CLINICAL QUESTION: Do the recently derived clinical prediction rules for brief resolved unexplained events (BRUE) perform better than the American Academy of Pediatrics (AAP) higher-risk criteria in estimating risk for serious underlying diagnosis?
BACKGROUND: Current AAP criteria for higher-risk BRUE have low positive predictive value and over-classify most infants as higher risk. A new prediction tool from a U.S. cohort showed improved discrimination in identifying serious underlying diagnoses and predicting event recurrence. The objective of this study was to externally validate these new BRUE prediction rules and compare their performance with the AAP higher-risk criteria in an independent cohort.
STUDY DESIGN: Retrospective multicenter cohort study
SETTING: 11 Canadian hospitals
SYNOPSIS: The study included 1,042 Canadian infants under 1 year of age who presented with a BRUE between 2017 and 2021 and compared the performance of the BRUE prediction rules against the AAP higher-risk criteria for the identification of a serious underlying diagnosis and event recurrence within 90 days. A serious underlying diagnosis was detected in 7.6% of patients, and event recurrence occurred in 15.6% of patients. The AAP higher-risk criteria demonstrated poor discrimination for serious underlying diagnosis (Area under the curve [AUC], 0.53) and event recurrence (AUC, 0.53). The BRUE prediction rules showed significantly improved discrimination for serious underlying diagnosis (AUC, 0.71 after model revision) and event recurrence (AUC, 0.67). A key limitation of this study is that the discrimination of the BRUE prediction rules, while superior, was still only fair. The BRUE prediction rules represent the best available evidence for risk prediction, however, allowing clinicians to provide individualized risk assessments to inform shared decision making regarding the management strategy. A calculator has been developed on MDCalc to facilitate the use of the new prediction rules.
BOTTOM LINE: The now externally validated BRUE prediction rules provide a superior method for assessing risk of serious underlying diagnoses and event recurrence compared to the AAP higher-risk criteria.
CITATION: Nama N, et al. External validation of brief resolved unexplained events prediction rules for serious underlying diagnosis. JAMA Pediatr. 2025;179(2):188-196. doi: 10.1001/jamapediatrics.2024.4399.
Dr. Graham
Dr. Graham is a med-peds hospitalist in the departments of internal medicine and pediatrics at The Ohio State University Wexner Medical Center and Nationwide Children’s Hospital and an assistant professor of medicine at The Ohio State University College of Medicine, all in Columbus, Ohio.
Dr. McIntosh
Dr. McIntosh is a med-peds hospitalist in the departments of internal medicine and pediatrics at The Ohio State University Wexner Medical Center and Nationwide Children’s Hospital and an assistant professor of medicine at The Ohio State University College of Medicine, all in Columbus, Ohio
