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Tanaka D, Amagasa S, Kikuchi N, Sasaki R, Uematsu S, Tsuji S, Kubota M, Nakagawa S. Clinical Utility and Patient Distribution of Brief Resolved Unexplained Event Classification for Apparent Life-Threatening Events. Pediatr Emerg Care 2023; 39:507-510. [PMID: 37318851 DOI: 10.1097/pec.0000000000002986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
OBJECTIVES In 2016, brief resolved unexplained events (BRUEs) were proposed as alternative concepts to apparent life-threatening event (ALTE). The clinical utility of managing ALTE cases according to the BRUE classification is controversial. To verify the clinical utility of the BRUE criteria, we evaluated the proportion of ALTE patients who met and those who did not meet the BRUE criteria and assessed the diagnoses and outcomes of each group. METHODS We retrospectively investigated patients with ALTE younger than 12 months who visited the emergency department of the National Center for Child Health and Development from April 2008 to March 2020. The patients were classified into the higher-risk and lower-risk BRUE groups; however, those who did not meet the BRUE criteria were classified into the ALTE-not-BRUE group. We evaluated the diagnoses and outcomes of each group. Adverse outcomes included death, recurrence, aspiration, choking, trauma, infection, convulsions, heart disease, metabolic disease, allergies, and others. RESULTS Over the period of 12 years, a total of 192 patients were included, among which 140 patients (71%) were classified into the ALTE-not-BRUE group, 43 (22%) into the higher-risk BRUE group, and 9 (5%) into the lower-risk BRUE group. Adverse outcomes occurred in 27 patients in the ALTE-not-BRUE group and 10 patients in the higher-risk BRUE group. No adverse outcome occurred in the lower-risk BRUE group. CONCLUSIONS Many of the patients with ALTE were classified into the ALTE-not-BRUE group, suggesting that replacing ALTE with BRUE is difficult. Although patients classified as lower-risk BRUE showed no adverse outcomes, there were only a few of them. In the pediatric emergency medicine setting, the BRUE risk classification may be beneficial for certain patients.
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Affiliation(s)
- Daiki Tanaka
- From the Division of Emergency and Transport Services
| | | | - Nanae Kikuchi
- From the Division of Emergency and Transport Services
| | - Ryuji Sasaki
- From the Division of Emergency and Transport Services
| | | | - Satoshi Tsuji
- From the Division of Emergency and Transport Services
| | - Mitsuru Kubota
- Departments of General Pediatrics & Interdisciplinary Medicine
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
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Vigne MH, Moreau M, Gascoin G, Darviot E. Descriptive analysis of infant population younger than 1 year admitted for BRUE. Arch Pediatr 2023:S0929-693X(23)00026-X. [PMID: 37069022 DOI: 10.1016/j.arcped.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 11/20/2022] [Accepted: 02/12/2023] [Indexed: 04/19/2023]
Abstract
INTRODUCTION In 2016, the American Academy of Pediatrics defined the brief resolved unexplained event (BRUE) of high and low risk to characterize fainting in infants under 1 year of age. In the case of low-risk BRUE, it is recommended to perform no further systematic examination, but to monitor the child with a saturometer in the emergency room for 1-4 h. OBJECTIVE The objective of this study was to identify events corresponding to high- and low-risk BRUE criteria for infants admitted to the Angers University Hospital Center, and to analyze their medical care. METHOD We conducted an observational, retrospective, descriptive and single-center study of the population of infants younger than 1 year admitted for an unexplained event to the Pediatric Emergency Department of Angers University Hospital Center between 1 January 2017 and 31 December 2019. Two patient databases were crossed to identify patients. RESULTS Among the 203 patients presenting for fainting, 54 patients met the criteria for BRUE, including 40 high-risk BRUE and 14 low-risk BRUE cases. All complementary examinations performed on low-risk BRUE children were normal. Two of these patients had a recurrence of non-severe fainting several months after the first episode. CONCLUSION Identification of infants according to the BRUE criteria helps to harmonize practices and to limit the number of complementary examinations or hospitalizations for low-risk BRUE.
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Affiliation(s)
- M H Vigne
- Centre Hospitalier Universitaire d'Angers, 49100 Angers, France.
| | - M Moreau
- Centre Hospitalier Universitaire d'Angers, 49100 Angers, France
| | - G Gascoin
- Centre Hospitalier Universitaire d'Angers, 49100 Angers, France
| | - E Darviot
- Centre Hospitalier Universitaire d'Angers, 49100 Angers, France
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Ramgopal S, Colgan JY, Roland D, Pitetti RD, Katsogridakis Y. Brief resolved unexplained events: a new diagnosis, with implications for evaluation and management. Eur J Pediatr 2022; 181:463-470. [PMID: 34455524 DOI: 10.1007/s00431-021-04234-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/02/2021] [Accepted: 08/03/2021] [Indexed: 10/20/2022]
Abstract
Brief resolved unexplained events (BRUE) are concerning episodes of short duration (typically < 1 min) characterized by a change in breathing, consciousness, muscle tone (hyper- or hypotonia), and/or skin color (cyanosis or pallor). The episodes occur in a normal-appearing infant in the first year of life, self-resolve, and have no readily identifiable explanation for the cause of the event. Previously called apparent life-threatening events (ALTE), the term BRUE was first defined by the American Academy of Pediatrics (AAP) in 2016. The criteria for BRUE carry greater specificity compared to that of ALTE and additionally are indicative of a diagnosis of exclusion. While most patients with BRUE will have a benign clinical course, important etiologies, including airway, cardiac, gastrointestinal, genetic, infectious, neurologic, and traumatic conditions (including nonaccidental), must be carefully considered. A BRUE is classified as either lower- or higher-risk based on patient age, corrected gestational age, event duration, number of events, and performance of cardiopulmonary resuscitation at the scene. The AAP clinical practice guideline provides recommendations for the management of lower-risk BRUEs, advocating against routine admission, blood testing, and imaging for infants with these events, though a short period of observation and/or an electrocardiogram may be advisable. While guidance exists for higher-risk BRUE, more data are required to better identify proportions and risk factors for serious outcomes among these patients. Conclusion: BRUE is a diagnosis with greater specificity relative to prior definitions and is now a diagnosis of exclusion. Additional research is needed, particularly in the evaluation of higher-risk events. Recent data suggest that the AAP guidelines for the management of lower-risk infants can be safely implemented.This review article summarizes the history, definitional changes, current guideline recommendations, and future research needs for BRUE. What is Known: • BRUE, first described in 2016, is a diagnosis used to describe a well-appearing infant who presents with change in breathing, consciousness, muscle tone (hyper- or hypotonia), and/or skin color (cyanosis or pallor). • BRUE can be divided into higher- and lower-risk events. Guidelines have been published for lower-risk events, with expert recommendations for higher-risk BRUE. What is New: • BRUE carries a low rate of serious diagnoses (< 5%), with the most common representing seizures and airway abnormalities. • Prior BRUE events are associated with serious diagnoses and episode recurrence.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Jennifer Y Colgan
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, University Hospitals of Leicester NHS Trust, Leicester, UK.,SAPPHIRE Group, Health Sciences, Leicester University, Leicester, UK
| | - Raymond D Pitetti
- Division of Pediatric Emergency Medicine, Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Bochner R, Tieder JS, Sullivan E, Hall M, Stephans A, Mittal MK, Singh N, Delaney A, Harper B, Shastri N, Hochreiter D, Neuman MI. Explanatory Diagnoses Following Hospitalization for a Brief Resolved Unexplained Event. Pediatrics 2021; 148:peds.2021-052673. [PMID: 34607936 DOI: 10.1542/peds.2021-052673] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Most young infants presenting to the emergency department (ED) with a brief resolved unexplained event (BRUE) are hospitalized. We sought to determine the rate of explanatory diagnosis after hospitalization for a BRUE. METHODS This was a multicenter retrospective cohort study of infants hospitalized with a BRUE after an ED visit between October 1, 2015, and September 30, 2018. We included infants without an explanatory diagnosis at admission. We determined the proportion of patients with an explanatory diagnosis at the time of hospital discharge and whether diagnostic testing, consultation, or observed events occurring during hospitalization were associated with identification of an explanatory diagnosis. RESULTS Among 980 infants hospitalized after an ED visit for a BRUE without an explanatory diagnosis at admission, 363 (37.0%) had an explanatory diagnosis identified during hospitalization. In 805 (82.1%) infants, diagnostic testing, specialty consultations, and observed events did not contribute to an explanatory diagnosis, and, in 175 (17.9%) infants, they contributed to the explanatory diagnosis (7.0%, 10.0%, and 7.0%, respectively). A total of 15 infants had a serious diagnosis (4.1% of explanatory diagnoses; 1.5% of all infants hospitalized with a BRUE), the most common being seizure and infantile spasms, occurring in 4 patients. CONCLUSIONS Most infants hospitalized with a BRUE did not receive an explanation during the hospitalization, and a majority of diagnoses were benign or self-limited conditions. More research is needed to identify which infants with a BRUE are most likely to benefit from hospitalization for determining the etiology of the event.
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Affiliation(s)
- Risa Bochner
- State University of New York Downstate Health Sciences University and Department of Pediatrics, New York City Health and Hospitals Kings County, Brooklyn, New York
| | - Joel S Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's and School of Medicine, University of Washington, Seattle, Washington.,Seattle Children's Hospital, Seattle, Washington
| | | | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Allayne Stephans
- Division of Pediatric Hospital Medicine, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | - Manoj K Mittal
- Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nidhi Singh
- Section of Emergency Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Atima Delaney
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Beth Harper
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Nirav Shastri
- Division of Emergency Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Kansas
| | - Daniela Hochreiter
- Division of Hospital Medicine, Department of Pediatrics, School of Medicine, Yale University, New Haven, Connecticut
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
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Pavić I, Navratil M, Bosanac M, Fureš JS, Jureković II, Hojsak I. The Role of Combined Multichannel Intraluminal Impedance-pH Monitoring in Infants with Brief, Resolved, Unexplained Events. Pediatr Gastroenterol Hepatol Nutr 2021; 24:256-264. [PMID: 34046328 PMCID: PMC8128782 DOI: 10.5223/pghn.2021.24.3.256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/20/2021] [Accepted: 02/21/2021] [Indexed: 12/04/2022] Open
Abstract
PURPOSE Data on the relationship between gastroesophageal reflux (GER) and brief resolved unexplained events (BRUE) in infants is scarce. The aim of this study was to identify the characteristics of combined multichannel intraluminal impedance-pH (MII-pH) monitoring in infants who have experienced BRUE. METHODS We conducted a prospective study of infants who were hospitalized on account of BRUE and required 24-hour MII-pH monitoring. RESULTS Twenty-one infants (mean age, 4.7 months; range, 0.9-8.9 months; male/female, 11/10) participated in this study. BRUE symptoms associated with GER were found in 10 infants (47.6%). Based on the RI on pH-metry alone, only 7 (33.3%) infants were diagnosed with GERD. More than 100 GER episodes detected by MII were found in 10 (47.6%) infants. Nineteen percent of infants were diagnosed with GERD based on both pH and MII. CONCLUSION Both acid and non-acid reflux seem to play a significant role in the pathogenesis of GER-related BRUE in infants.
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Affiliation(s)
- Ivan Pavić
- Department of Pediatrics, Children's Hospital Zagreb, Zagreb, Croatia.,Department of Pediatrics, University of Split, School of Medicine, Split, Croatia
| | - Marta Navratil
- Department of Pediatrics, Children's Hospital Zagreb, Zagreb, Croatia.,Department of Pediatrics, University J.J. Strossmayer School of Medicine Osijek, Osijek, Croatia
| | - Maja Bosanac
- Department of Pediatrics, Children's Hospital Zagreb, Zagreb, Croatia
| | - Jadranka Sekelj Fureš
- Department of Pediatrics, Children's Hospital Zagreb, Zagreb, Croatia.,Department of Pediatrics, University J.J. Strossmayer School of Medicine Osijek, Osijek, Croatia
| | - Irena Ivković Jureković
- Department of Pediatrics, Children's Hospital Zagreb, Zagreb, Croatia.,Department of Pediatrics, University J.J. Strossmayer, Faculty of Dental Medicine and Health, Osijek, Croatia
| | - Iva Hojsak
- Department of Pediatrics, Children's Hospital Zagreb, Zagreb, Croatia.,Department of Pediatrics, University J.J. Strossmayer School of Medicine Osijek, Osijek, Croatia.,Department of Pediatrics, University of Zagreb School of Medicine, Zagreb, Croatia
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Raj Ghosh G, Nelson ALA. Indications for epilepsy monitoring in pediatric and adolescent health care. Curr Probl Pediatr Adolesc Health Care 2020; 50:100890. [PMID: 33139209 DOI: 10.1016/j.cppeds.2020.100890] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Seizures present in childhood with infinite diversity. History alone may suffice for diagnosis in some cases; more often additional evidence is needed to clarify events of concern. Electroencephalography (EEG) is a primary methodology used for seizure identification and management. Pediatric and adolescent health care providers are increasingly asked to make decisions about when and how to refer patients for eventual monitoring and must then be able to confidently interpret any resulting report(s). Comprehensive literature review was undertaken to provide a succinct and up-to-date overview aimed at general and subspecialty non-neurologist pediatric and adolescent health care providers to not only convey a solid general understanding of EEG and what it entails for patients and their families, but also foster a deeper understanding of the indications for monitoring-and how to interpret documented findings. In plain language this resultant guide reviews EEG basics, provides a crash course in the various types of EEG available, discusses broad indications for epilepsy monitoring, guides counseling and management for patients and their families both before and after EEG, and ultimately aids in the interpretation of both findings and prognosis. This review should allow both primary and subspecialty non-neurologic pediatric and adolescent health care providers to better identify when and how to best utilize EEG as part of a larger comprehensive clinical approach, distinguishing and managing both epileptic and nonepileptic disorders of concern while fostering communication across providers to facilitate and coordinate better holistic long-term care of pediatric and adolescent patients.
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Affiliation(s)
- Gayatri Raj Ghosh
- The Department of Neurology, NYU Langone Health, 462 First Avenue, 7th Floor Room 7W12C, New York, NY 10016, United States
| | - Aaron L A Nelson
- The Department of Neurology, NYU Langone Health, 462 First Avenue, 7th Floor Room 7W12C, New York, NY 10016, United States; The Department of Neurology, Bellevue Hospital Center, New York, NY, United States.
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