienced a BRUE but are at lower risk for death after acute evaluation.


I've thought a lot about this question over the years, given that BRUEs are such common reasons for admission to children's hospitals. Perhaps the frequency of such admissions will decline over time, but these data will be helpful when it comes to quantifying risk and counseling parents. Certainly, to anxious parents, no degree of risk is low enough to make them feel comfortable at discharge, but these data may help other parents and providers who are on the fence about admission to the hospital.


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