Version May 2024
| Event |
| State – Was the infant asleep, awake, or crying? What was the timing of the BRUE in relationship to feeding or vomiting? If the infant was sleeping, what was the sleep position and location (eg, alone in the crib versus in a bed with the parent)? |
| Respiratory effort – Were respiratory efforts none, shallow, or increased? Was the infant struggling or choking during the event? |
| Color – Was the infant cyanotic, pallid, gray, red, or purple? |
| Color change – Did the color change affect the entire body, extremities, face, perioral area, or lips? |
| Tone – Was the infant limp, rigid, or tonic/clonic? |
| Eyes – Were the infant's eyes open, closed, dazed, staring, rolled, or bulging? |
| Noise – Did the infant make any sound, such as a cough, choking, stridor, cry, or gasp? |
| Fluid – Did the infant spit up or vomit anything? If so, was it mucus, milk, vomitus, or blood? Did this occur at the beginning of the BRUE or later? |
| Duration – For how many seconds or minutes did the event last? |
| Witnesses – Who was present before and during the event? Document the caretaker(s) present, and obtain a description of the event from each. |
| Intervention |
| None |
| Gentle stimulation or "puff of air in the face"? |
| Vigorous stimulation? If so, did this include vigorous shaking? |
| Mouth-to-mouth resuscitation? |
| CPR by trained personnel? |
| Duration of the intervention? |
| Past history |
| Prior events – Have any similar events occurred in the past? If so, describe the event in detail, when and where it occurred, and which caretaker(s) was present. |
| Medical history – Does the infant have any known medical problems or other symptoms causing concern? |
| Medications – Was the infant given any medication (prescription, over-the-counter, or herbal) in the day prior to the event? What medications are in the home? Is there any chance that the baby swallowed a medication or poison by accident? |
| Birth history – Was the baby born "on time," and were there any problems with the delivery or in the nursery? |
| Family history – Are there any siblings or other children in the household who have had similar events or early deaths or who have other medical problems? |
| Social history – Do the parents or other household members smoke or use drugs or alcohol? Has the family been reported for possible child maltreatment in the past? |
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