Risk Factors and Outcomes After a Brief Resolved Unexplained Event: A Multicenter Study

Brief Resolved Unexplained Events Symptoms Frequently Result in Inappropriate Gastrointestinal Diagnoses and Treatment

OBJECTIVE

To determine associations between presenting symptoms and oropharyngeal dysphagia diagnoses, gastroesophageal reflux disease (GERD) diagnoses, and treatment with acid suppression medication in infants with brief resolved unexplained event (BRUE).

STUDY DESIGN

We performed a prospective cohort study of infants with BRUE to review presenting symptoms and their potential impact on testing and treatment. Videofluoroscopic swallow study (VFSS) results and explanatory diagnoses were obtained from medical record review; acid suppression use was determined by parental survey. Binary and multivariable logistic regression models were used to evaluate associations between presenting symptoms and obtaining VFSS, VFSS results, GERD diagnoses, and acid suppression medication.

RESULTS

Presenting symptoms were varied in 157 subjects enrolled at 51.0±5.3 days of age, with many symptoms that may be related to GERD or dysphagia. Of these, 28% underwent VFSS with 71% abnormal. Overall, 42% had their BRUE attributed to GERD and 33% were treated with acid suppression during follow-up. Presenting symptoms were significantly associated with the decision to obtain VFSS but not with abnormal VFSS results. Presenting symptoms were also associated with provision of GERD explanatory diagnoses. Both presenting symptoms and GERD explanatory diagnoses were associated with acid suppression use (aOR 2.3, 95% CI 1.03-5.3, p=0.04).

CONCLUSIONS

Presenting symptoms may play a role in clinicians' decisions about which BRUE patients undergo VFSS but are unreliable to make a diagnosis of oropharyngeal dysphagia. Presenting symptoms may also influence assignment of a GERD explanatory diagnoses that is associated with increased acid suppression medication use.

Epidemiology of brief resolved unexplained events and impact of clinical practice guidelines in general and pediatric emergency departments

OBJECTIVES

The aim of this study was to describe the incidence of brief resolved unexplained events (BRUEs) and compare the impact of a national clinical practice guideline (CPG) on admission and diagnostic testing practices between general and pediatric emergency departments (EDs).

METHODS

Using the Nationwide Emergency Department Sample for 2012-2019, we conducted a cross-sectional study of children <1 year of age with an International Classification of Diseases diagnostic code for BRUE. Population incidence rate was estimated using Centers for Disease Control and Prevention birth data. ED incidence rate was estimated for all ED encounters. We used interrupted time series to evaluate the associated impact of the CPG publication on the outcomes of ED disposition (discharge, admission, and transfer) and electrocardiogram (ECG) use.

RESULTS

Of 133,972 encounters for BRUE, 80.0% occurred in general EDs. BRUE population incidence was 4.28 per 1000 live births and the annual incidence remained stable (p = 0.19). BRUE ED incidence was 5.06 per 1000 infant ED encounters (p = 0.14). The impact of the BRUE CPG on admission rates was limited to pediatric EDs (level shift -23.3%, p = 0.002). Transfers from general EDs did not change with the CPG (level shift 2.2%, p = 0.17). After the CPG was published, ECGs increased by 13.7% in pediatric EDs (p = 0.005) but did not change in general EDs (level shift -0.2%, p = 0.82).

CONCLUSIONS

BRUEs remain a common pediatric problem at a population level and in EDs. Although a disproportionate number of infants present to general EDs, there is differential uptake of the CPG recommendations between pediatric and general EDs. These findings may support quality improvement opportunities aimed at improving care for these infants and decreasing unnecessary hospital admissions or transfers.

Learning From a National Quality Improvement Collaborative for Brief Resolved Unexplained Events

OBJECTIVE

In 2016, the American Academy of Pediatrics published the Brief Resolved Unexplained Event (BRUE) Clinical Practice Guideline (CPG). A multicenter quality improvement (QI) collaborative aimed to improve CPG adherence.

METHODS

A QI collaborative of 15 hospitals aimed to improve testing adherence, the hospitalization of lower-risk infants, the correct use of diagnostic criteria, and risk classification. Interventions included CPG education, documentation practices, clinical pathways, and electronic medical record integration. By using medical record review, care of emergency department (ED) and inpatient patients meeting BRUE criteria was displayed via control or run charts for 3 time periods: pre-CPG publication (October 2015 to June 2016), post-CPG publication (July 2016 to September 2018), and collaborative (April 2019 to June 2020). Collaborative learning was used to identify and mitigate barriers to iterative improvement.

RESULTS

A total of 1756 infants met BRUE criteria. After CPG publication, testing adherence improved from 56% to 64% and hospitalization decreased from 49% to 27% for lower-risk infants, but additional improvements were not demonstrated during the collaborative period. During the collaborative period, correct risk classification for hospitalized infants improved from 26% to 49% (ED) and 15% to 33% (inpatient) and the documentation of BRUE risk factors for hospitalized infants improved from 84% to 91% (ED).

CONCLUSIONS

A national BRUE QI collaborative enhanced BRUE-related hospital outcomes and processes. Sites did not improve testing and hospitalization beyond the gains made after CPG publication, but they did shift the BRUE definition and risk classification. The incorporation of caregiver perspectives and the use of shared decision-making tools may further improve care.

Clinical Utility and Patient Distribution of Brief Resolved Unexplained Event Classification for Apparent Life-Threatening Events

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.

Brief resolved unexplained event: Severity-associated factors at admission in the pediatric emergency ward

OBJECTIVE

A brief resolved unexplained event (BRUE) is a recent clinical entity that has now replaced the term "infant discomfort". Despite the availability of recent recommendations, identification of patients requiring further examination remains difficult.

METHOD

We aimed to identify factors associated with severe pathology and/or recurrence by studying the medical files of 767 patients admitted to the pediatric emergency department of a French university hospital for a BRUE.

RESULTS

Overall, 255 files were studied; 45 patients had a recurrence and 23 patients had a severe diagnosis. The most frequently found etiology was gastroesophageal reflux in the benign diagnosis group and apnea or central hypoventilation in the severe diagnosis group. Prematurity (p = 0.032) and time since last meal >1 h (p = 0.019) were the main factors associated with severe disease. Most of the routine examination results remained non-contributive to the etiology.

CONCLUSION

As prematurity is a factor associated with severe diagnosis, special attention should be given to this population, without subjecting them to multiple tests, since the main complication was found to be apnea or central hypoventilation. Prospective research is needed to establish the usefulness and prioritization of diagnostic tests for infants who are at "high risk" of experiencing a BRUE.

Descriptive analysis of infant population younger than 1 year admitted for BRUE

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.

Diagnostic testing for and detection of physical abuse in infants with brief resolved unexplained events

BACKGROUND

A Brief Resolved Unexplained Event (BRUE) can be a sign of occult physical abuse.

OBJECTIVES

To identify rates of diagnostic testing able to detect physical abuse (head imaging, skeletal survey, and liver transaminases) at BRUE presentation. The secondary objective was to estimate the rate of physical abuse diagnosed at initial BRUE presentation through 1 year of age.

PARTICIPANTS AND SETTING

Infants who presented with a BRUE at one of 15 academic or community hospitals were followed from initial BRUE presentation until 1 year of age for BRUE recurrence or revisits.

METHODS

This study was part of the BRUE Research and Quality Improvement Network, a multicenter retrospective cohort examining infants with BRUE. Generalized estimating equations assessed associations with performance of diagnostic testing (adjusted odds ratio (aOR)).

RESULTS

Of the 2036 infants presenting with a BRUE, 6.2 % underwent head imaging, 7.0 % skeletal survey, and 12.1 % liver transaminases. Infants were more likely to undergo skeletal survey if there were physical examination findings concerning for trauma (aOR 8.23, 95 % CI [1.92, 35.24], p < 0.005) or concerning social history (aOR 1.89, 95 % CI [1.13, 3.16], p = 0.015). There were 7 (0.3 %) infants diagnosed with physical abuse: one at BRUE presentation, one <3 days after BRUE presentation, and five >30 days after BRUE presentation.

CONCLUSION

There were low rates of diagnostic testing and physical abuse identified in infants presenting with BRUE. Further study including standardized testing protocols is warranted to identify physical abuse in infants presenting with a BRUE.

A Prospective Study of Brief Resolved Unexplained Events: Risk Factors for Persistent Symptoms

OBJECTIVE

The risk of persistent symptoms after a brief resolved unexplained event (BRUE) is not known. Our objective was to determine the frequency and risk factors for persistent symptoms after BRUE hospitalizations.

METHODS

We conducted a prospective longitudinal cohort study of infants hospitalized with an admitting diagnosis of BRUE. Caregiver-reported symptoms, anxiety levels, and management changes were obtained by questionnaires during the 2-month follow-up period. Clinical data including repeat hospitalizations were obtained from a medical record review. Multivariable analyses with generalized estimating equations were conducted to determine the risk of persistent symptoms.

RESULTS

Of 124 subjects enrolled at 51.6 ± 5.9 days of age, 86% reported symptoms on at least 1 questionnaire after discharge; 65% of patients had choking episodes, 12% had BRUE spells, and 15% required a repeat hospital visit. High anxiety levels were reported by 31% of caregivers. Management changes were common during the follow-up period and included 30% receiving acid suppression and 27% receiving thickened feedings. Only 19% of patients had a videofluoroscopic swallow study while admitted, yet 67% of these studies revealed aspiration/penetration.

CONCLUSIONS

Many infants admitted with BRUE have persistent symptoms and continue to access medical care, suggesting current management strategies insufficiently address persistent symptoms. Future randomized trials will be needed to evaluate the potential efficacy of therapies commonly recommended after BRUE.

Canadian infants presenting with Brief Resolved Unexplained Events (BRUEs) and validation of clinical prediction rules for risk stratification: a protocol for a multicentre, retrospective cohort study

INTRODUCTION

Brief Resolved Unexplained Events (BRUEs) are a common presentation among infants. While most of these events are benign and self-limited, guidelines published by the American Academy of Pediatrics inaccurately identify many patients as higher-risk of a serious underlying aetiology (positive predictive value 5%). Recently, new clinical prediction rules have been derived to more accurately stratify patients. This data were however geographically limited to the USA, with no large studies to date assessing the BRUE population in a different healthcare setting. The study's aim is to describe the clinical management and outcomes of infants presenting to Canadian hospitals with BRUEs and to externally validate the BRUE clinical prediction rules in identified cases.

METHODS AND ANALYSIS

This is a multicentre retrospective study, conducted within the Canadian Paediatric Inpatient Research Network (PIRN). Infants (<1 year) presenting with a BRUE at one of 11 Canadian paediatric centres between 1 January 2017 and 31 December 2021 will be included. Eligible patients will be identified using diagnostic codes.The primary outcome will be the presence of a serious underlying illness. Secondary outcomes will include BRUE recurrence and length of hospital stay. We will describe the rates of hospital admissions and whether hospitalisation was associated with an earlier diagnosis or treatment. Variation across Canadian hospitals will be assessed using intraclass correlation coefficient. To validate the newly developed clinical prediction rule, measures of goodness of fit will be evaluated. For this validation, a sample size of 1182 is required to provide a power of 80% to detect patients with a serious underlying illness with a significance level of 5%.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the UBC Children's and Women's Research Board (H21-02357). The results of this study will be disseminated as peer-reviewed manuscripts and presentations at national and international conferences.

Impact of the AAP Guideline on Management of Brief Resolved Unexplained Events

OBJECTIVES

In May 2016, the American Academy of Pediatrics published a clinical practice guideline (CPG) defining apparent life-threatening events (ALTEs) as brief resolved unexplained events (BRUEs) and recommending risk-based management. We analyzed the association of CPG publication on admission rate, diagnostic testing, treatment, cost, length of stay (LOS), and revisits in patients with BRUE.

METHODS

Using the Pediatric Health Information Systems database, we studied patients discharged from the hospital with a diagnosis of ALTE/BRUE from January 2012 to December 2019. We grouped encounters into 2 time cohorts on the basis of discharge date: preguideline (January 2012-January 2016) and postguideline (July 2016-December 2019). We used interrupted time series to test if the CPG publication was associated with level change and change in slope for each metric.

RESULTS

The study included 27 941 hospitalizations for ALTE/BRUE from 36 hospitals. There was an early decrease in 12 diagnostic tests that the CPG strongly recommended against. There was a positive change in the use of electrocardiogram (+3.5%, P < .001), which is recommended by CPG. There was a significant reduction in admissions (-13.7%, P < .001), utilization of medications (-8.3%, P < .001), cost (-$1146.8, P < .001), and LOS (-0.2 days, P < .001), without a change in the revisit rates. In the postguideline period, there were an estimated 2678 admissions avoided out of 12 508 encounters.

CONCLUSIONS

Publication of the American Academy of Pediatrics BRUE CPG was associated with substantial reductions in testing, utilization of medications, admission rates, cost, and LOS, without a change in the revisit rates.

Risk Prediction After a Brief Resolved Unexplained Event

OBJECTIVES

Only 4% of brief resolved unexplained events (BRUE) are caused by a serious underlying illness. The American Academy of Pediatrics (AAP) guidelines do not distinguish patients who would benefit from further investigation and hospitalization. We aimed to derive and validate a clinical decision rule for predicting the risk of a serious underlying diagnosis or event recurrence.

METHODS

We retrospectively identified infants presenting with a BRUE to 15 children's hospitals (2015-2020). We used logistic regression in a split-sample to derive and validate a risk prediction model.

RESULTS

Of 3283 eligible patients, 565 (17.2%) had a serious underlying diagnosis (n = 150) or a recurrent event (n = 469). The AAP's higher-risk criteria were met in 91.5% (n = 3005) and predicted a serious diagnosis with 95.3% sensitivity, 8.6% specificity, and an area under the curve of 0.52 (95% confidence interval [CI]: 0.47-0.57). A derived model based on age, previous events, and abnormal medical history demonstrated an area under the curve of 0.64 (95%CI: 0.59-0.70). In contrast to the AAP criteria, patients >60 days were more likely to have a serious underlying diagnosis (odds ratio:1.43, 95%CI: 1.03-1.98, P = .03).

CONCLUSIONS

Most infants presenting with a BRUE do not have a serious underlying pathology requiring prompt diagnosis. We derived 2 models to predict the risk of a serious diagnosis and event recurrence. A decision support tool based on this model may aid clinicians and caregivers in the discussion on the benefit of diagnostic testing and hospitalization (https://www.mdcalc.com/calc/10400/brief-resolved-unexplained-events-2.0-brue-2.0-criteria-infants).

A Pediatric Hospital Medicine Primer for Performing Research Using Administrative Data

Provider- and claims-focused administrative databases are powerful tools for conducting health services research, and these studies often have good generalizability owing to diversity of hospitals from which samples are derived. In this research methods article, we describe administrative data and how available provider- and claims-focused administrative databases can be used to conduct health services research. We describe common observational study designs using administrative data and provide real-world examples. We highlight the strengths and weaknesses of studies conducted using administrative data and describe methodological considerations to reduce bias and improve the rigor of observational studies using administrative data. Finally, we provide guidance on the types of study questions suitable for observational study designs using administrative data.

Brief resolved unexplained events: a new diagnosis, with implications for evaluation and management

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.

Explanatory Diagnoses Following Hospitalization for a Brief Resolved Unexplained Event

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.

Pediatrician Perspectives on Brief Resolved Unexplained Events

BACKGROUND AND OBJECTIVE

The objective with this study was to describe pediatric emergency department (ED) physicians' perspective on the evaluation and management of brief resolved unexplained events (BRUEs) to help support the development of quality improvement interventions for this population.

METHODS

We conducted qualitative semistructured interviews with pediatric ED providers who practice in a single state. Interviews were audio-recorded and transcribed and demographic information was also obtained. The 6-phase approach to reflexive thematic analysis was used to conduct the qualitative analysis.

RESULTS

Nineteen pediatric ED physicians practicing in 4 institutions across our state participated in the study. The majority of participants (95%) practice in a university-affiliated setting. The primary themes related to providing care for patients with a BRUE identified in our analysis were (1) reassurance, (2) caregiver or provider concern, and (3) clinical practice guideline availability and interpretation. Closely intertwined underlying topics informing BRUE patient management were also noted: (1) ambiguity in the BRUE diagnosis and its management; (2) a need for shared decision-making between the caregiver and the provider; and (3) concern over the increased time spent with caregivers during an ED visit for a diagnosis of BRUE. These complex relationships were found to influence patient evaluation and disposition.

CONCLUSION

Multifaceted quality improvement interventions should address caregiver and provider concerns regarding the diagnosis of BRUE while providing decision aids to support shared decision-making with caregivers.