The Impact of the American Academy of Pediatrics Brief Resolved Unexplained Event Guidelines on Gastrointestinal Testing and Prescribing Practices

Abstract

Objectives: To determine if hospitalization, testing, diagnosis, and management of suspected gastroesophageal reflux, and follow-up visits decreased since introduction of American Academy of Pediatrics guidelines for brief resolved unexplained events (BRUEs).

Study design: We performed a retrospective cohort study of infants with BRUE evaluated at Boston Children's Hospital in the year before and after guideline implementation to determine if practice patterns have changed. Outcomes included hospitalization rates, frequency of swallow assessments, other diagnostic testing, and reflux diagnoses, cost of care, and number of repeat visits. Groups were compared based on whether they presented before or after guideline implementation.

Results: In total, 359 subjects (186 pre-, 173 post-guidelines) were identified. There were no significant differences in practice patterns or outcomes before or after guideline implementation. Subjects had mean age 2.53 ± 0.15 months, and 80% were hospitalized for 2.49 ± 0.26 days. Each subject had 2.47 diagnostic tests performed, and 89% were noncontributory. Despite only 13% having videofluoroscopic swallow study performed, 72% showed aspiration/penetration. No subject had gastroesophageal reflux testing, yet reflux was implicated as the cause for admission in 40% of subjects, resulting in increased odds of discharge on acid suppressing medications (OR 2.88, 95% CI 1.68-4.92, P = .0001). In follow-up, 28% of subjects had repeat hospitalizations or emergency department visits for persistent symptoms.

Conclusions: Infants with BRUE continue to undergo low-yield diagnostic testing and after admission remain symptomatic and frequently re-present to medical care. Swallow testing remains infrequent despite its high-yield, reflux continues to be implicated and children are still being discharged on acid suppression despite lack of efficacy.

Keywords: aspiration; brief resolved unexplained event; gastroesophageal reflux; oropharyngeal dysphagia; videofluoroscopic swallow study.

Figure 1 (online).. Flow Diagram.

Flow diagram of study population showing proportion of BRUE subjects admitted and seen in ED, along with clinical feeding evaluation (CFE) and videofluoroscopic swallow study (VFSS) testing rates during and after initial BRUE evaluation.

Figure 2 (online).. A. Subject Demographics and B. Graph of Charges.

Part A shows that the patient population was primarily local with a mix of commercial and state insurance. Part B shows the distribution of charges for all BRUE presentations, consisting largely of charges for room and board, diagnostic testing and ED care.

Figure 3.. Proportion of Subjects Discharged on Acid Suppression Varies by Attribution to Reflux.

Association between whether BRUE was attributed to reflux and whether subjects were discharged on acid suppression, showing that attribution to reflux by SLP in clinical feeding evaluation, lactation consultant or hospitalist team in discharge summary are all associated with increased odds of discharge on acid suppression.

Figure 4 (online).. Kaplan-Meier Curves for Treatment with Acid Suppression and Risk of Repeat Admission or Emergency Room Visit.

Kaplan-Meier curves showing risk of subsequent admission or ED visit for subjects discharged on acid suppression (p=0.28) in (A) and subjects ever treated with acid suppression (p=0.08) in (B), showing no benefit of acid suppression in BRUE.