For a patient who falls into a low-risk category, the guideline authors developed 29 separate action statements. Each of these action statements were graded with a specific level of evidence quality rating (A, B, C, or D, with A being the highest and D being the lowest rating). An overall strength of the recommendation was provided also (strong, moderate, or weak).

Only one of the action statements was rated as a “strong” recommendation: 4A. Should not obtain a white blood cell count, blood culture, or cerebrospinal fluid analysis or culture to detect an occult bacterial infection (Level B; strong recommendation). Table 5¹

Some examples of management recommendations particularly pertinent to emergency medicine are that low-risk patients do not have to be admitted solely for continuous monitoring, imaging is not mandatory, and an electrocardiogram is worth considering.

While it would be exhaustive to present every action statement from the guideline, emergency medicine providers should know that this guideline exists and recommends a minimalist workup in the low-risk patient meeting criteria for a BRUE. It cannot be stressed enough that the determination of a low-risk patient by this guideline is based on a very extensive history and physical examination with more than 75 separate historical features and physical examination findings/considerations highlighted in the guideline tables. In patients determined to be a low-risk BRUE, discharge home after minimal or no workup with a detailed, timely follow-up plan and return precautions is a safe and reasonable disposition. Shared decision making should be employed with the family, emergency provider, and primary care provider.

References

1. Tieder JS, Bonkowsky JL, Etzel RA, et al; for the Subcommittee on Apparent Life Threatening Events. Brief Resolved Unexplained Events (formerly Apparent Life-Threatening Events) and evaluation of lower-risk infants. Pediatrics. 2016;137(5):e20160590.
2. McGovern MC, Smith MB. Causes of apparent life threatening events in infants: a systematic review. Arch Dis Child. 2004;89:1043-1048.

Dr. Ingalsbe is clinical assistant professor of emergency medicine at the University of Nevada, Reno School of Medicine.

Dr. Mace is professor of medicine at the Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and director of research at the Cleveland Clinic in Cleveland, Ohio.

Dr. Valente is associate professor in the departments of emergency medicine and pediatrics at the Alpert Medical School of Brown University, Rhode Island Hospital, and Hasbro Children’s Hospital, all in Providence, Rhode Island.