Originally published by 2 Minute Medicine® (view original article). Reused on AccessMedicine with permission.

1. After the 2016 change in the American Academy of Pediatrics’ (AAP) guidelines for brief resolved unexplained events (BRUEs), both rates of admission and of diagnostic testing for infants who presented to the emergency room with BRUEs decreased significantly from 2015 to 2017.

2. Despite this downtrend in admissions and diagnostic testing, revisits after initial presentation for BRUEs did not increase after the guideline changes and, rather, decreased slightly for infants less than 60 days old.

Evidence Rating Level: 2 (Good)

Study Rundown:

In 2016, the AAP renamed the previously-termed apparent life-threatening event (ALTE), instead referring to these episodes as BRUEs. In addition to renaming the events, the AAP also redefined the entity and changed management guidelines to include risk stratification and management recommendations for low-risk patients. Authors of this study sought to determine whether or not rates of admissions and diagnostic testing (such as MRIs, chest radiographs, electrocardiograms, and cerebral spinal fluid testing, among other things) decreased after the changes in these guidelines. Results from this retrospective cohort study suggested that rates of both admissions and diagnostic testing decreased, with admission rates being particularly low in infants greater than 2 months of age. Despite decreased rates of admissions and diagnostic testing, rates of revisits after initial presentation for BRUE did not increase after implementation of the new guidelines. Further study is required to determine whether or not outcomes changed following the guideline changes for this population of patients. Still, the overall trend away from admission and diagnostic testing without an increase in revisit rates indicates that the new guidelines have given providers both a safe and more cost-effective means of managing patients presenting with BRUE.

In-Depth [retrospective cohort]:

In this study, researchers initially identified 16 556 infants across 26 states and the District of Columbia with BRUE or ALTE; they ultimately included 9501 infants in the final sample (54.5% white, 46.9-47.3% male). Dividing the cohort into infants age 0 to 60 days and 61 to 365 days, researchers reviewed admission rates in this population before and after implementation of the new guidelines, in 2015 and 2017, respectively. Using billing codes, researchers reviewed whether the following tests (among others) were completed during hospitalization: electrocardiogram, electroencephalogram, cerebral spinal fluid testing, computed tomography (CT) imaging, MRI of the brain, chest radiograph, abdominal ultrasound, blood glucose, electrolyte testing, and testing for inborn errors of metabolism. Researchers also sought to determine whether revisit rates decreased before and after implementation of the guideline. Ultimately, researchers found that admission rates decreased for both groups, with an even more significant decrease for infants 61 to 365 days (18.0%, 95% CI 15.3% to 20.7%) than for infants age 0 to 60 days (5.7%, 95% CI 3.8 to 7.5%). Diagnostic testing also decreased for both groups, with chest radiograph rates decreasing most significantly for both infants 0 to 60 days (9.8%, 95% CI 7.2 to 12.5%) and 61 to 365 days (11.5%, 95% CI 8.3 to 14.6%). Revisit rates showed no significant increase or decrease for either group (0-60 days: -1.0%, 95% CI -3.1 to 1.0%; 61-365 days: 2.3%, 95% CI -0.2 to 4.8%).

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