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Background: “Apparent Life-Threatening Events” (ALTEs) have been associated with child physical abuse (CPA). In 2016, “Brief Resolved Unexplained Event” (BRUE) and the development of its clinical guidelines and risk-stratification replaced ALTE. However, it is unknown if there is a similar association between BRUEs and CPA. Hypothesis/Objectives: To determine the rate of CPA in infants presenting with a BRUE, examine differences between infants with and without CPA, and to examine rates of diagnostic testing used to detect CPA. Methods: This study was part of the BRUE Research and Quality Improvement Network, composed of 15 hospitals. Subjects were infants presenting with BRUE in emergency department or inpatient settings. Subjects were followed from BRUE presentation through the first year of life for possible diagnosis of CPA at either initial BRUE or subsequent presentations. The primary outcome was CPA diagnosis at either initial BRUE or subsequent presentations. CPA was the only maltreatment type identified. The secondary outcomes were minor evidence of trauma and diagnostic testing used to detect CPA (head imaging, skeletal survey, and/or liver transaminases) at initial BRUE presentation. Chi-square tests assessed for differences. Results/Conclusion: Of the 2036 infants presenting with a BRUE, 7 (0.3%) were diagnosed with CPA, 5 of whom had findings consistent with abusive head trauma (AHT). Only 1 infant was diagnosed with CPA (cutaneous injury) at initial BRUE presentation (<0.1%). For the remaining cases, 1 infant was diagnosed with AHT within 3 days, 1 with AHT and cutaneous injury within 31-60 days, 1 with abusive fractures within 31-60 days and 3 with AHT more than 60 days after initial BRUE presentation. Infants diagnosed with CPA were more likely to be White (85.7% vs. 48.3%, p<0.05), to exhibit color change (100% vs. 51.1%, p=0.01) and have minor evidence of trauma (14.3% vs. 0.3%, p<0.001) at initial BRUE presentation. There was no difference between CPA diagnosis and BRUE risk stratification. There were 7 (0.3%) infants with minor evidence of trauma: 1 was diagnosed with CPA, 3 were iatrogenic, 1 birth-related and 2 multiple yet nonspecific minor traumas. Of all infants, only 6.2% underwent head imaging, 7% skeletal survey, and 12.1% liver transaminases. Skeletal survey was more likely to be performed if there was minor evidence of trauma (42.9 vs. 6.9%, P <0.001) or a concerning social history (13.9% vs. 5.9%, p <0.05). Head imaging was more often performed if infants had minor evidence of trauma (71.4% vs. 6.0%; p< 0.001), family history of sudden unexplained death (10.2% vs. 6.3%; p= 0.047) or concerning social history (22.8% vs. 5.4%; p< 0.001). There was a lower rate of CPA in infants at initial BRUE presentation (<0.1%) than in infants with ALTE, although testing rates at initial BRUE presentation were also low. Minor evidence of trauma and other clinical features appeared to raise suspicion and initiate diagnostic testing to detect CPA. Further research is warranted to systematically identify and diagnose infants with BRUE at increased risk for CPA.
When and Where Presented
Presented at the Annual Ray E. Helfer Society Meeting; San Diego, California; April 10-13, 2022
Doswell, Angela; Anderst, James; Tieder, Joel; Puls, Henry T.; and BRUE Research and Quality Improvement Network, "Rates of Physical Abuse Screening and Detection in Infants with Brief Resolved Unexplained Events (BRUEs)" (2022). Presentations. 65.