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Pediatrics. 2019 Aug;144(2). pii: e20184101. doi: 10.1542/peds.2018-4101.

A Framework for Evaluation of the Higher-Risk Infant After a Brief Resolved Unexplained Event.

Author information

Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Texas.
Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah.
Brain and Spine Center, Primary Children's Hospital, Salt Lake City, Utah.
Department of Pediatrics, Stritch School of Medicine, Loyola University, Maywood, Illinois.
Department of Pediatrics, University of South Alabama, Mobile, Alabama.
Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington.
Department of Medicine, Harvard Medical School, Harvard University, Boston, Massachusetts.
Department of Pediatrics, New York University Winthrop, Mineola, New York; and.
Department of Emergency Medicine, Health Sciences Center, University of New Mexico, Albuquerque, New Mexico.


In 2016, the American Academy of Pediatrics published a clinical practice guideline that more specifically defined apparent life-threatening events as brief resolved unexplained events (BRUEs) and provided evidence-based recommendations for the evaluation of infants who meet lower-risk criteria for a subsequent event or serious underlying disorder. The clinical practice guideline did not provide recommendations for infants meeting higher-risk criteria, an important and common population of patients. Therefore, we propose a tiered approach for clinical evaluation and management of higher-risk infants who have experienced a BRUE. Because of a vast array of potential causes, the initial evaluation prioritizes the diagnosis of time-sensitive conditions for which delayed diagnosis or treatment could impact outcomes, such as child maltreatment, feeding problems, cardiac arrhythmias, infections, and congenital abnormalities. The secondary evaluation addresses problems that are less sensitive to delayed diagnosis or treatment, such as dysphagia, intermittent partial airway obstruction, and epilepsy. The authors recommend a tailored, family-centered, multidisciplinary approach to evaluation and management of all higher-risk infants with a BRUE, whether accomplished during hospital admission or through coordinated outpatient care. The proposed framework was developed by using available evidence and expert consensus.


Conflict of interest statement

POTENTIAL CONFLICT OF INTEREST: Drs Bonkowsky and Tieder report published research related to brief resolved unexplained events and apparent life-threatening events and are members of the Society of Hospital Medicine Apparent Life-Threatening Events Expert Panel; the other authors have indicated they have no potential conflicts of interest to disclose.

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