BRUE — AAP 2016 Lower-Risk Criteria

• Infant with a sudden, brief, now resolved event and no explanation after history and exam.
• Apply only after alternative diagnoses (seizure, infection, choking) are excluded.
• Use to distinguish lower vs higher risk per AAP 2016 criteria.

Lower risk requires that all six AAP 2016 criteria are met: age >60 days; born ≥32 weeks and postconceptional age ≥45 weeks; first/only event; duration <1 minute; no CPR by a trained provider; no concerning history or abnormal exam.

1. Confirm the event is resolved and infant has returned to baseline before assigning BRUE category.
2. Use targeted history/exam to look for alternate diagnoses (infection, seizure, airway, trauma, feeding-related aspiration).
3. Apply all six AAP lower-risk criteria; lower risk requires every criterion to be met.
4. Document disposition, return precautions, and caregiver education with explicit reasons for follow-up timing.

1. Confirm sustained return to baseline behavior and feeding tolerance.
2. Repeat targeted cardiorespiratory and neurologic assessments before discharge.
3. Recheck for evolving clues that suggest an alternate diagnosis.
4. Document caregiver teach-back of return precautions and follow-up plan.

• During ED observation: repeat focused cardiorespiratory and neurologic checks in the same care block.
• Before discharge decision: confirm sustained baseline behavior and feeding tolerance on repeat assessment.
• Any recurrent event or evolving concern: immediate reassessment and escalation regardless of initial lower-risk classification.

• Age 60 days or younger, prematurity, or corrected age under 45 weeks.
• Recurrent events, duration over 1 minute, or CPR by trained provider.
• Concerning history/exam (fever, abnormal vitals, poor feeding, trauma, or focal neurologic findings).

• Recurrent episode with color change, apnea, tone change, or altered responsiveness.
• Poor feeding, persistent vomiting, fever, lethargy, or reduced urine output.
• Concern for trauma, seizure activity, or progressive respiratory distress.
• Any caregiver concern that infant is not behaving normally from baseline.

• Lower-risk events often qualify for brief observation and caregiver education; higher-risk events may require targeted testing and longer observation.
• Always consider alternative diagnoses (e.g., infection, seizure, reflux with apnea) when features are atypical.

• Event description with duration and whether complete baseline recovery occurred.
• AAP lower-risk criteria status (met/not met) and any exclusion details.
• Alternative diagnoses considered and why they were deprioritized or pursued.
• Observation findings, recurrence status, and disposition rationale.
• Follow-up timing and explicit return triggers reviewed with caregivers.

• Calling an event BRUE before ruling out obvious etiologies from history/exam.
• Classifying lower risk when one criterion is unknown or not clearly met.
• Overtesting lower-risk infants without guideline-based indications.
• Underdocumenting caregiver counseling and return precautions at discharge.

• Event description, duration, and recovery to baseline.
• Age, gestational age, and corrected age.
• History/exam findings that exclude alternative diagnoses.
• Risk classification, observation plan, and caregiver counseling.

• Today’s event fits lower-risk BRUE criteria after exam and history review.
• Most lower-risk infants do well, but recurrence or any breathing/color/tone change needs immediate reassessment.
• Follow-up timing and return precautions were reviewed and understood by caregivers.

• Pediatric Vital Signs to interpret cardiorespiratory status.
• CRIES pain scale for neonatal postoperative pain assessment.

• AAP BRUE Guideline. Pediatrics. 2016;137(5):e20160590.
• Tieder JS et al. Clinical Practice Guideline: BRUE and evaluation of lower-risk infants. Pediatrics. 2016;137(5):e20160590.