Historical Features To Be Considered in the Evaluation of a Potential BRUE

Features To Be Considered
Considerations for possible child abuse:
 Multiple or changing versions of the history/circumstances
 History/circumstances inconsistent with child’s developmental stage
 History of unexplained bruising
 Incongruence between caregiver expectations and child’s developmental stage, including assigning negative attributes to the child
History of the event
 General description
 Who reported the event?
 Witness of the event? Parent(s), other children, other adults? Reliability of historian(s)?
 State immediately before the event
  Where did it occur (home/elsewhere, room, crib/floor, etc)?
  Awake or asleep?
  Position: supine, prone, upright, sitting, moving?
  Feeding? Anything in the mouth? Availability of item to choke on? Vomiting or spitting up?
  Objects nearby that could smother or choke?
 State during the event
  Choking or gagging noise?
  Active/moving or quiet/flaccid?
  Conscious? Able to see you or respond to voice?
  Muscle tone increased or decreased?
  Repetitive movements?
  Appeared distressed or alarmed?
  Breathing: yes/no, struggling to breathe?
  Skin color: normal, pale, red, or blue?
  Bleeding from nose or mouth?
  Color of lips: normal, pale, or blue?
 End of event
  Approximate duration of the event?
  How did it stop: with no intervention, picking up, positioning, rubbing or clapping back, mouth-to-mouth, chest compressions, etc?
  End abruptly or gradually?
  Treatment provided by parent/caregiver (eg, glucose-containing drink or food)?
  911 called by caregiver?
 State after event
  Back to normal immediately/gradually/still not there?
  Before back to normal, was quiet, dazed, fussy, irritable, crying?
Recent history
 Illness in preceding day(s)?
  If yes, detail signs/symptoms (fussiness, decreased activity, fever, congestion, rhinorrhea, cough, vomiting, diarrhea, decreased intake, poor sleep)
 Injuries, falls, previous unexplained bruising?
Past medical history
 Pre-/perinatal history
 Gestational age
 Newborn screen normal (for IEMs, congenital heart disease)?
 Previous episodes/BRUE?
 Reflux? If yes, obtain details, including management
 Breathing problems? Noisy ever? Snoring?
 Growth patterns normal?
 Development normal? Assess a few major milestones across categories, any concerns about development or behavior?
 Illnesses, injuries, emergencies?
 Previous hospitalization, surgery?
 Recent immunization?
 Use of over-the-counter medications?
Family history
 Sudden unexplained death (including unexplained car accident or drowning) in first- or second-degree family members before age 35, and particularly as an infant?
 Apparent life-threatening event in sibling?
 Long QT syndrome?
 Inborn error of metabolism or genetic disease?
 Developmental delay?
Environmental history
 Housing: general, water damage, or mold problems?
 Exposure to tobacco smoke, toxic substances, drugs?
Social history
 Family structure, individuals living in home?
 Housing: general, mold?
 Recent changes, stressors, or strife?
 Exposure to smoke, toxic substances, drugs?
 Recent exposure to infectious illness, particularly upper respiratory illness, paroxysmal cough, pertussis?
 Support system(s)/access to needed resources?
 Current level of concern/anxiety; how family manages adverse situations?
 Potential impact of event/admission on work/family?
 Previous child protective services or law enforcement involvement (eg, domestic violence, animal abuse), alerts/reports for this child or others in the family (when available)?
 Exposure of child to adults with history of mental illness or substance abuse?