Apparent life-threatening event (ALTE) – BRUE

Last Updated on by frcemuser


  • BRUE has a strict age limit < 1yo

ALTE definition
An episode that is frightening to the observer and is characterised by some combination of:

  • apnoea (central or obstructive)
  • colour change (cyanotic, pallid, or plethoric)
  • change in muscle tone (usually diminished but may be stiffening)
  • choking or gagging
  • decreased consciousness
  • Less than one minute duration but typically 20 – 30 seconds.
  • Accompanied by a return to a baseline state
  • Not explained by identifiable medical conditions.

Many parents/ carers will believe that the child is dead or going to die.


History should be taken, ideally first-hand, from persons who observed the infant during or immediately after the event.

  1. Description of event:
    1. Choking, gagging
    2. Breathing: yes/no or attempting to breathe
    3. Colour and colour distribution: normal, cyanosis, pallor, plethora
    4. Distress
    5. Conscious state: responsive to voice, touch, or visual stimulus.
    6. Tone: stiff, floppy, or normal
    7. Movement including eye movements: purposeful, repetitive, or flaccid
  2. Circumstances and environment prior to event:
    1. Awake or asleep and position (prone / supine / side)
    2. Relationship of the event to feeding and history of vomiting
    3. Environment: sleeping arrangement, temperature, bedding
    4. Availability of items that could be swallowed, cause choking or suffocation.
    5. Illness in preceding days
  3. End of event
    1. Duration of event
    2. Circumstances of cessation: self-resolved, repositioned, stimulation, mouth to mouth, chest compressions
    3. Recovery phase: Rapid or gradual
    4. Residual symptoms
  4. Other history:
    1. Past medical history including previous events
    2. Sick contacts
    3. Family history of sudden death or significant childhood illness.

Risk factors

  • Age less than 28 days
  • Significant prematurity
  • Significant prior medical illness
  • Clinically unwell looking, abnormal physical examination
  • Recurrent events before presentation
  • More severe/prolonged ALTE symptoms and need for resuscitation measures
  • Colour change (cyanosis or severe pallor)
  • Absence of upper respiratory symptoms or a history of choking

low Risk

If the infant has fully recovered, has benign examination findings and the event meets the criteria for a BRUE, the event can be risk stratified.

A lower risk BRUE occurs when there are no concerning features on history or examination AND:

  • Age > 60 days
  • Born ≥ 32 weeks gestation and corrected gestational age ≥ 45 weeks
  • No CPR by trained healthcare professional
  • First event (cannot be lower risk if event has been repeated)
  • event lasted < 1 minute


  • Vital signs (including oxygen saturations, temperature, HR, RR, BP)
  • Blood glucose
  • Nasopharyngeal aspirate for viruses
  • ECG (measure QT interval)
  • Urine dipstick and M,C&S

Differential diagnoses

  • Normal physiological response:  laryngospasm, gagging
  • Inflicted injury: (shaken baby, drug overdose, Factitious illness by proxy or intentional suffocation)
  • Infection : Pertussis, septicaemia, pneumonia, meningitis,
  • Airway obstruction: congenital abnormalities, infection, hypotonia
  • Abdominal: intussusception, strangulated hernia, testicular torsion
  • Metabolic problems: hypoglycaemia, hypocalcaemia, hypokalaemia, other inborn errors of metabolism
  • Cardiac disease: congenital heart disease, arrhythmias, vascular ring, prolonged QT.
  • Respiratory: inhaled FB
  • Toxin / Drugs: accidental or non-accidental
  • Neurological causes: head injury, seizures, infections, cerebral malformations etc



  • Discharge if Term-babies who well on examination,related to feeding
  • parents can be reassurance and educated to return if they have further concerns,
  • early follow-up with their GP or a paediatrician.
  • admit if any concern

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