Risk Prediction After a Brief Resolved Unexplained Event

Global research trends of BRUE (brief resolved unexplained event) or formerly ALTE (apparent life-threatening event): A comprehensive visualization and bibliometric analysis from 1988 to 2024

OBJECTIVE

This study aimed to conduct a comprehensive bibliometric analysis of the literature on Brief Resolved Unexplained Event (BRUE) and its predecessor, Apparent Life-Threatening Event (ALTE), from 1988 to 2024, in order to identify research trends, collaborative networks, and areas of focus in this field.

METHODS

We analyzed articles indexed in Scopus and Web of Science using various bibliometric indicators. The visualization of bibliometric networks was performed using VOSviewer and bibliometrix. Publication trends, citation analysis, co-authorship networks, and keyword co-occurrence were examined.

RESULTS

A total of 270 articles were analyzed, of which 85.56 % were research articles and 14.44 % were review articles. The number of publications showed a significant increase over time (r = 0.73, p < 0.001). The United States emerged as the leading contributor with strong international collaborations. The most prolific journals were Pediatrics, Pediatric Emergency Care, and Journal of Pediatrics. Keyword analysis revealed a shift from terms associated with life-threatening events (e.g., SIDS, sleep apnea syndrome) to more specific terminology (BRUE) and methodological keywords over time. However, the 2016 redefinition of ALTE to BRUE did not result in a corresponding increase in publications.

CONCLUSION

This bibliometric analysis provides valuable insights into the evolution and current state of BRUE/ALTE research. The findings highlight the field's progression toward more precise, evidence-based approaches. The identified research trends and gaps, particularly the limited studies from developing countries, offer direction for future research. These results can inform clinical practice, guide research priorities, and support the development of standardized guidelines for BRUE/ALTE management.

A prospective study of diagnostic testing and hospital charges after brief resolved unexplained event

OBJECTIVES

To evaluate diagnostic testing frequency/yield and determine drivers of hospital charges in a prospective cohort of infants with brief resolved unexplained event (BRUE) to test the hypothesis that length of stay (LOS), low-yield diagnostic testing, and repeat hospital visits increase costs.

METHODS

We conducted a prospective cohort study of infants admitted after BRUE to determine how clinical practice impacts the cost of care. Charge data from our institution's billing records database included room and board, diagnostics, medications, and professional fees for index hospitalizations and 6-month follow-ups. Charts were reviewed for clinical data, testing results, and repeat hospitalizations. Parent-reported symptoms and management changes were obtained by questionnaires. Multivariable analyses with linear regression were conducted to determine risk factors for hospitalization charges and total charges including hospitalization and 6-month follow-up.

RESULTS

The cohort included 155 subjects with median index hospitalization charges of $11,256 and total charges of $15,675. Overall, 76% had persistent BRUE symptoms and 15% repeat hospitalization; 34% were treated with acid suppression. Only 9.7% of the tests performed provided a potential diagnosis, but the videofluoroscopic swallow study (VFSS) had the highest yield with 70% abnormal. On multivariable analysis, LOS, VFSS, flexible laryngoscopy, electroencephalogram, and repeat hospital visits were all associated with increased charges (fold change: 142%-354%).

CONCLUSIONS

Hospitalization and follow-up care are costly after BRUE. Potentially modifiable drivers of charges include test number, LOS, and repeat hospital visits. Most testing is low-yield, but timely performance of VFSS may allow for cost-effective and appropriate treatment of oropharyngeal dysphagia and prevention of persistent symptoms. Gastroenterologists are frequently involved in caring for these children and are uniquely positioned to help guide testing and treatment related to gastroesophageal reflux disease and oropharyngeal dysphagia.

Acute Care Management of Brief Resolved Unexplained Events

ABSTRACT

A brief resolved unexplained event was defined in 2016 by the American Academy of Pediatrics in their clinical practice guideline. Since introduction of this term, research has characterized the epidemiology, clinical outcomes, and management of patients following a brief resolved unexplained event. Pediatric health care providers should be familiar with the current brief resolved unexplained event literature to minimize unnecessary health care utilization and guide shared decision-making discussions with caregivers.

External Validation of Brief Resolved Unexplained Events Prediction Rules for Serious Underlying Diagnosis

Importance

The American Academy of Pediatrics (AAP) higher-risk criteria for brief resolved unexplained events (BRUE) have a low positive predictive value (4.8%) and misclassify most infants as higher risk (>90%). New BRUE prediction rules from a US cohort of 3283 infants showed improved discrimination; however, these rules have not been validated in an external cohort.

Objective

To externally validate new BRUE prediction rules and compare them with the AAP higher-risk criteria.

Design, Setting, and Participants

This was a retrospective multicenter cohort study conducted from 2017 to 2021 and monitored for 90 days after index presentation. The setting included infants younger than 1 year with a BRUE identified through retrospective chart review from 11 Canadian hospitals. Study data were analyzed from March 2022 to March 2024.

Exposures

The BRUE prediction rules.

Main Outcome and Measure

The primary outcome was a serious underlying diagnosis, defined as conditions where a delay in diagnosis could lead to increased morbidity or mortality.

Results

Of 1042 patients (median [IQR] age, 41 [13-84] days; 529 female [50.8%]), 977 (93.8%) were classified as higher risk by the AAP criteria. A total of 79 patients (7.6%) had a serious underlying diagnosis. For this outcome, the AAP criteria demonstrated a sensitivity of 100.0% (95% CI, 95.4%-100.0%), a specificity of 6.7% (95% CI, 5.2%-8.5%), a positive likelihood ratio (LR+) of 1.07 (95% CI, 1.05-1.09), and an AUC of 0.53 (95% CI, 0.53-0.54). The BRUE prediction rule for discerning serious diagnoses displayed an AUC of 0.60 (95% CI, 0.54-0.67; calibration intercept: 0.60), which improved to an AUC of 0.71 (95% CI, 0.65-0.76; P < .001; calibration intercept: 0.00) after model revision. Event recurrence was noted in 163 patients (15.6%). For this outcome, the AAP criteria yielded a sensitivity of 99.4% (95% CI, 96.6%-100.0%), a specificity of 7.3% (95% CI, 5.7%-9.2%), an LR+ of 1.07 (95% CI, 1.05-1.10), and an AUC of 0.58 (95% CI, 0.56-0.58). The AUC of the prediction rule stood at 0.67 (95% CI, 0.62-0.72; calibration intercept: 0.15).

Conclusions and Relevance

Results of this multicenter cohort study show that the BRUE prediction rules outperformed the AAP higher-risk criteria on external geographical validation, and performance improved after recalibration. These rules provide clinicians and families with a more precise tool to support decision-making, grounded in individual risk tolerance.

Outcomes for infants with BRUE diagnosed with oropharyngeal dysphagia or gastroesophageal reflux disease: a multicenter study from the Pediatric Health Information System Database

We aimed to determine the prevalence of gastroesophageal reflux disease (GERD) and oropharyngeal dysphagia as explanatory diagnoses, risk factors for acid suppression treatment, and risk factors for repeat hospital visit in infants hospitalized after brief resolved unexplained event (BRUE) using a multicenter pediatric database. We performed a multicenter retrospective database study of infants admitted with BRUE in the Pediatric Health Information System between 2016 and 2021. Data included diagnostic testing, explanatory diagnoses, treatment with acid suppression, and related repeat hospital visits within 6 months. Multivariable logistic regression models were used to determine risk factors for treatment with acid suppression and repeat hospital visit. Of 17,558 subjects admitted to 47 hospitals, 34% were given an explanatory diagnosis of GERD and 1.4% oropharyngeal dysphagia. Twelve percent were treated with acid suppression, with some centers having rates as high as 26%. Multiple factors, including most notably the GERD diagnosis, were associated with increased prescribing risk. Ten percent of subjects had repeat hospital visits. Subjects given an explanatory diagnosis of GERD (OR 1.66, 95% CI 1.48-1.86, p < 0.001) or oropharyngeal dysphagia (OR 2.13, 95% CI 1.55-2.91, p < 0.001) had increased risk for repeat hospital visit as did those treated with acid suppression. CONCLUSION: GERD as an explanatory diagnosis was associated with increased risk of repeat hospital visit, despite its conception as a benign, treatable condition. Treatment with acid suppression was common but did not prevent repeat hospitalization. Oropharyngeal dysphagia as an explanatory diagnosis was also associated with increased risk of repeat hospital visit.

Identifying serious underlying diagnoses among patients with brief resolved unexplained events (BRUEs): a Canadian cohort study

OBJECTIVE

To describe the demographics and clinical outcomes of infants with brief resolved unexplained events (BRUE).

DESIGN

A retrospective cohort study.

SETTING

11 centres within the Canadian Paediatric Inpatient Research Network.

PATIENTS

Patients presenting to the emergency department (ED) following a BRUE (2017-2021) were eligible, when no clinical cause identified after a thorough history and physical examination.

MAIN OUTCOME MEASURES

Serious underlying diagnosis (requiring prompt identification) and event recurrence (within 90 days).

RESULTS

Of 1042 eligible patients, 665 were hospitalised (63.8%), with a median stay of 1.73 days. Diagnostic tests were performed on 855 patients (82.1%), and 440 (42.2%) received specialist consultations. In total, 977 patients (93.8%) were categorised as higher risk BRUE per the American Academy of Pediatrics guidelines. Most patients (n=551, 52.9%) lacked an explanatory diagnosis; however, serious underlying diagnoses were identified in 7.6% (n=79). Epilepsy/infantile spasms were the most common serious underlying diagnoses (2.0%, n=21). Gastro-oesophageal reflux was the most common non-serious underlying diagnosis identified in 268 otherwise healthy and thriving infants (25.7%). No instances of invasive bacterial infections, arrhythmias or metabolic disorders were found. Recurrent events were observed in 113 patients (10.8%) during the index visit, and 65 patients had a return to ED visit related to a recurrent event (6.2%). One death occurred within 90 days.

CONCLUSIONS

There is a low risk for a serious underlying diagnosis, where the majority of patients remain without a clear explanation. This study provides evidence-based risk for adverse outcomes, critical information to be used when engaging in shared decision-making with caregivers.

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 = .04).

CONCLUSIONS

Presenting symptoms may play a role in clinicians' decisions on which BRUE patients undergo VFSS but are unreliable to make a diagnosis of oropharyngeal dysphagia. Presenting symptoms may also influence assignment of 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.

Discontinuation of Car Seat Tolerance Screening and Postdischarge Adverse Outcomes in Infants Born Preterm

OBJECTIVE

To study the association between discontinuing predischarge car seat tolerance screening (CSTS) with 30-day postdischarge adverse outcomes in infants born preterm.

STUDY DESIGN

Retrospective cohort study involving all infants born preterm from 2010 through 2021 who survived to discharge to home in a 14-hospital integrated health care system. The exposure was discontinuation of CSTS. The primary outcome was a composite rate of death, 911 call-triggered transports, or readmissions associated with diagnostic codes of respiratory disorders, apnea, apparent life-threatening event, or brief resolved unexplained events within 30 days of discharge. Outcomes of infants born in the periods of CSTS and after discontinuation were compared.

RESULTS

Twelve of 14 hospitals initially utilized CSTS and contributed patients to the CSTS period; 71.4% of neonatal intensive care unit (NICU) patients and 26.9% of non-NICU infants were screened. All hospitals participated in the discontinuation period; 0.1% was screened. Rates of the unadjusted primary outcome were 1.02% in infants in the CSTS period (n = 21 122) and 1.06% after discontinuation (n = 20 142) (P = .76). The aOR (95% CI) was 0.95 (0.75, 1.19). Statistically insignificant differences between periods were observed in components of the primary outcome, gestational age strata, NICU admission status groups, and other secondary analyses.

CONCLUSIONS

Discontinuation of CSTS in a large integrated health care network was not associated with a change in 30-day postdischarge adverse outcomes. CSTS's value as a standard predischarge assessment deserves further evaluation.

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.