Question
Among infants presenting to emergency departments (ED) with a brief resolved unexplained event (BRUE) and admitted for workup, what is the rate of explanatory-diagnosis identification?
Design
Multicenter retrospective cohort study.
Setting
15 EDs participating in the BRUE Research and Quality Improvement Network.
Participants
Infants <1 year of age with a BRUE.
Intervention
Inpatient workup.
Outcomes
Event explanation at discharge.
Main Results
Among 980 infants, 37.0% (95% CI, 34.0%-40.2%) received an explanatory diagnosis at discharge. In only 17.9% (95% CI, 15.5%-20.4%) testing, consultations, and observed events contributed to a diagnosis. 15 infants had a serious diagnosis, the most common (4 patients) was seizures or infantile spasms.
Conclusions
Most hospitalized infants did not receive a diagnosis, and most diagnoses were not serious (e.g., reflux, periodic breathing).
Commentary
This large multicenter retrospective study provides much-needed insight on the yield of inpatient diagnostic workup for BRUE. Findings suggest that this evaluation remains low-yield, consistent with results of prior studies.1 Most explanatory diagnoses were made based on clinical history alone with no confirmatory testing. Fifty-four percent were given a diagnosis of gastroesophageal reflux, but this diagnosis can be misleading since gastroesophageal reflux events have never been shown to correlate with BRUE episodes and reflux therapies do not improve symptoms. Recent data suggest that symptoms of GERD overlap with symptoms of oropharyngeal dysphagia with aspiration, a more nuanced explanation for BRUE. Unfortunately, oropharyngeal dysphagia with aspiration cannot be diagnosed by observed bedside feedings due to the high rate of silent aspiration in infants.2 While the authors do not report on the yield of individual diagnostic tests in their cohort, videofluoroscopic swallow studies might have a much higher yield than other tests.1,2 Given the high rate of low-yield testing and the risk of misattribution of symptoms to gastroesophageal reflux, close follow-up of patients is needed, as 11-24% of infants require repeat hospital evaluation for persistent symptoms.1,3 While this study adds evidence that hospitalization may be of low yield, prospective outcomes studies are needed to better stratify high risk patients requiring hospitalization and more targeted diagnostic testing.
References
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