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Brief resolved unexplained events (formerly apparent life-threatening events) and evaluation of lower-risk infants
  1. Chris Tate,
  2. Rachel Sunley
  1. Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
  1. Correspondence to Dr Rachel Sunley, Bristol Royal Hospital for Children, Bristol BS2 8BJ, UK; Rachel.sunley{at}

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Information about current guideline

In May 2016, the American Academy of Paediatrics issued a clinical practice guideline on brief resolved unexplained events (BRUEs) in infancy, previously known as acute life-threatening events (ALTEs)

The aims of the guideline were threefold:

  1. Replace terminology and update the criteria for an ALTE.

  2. Provide an approach to patient evaluation that is based on the risk that the infant will have a repeat event.

  3. Provide management recommendations for infants deemed to be low risk.

This is the first clinical practice guideline from the Academy, which applies specifically to children who have experienced an ALTE (full reference box 1).

Box 1


Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent life- threatening events) and evaluation of lower-risk infants. Pediatrics 2016;137:e20160590.

Previous guidance and definitions

The term BRUE is a new concept and has no previous guidelines. ALTE was first defined in 1986 by the National Institute of Health Consensus Development Conference of Infantile Apnoea and Home Monitoring as ‘an episode that is frightening to the observer and that is characterised by some combination of apnoea, colour change, marked change in muscle tone, choking or gagging’.1

The definition is open to interpretation and has made guideline development and research difficult.

Key issues

Definition of BRUE

The authors aimed to create a precise definition, which would aid in clinical care and research. It centred on the concept of a brief, resolved, unexplained event (BRUE, box 2). The term ALTE and the suggestion of a ‘life-threatening event’ has purposefully been avoided as it was thought to cause undue anxiety in caregivers, lead to unnecessary testing and generate avoidable hospital admissions.

Box 2


  • Brief: duration <1 min; age <1 year

  • Resolved: patient returned to their baseline state of health after the event Normal observations, normal appearance

  • Unexplained: not explained by …

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  • Competing interests None declared.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Data sharing statement We have based our guideline here from the original published from the American Academy Pediatrics, Vol 137, no 5, May 2016.