The role of overfeeding in infants with brief resolved unexplained events (BRUE): a prospective observational study

Brief resolved unexplained event (BRUE) are transient and worrying episodes observed in infants and are characterized by changes in skin color, breathing, muscle tone, and/or responsiveness. We describe the case of a female infant who was initially diagnosed with BRUE but was later determined to have intussusception. She presented to our emergency department with a transient pallor and a single episode of vomiting that resolved before her visit. Physicians did not detect any abnormalities on physical or laboratory examinations, so she was diagnosed with BRUE and discharged to be re-evaluated the next day. After returning home, she vomited several times. The patient revisited our hospital the following day and was definitively diagnosed with intussusception using ultrasonography, which was successfully treated using fluoroscopy-guided hydrostatic reduction. This case was initially diagnosed as a BRUE; however, re-evaluation helped in identifying the proper diagnosis of intussusception. Physicians should exercise caution when diagnosing patients with BRUE. When the diagnostic criteria are not completely met, follow-up should be conducted, assuming that the patient has a potentially serious condition.

A brief resolved unexplained event (BRUE) describes an event associated with a change in muscle tone, color, respiration, and responsiveness that is unexplained after an appropriate examination. Some infants with higher risk BRUE may undergo endoscopy as part of their evaluation. This retrospective study aimed to identify the endoscopic findings in infants who have experienced a higher risk BRUE. We also compared the characteristics, prenatal, natal, and postnatal risk factors between 23 infants who underwent endoscopic evaluation and 23 race-matched/sex-matched/term-matched/preterm-matched infants who did not undergo endoscopic evaluation. This was a retrospective descriptive study. Infants were identified from a query of medical records using the ICD-10 code for BRUE (R68.13). Of 119 infants with BRUE, 23 infants with higher risk BRUE underwent an esophagogastroduodenoscopy and flexible sigmoidoscopy. Apnea (87%) was the most common presentation of BRUE. Most were female (57%) with a mean age at BRUE presentation of 2.73 months. We found 10 (43.5%) term infants and 13 (56.5%) preterm infants in our study. There were no significant differences in characteristics, prenatal, natal, and postnatal risk factors between the infants who underwent endoscopy and those who did not undergo endoscopy. The most common abnormal endoscopic finding was lymphonodular hyperplasia (LNH) associated with eosinophilia in the rectosigmoid colon. The proportion of females in the LNH group was significantly higher than the non-LNH group. Rectosigmoid LNH and eosinophilia, which are associated with milk soy protein intolerance (MSPI), were the most common findings on endoscopic evaluation. Although there is no proof of causation between MSPI and BRUE, MSPI should be considered in the differential diagnosis for higher risk BRUE.

In 2016, brief resolved unexplained events (BRUEs) were proposed as alternative concepts to apparent life-threatening event (ALTE). The clinical utility of managing ALTE cases according to the BRUE classification is controversial. To verify the clinical utility of the BRUE criteria, we evaluated the proportion of ALTE patients who met and those who did not meet the BRUE criteria and assessed the diagnoses and outcomes of each group. We retrospectively investigated patients with ALTE younger than 12 months who visited the emergency department of the National Center for Child Health and Development from April 2008 to March 2020. The patients were classified into the higher-risk and lower-risk BRUE groups; however, those who did not meet the BRUE criteria were classified into the ALTE-not-BRUE group. We evaluated the diagnoses and outcomes of each group. Adverse outcomes included death, recurrence, aspiration, choking, trauma, infection, convulsions, heart disease, metabolic disease, allergies, and others. Over the period of 12 years, a total of 192 patients were included, among which 140 patients (71%) were classified into the ALTE-not-BRUE group, 43 (22%) into the higher-risk BRUE group, and 9 (5%) into the lower-risk BRUE group. Adverse outcomes occurred in 27 patients in the ALTE-not-BRUE group and 10 patients in the higher-risk BRUE group. No adverse outcome occurred in the lower-risk BRUE group. Many of the patients with ALTE were classified into the ALTE-not-BRUE group, suggesting that replacing ALTE with BRUE is difficult. Although patients classified as lower-risk BRUE showed no adverse outcomes, there were only a few of them. In the pediatric emergency medicine setting, the BRUE risk classification may be beneficial for certain patients.

Gastroesophageal Reflux

The American Academy of Pediatrics published guidelines for evaluation and management of lower-risk infants for a brief resolved unexplained event (BRUE). The guideline identified gaps in knowledge related to caregiver satisfaction, anxiety, and family-centered educational strategies to improve caregiver experience and patient outcomes. The objective of this study was to understand caregivers' experience with hospitalization for infants with BRUE, including their perception of the hospital stay, the diagnosis of BRUE, and their feelings toward the upcoming discharge from the hospital. We conducted a qualitative study using semistructured interviews with caregivers of infants aged 0 to 12 months who were admitted to a quaternary care children's hospital for a BRUE. Interviews were conducted within 24 hours of discharge. Two investigators coded transcripts and identified themes using consensus. Eighteen caregivers of 13 infants were interviewed. No infants met criteria for being low risk according to the American Academy of Pediatrics guidelines. The coding scheme produced 3 major themes. First, parents felt reassured by hospital monitoring, diagnostic evaluation, and staff support in the hospital. Second, parents felt unsettled by the uncertainty of the child's condition and whether BRUE's "unexplainable" quality is understood as being part of normal infant behavior. Third, these themes manifested as conflicting emotions about caregivers' readiness for discharge. Although hospital monitoring may provide reassurance for some caregivers, they continue to struggle with the uncertainty of the diagnosis. Caregiver perspectives can inform physicians' strategies to improve hospital experience and discharge readiness.

Brief resolved unexplained events (BRUEs) are frequently encountered in infants younger than 1 year. By definition, these events require the infant to be asymptomatic and at baseline at the time of presentation, with no significant abnormalities on examination and no discernible explanatory diagnosis. Research has shown that less than 5% of BRUE cases are attributable to serious underlying conditions, with no increased mortality risk and no increased risk of sudden infant death syndrome. Despite these findings, approximately 63% of patients with BRUEs are hospitalized and up to 82% undergo diagnostic tests, which predominantly result in false-positive findings. Such results may lead to unnecessarily prolonged hospital stays, additional tests or consultations, and increased parental anxiety. The management of a patient who has experienced a BRUE can be challenging for providers and parents alike. Although risk is known to be low in these infants, providers may be compelled to explain the event and provide reassurance. Caregivers oftentimes are concerned that the events may reoccur and be a harbinger of a missed diagnosis. Shared decision-making can be used to explain risk and the benefit of additional testing and hospitalization. This family-centered strategy can align care with the family's values, provide reassurance, and decrease decisional conflict.

ObjectiveA brief resolved unexplained event (BRUE) is a recent clinical entity that has now replaced the term “infant discomfort”. Despite the availability of recent recommendations, identification of patients requiring further examination remains difficult. MethodWe aimed to identify factors associated with severe pathology and/or recurrence by studying the medical files of 767 patients admitted to the pediatric emergency department of a French university hospital for a BRUE. ResultsOverall, 255 files were studied; 45 patients had a recurrence and 23 patients had a severe diagnosis. The most frequently found etiology was gastroesophageal reflux in the benign diagnosis group and apnea or central hypoventilation in the severe diagnosis group. Prematurity (p = 0.032) and time since last meal >1 h (p = 0.019) were the main factors associated with severe disease. Most of the routine examination results remained non-contributive to the etiology. ConclusionAs prematurity is a factor associated with severe diagnosis, special attention should be given to this population, without subjecting them to multiple tests, since the main complication was found to be apnea or central hypoventilation. Prospective research is needed to establish the usefulness and prioritization of diagnostic tests for infants who are at “high risk” of experiencing a BRUE.

The American Academy of Pediatrics (AAP) higher-risk criteria for brief resolved unexplained events (BRUE) have a low positive predictive value (4.8%) and misclassify most infants as higher risk (>90%). New BRUE prediction rules from a US cohort of 3283 infants showed improved discrimination; however, these rules have not been validated in an external cohort. To externally validate new BRUE prediction rules and compare them with the AAP higher-risk criteria. This was a retrospective multicenter cohort study conducted from 2017 to 2021 and monitored for 90 days after index presentation. The setting included infants younger than 1 year with a BRUE identified through retrospective chart review from 11 Canadian hospitals. Study data were analyzed from March 2022 to March 2024. The BRUE prediction rules. The primary outcome was a serious underlying diagnosis, defined as conditions where a delay in diagnosis could lead to increased morbidity or mortality. Of 1042 patients (median [IQR] age, 41 [13-84] days; 529 female [50.8%]), 977 (93.8%) were classified as higher risk by the AAP criteria. A total of 79 patients (7.6%) had a serious underlying diagnosis. For this outcome, the AAP criteria demonstrated a sensitivity of 100.0% (95% CI, 95.4%-100.0%), a specificity of 6.7% (95% CI, 5.2%-8.5%), a positive likelihood ratio (LR+) of 1.07 (95% CI, 1.05-1.09), and an AUC of 0.53 (95% CI, 0.53-0.54). The BRUE prediction rule for discerning serious diagnoses displayed an AUC of 0.60 (95% CI, 0.54-0.67; calibration intercept: 0.60), which improved to an AUC of 0.71 (95% CI, 0.65-0.76; P < .001; calibration intercept: 0.00) after model revision. Event recurrence was noted in 163 patients (15.6%). For this outcome, the AAP criteria yielded a sensitivity of 99.4% (95% CI, 96.6%-100.0%), a specificity of 7.3% (95% CI, 5.7%-9.2%), an LR+ of 1.07 (95% CI, 1.05-1.10), and an AUC of 0.58 (95% CI, 0.56-0.58). The AUC of the prediction rule stood at 0.67 (95% CI, 0.62-0.72; calibration intercept: 0.15). Results of this multicenter cohort study show that the BRUE prediction rules outperformed the AAP higher-risk criteria on external geographical validation, and performance improved after recalibration. These rules provide clinicians and families with a more precise tool to support decision-making, grounded in individual risk tolerance.

American Academy of Pediatrics released a clinical practice guideline (CPG) in 2016 recommending the term apparent life-threatening events (ALTE) be replaced by brief resolved unexplained events (BRUE). The CPG provides recommendations for the clinical evaluation and management of infants with this condition based on the risk of a serious underlying disorder or repeat event. The lower-risk CPG was applied to a modelled population, studying predictors of hospital admission, defined as length of stay (LOS)≥24hours. An algorithm was derived using a Pediatric Emergency Care Applied Research Network database. Propensity score weighting, based on probability of following the CPG, determined the adjusted odds ratio (aOR) and 95% confidence interval (CI) of hospital admission. Multiple imputation allowed any missing data problems be addressed and a sensitivity analysis of database robustness. Applying the modelling algorithm, 3116 observations were identified, among whom 1974 (63.4%) the CPG was followed and 1142 (36.6%) not followed. The CPG was followed for 60.1% of infants staying ≥24hours compared with 76.6% of infants staying <24hours (P<.001). After propensity score weighting and multiple imputation, the likelihood of hospital admission was significantly lower when the CPG was followed (aOR=0.49; 95% CI, 0.39-0.62, P<.001). Results suggest that use of the CPG under strict conditions would lead to fewer hospital admissions among infants with a lower-risk BRUE. Implementation of CPGs in modelled populations may help clinicians identify unanticipated factors and address these issues beforehand. We noted differences in care based on race, necessitating further investigation.

Aortopexy is the most common surgical intervention for pediatric tracheomalacia (TM). The thoracoscopic approach, despite being reported by a few authors, remains controversial due to the different reported techniques and outcomes.We report a retrospective review of our preliminary experience with thoracoscopic aortopexy from 2023 to date. Patients' demographic data and symptoms were collected: age and weight at surgery, comorbidities, presence of brief resolved unexplained event (BRUE), dyspnea, chest infections, and barking cough. The study describes our surgical technique and its evolution. We analyzed the clinical outcome and endoscopic improvement, success and complication rate, operative time, and length of stay. We then compared our findings with the results of open and thoracoscopic aortopexy reported in the current literature.A total of 12 thoracoscopic aortopexies were performed on 10 patients (including two redo). The mean age and weight at operation were 3.2 years (range: 4 months-6 years) and 13.6 kg (range: 3.5-23), respectively. Two patients presented with BRUE, one with dyspnea, in the other cases the indications were recurrent pneumonia (more than six per year or three in 6 months). All patients underwent preoperative flexible bronchoscopy for the diagnosis of TM. The average estimated tracheal collapse was 86% (range: 70-95%). One intraoperative bleeding caused a conversion to open surgery, but no other complications occurred. All patients were extubated on the same day. Two cases required a redo due to suture tearing, and one of them required an additional posterior tracheopexy for persistent symptoms. The remaining patients had significant improvement on follow-up: success rate is 75%. Both patients requiring redo underwent aortopexy without pledgeted sutures or innominate artery (IA) suspension: these steps are associated with a success rate of 88.9% (p = 0.0182). Our refined technique now includes total thymectomy, pericardiotomy, pledgeted horizontal mattress sutures on the aorta, and the IA after full mobilization of the innominate vein.Thoracoscopic aortopexy appears to be a feasible and effective option for pediatric TM, particularly when replicating open surgical principles. Further research is needed to optimize the technique and improve the clinical results.

<abstract><title><italic>Abstract. </italic></title> Daily body weight gains are an important indicator for the evaluation of beef production. The objective of this study was to verify the quality and detection abilities of selected data mining methods (artificial neural networks and decision trees) applied to the analysis of daily body weight gains in beef heifers. A total of 261 individuals (Charolais, Charolais × Simmental and Charolais × Hereford) were genotyped and their daily body weight gains were recorded. The genetic analysis included polymorphic variants of leptin, myostatin, and prion protein genes. The animals were divided into two categories: those with daily body weight gains equal to or lower than the mean for the analyzed population (99 heifers) and those with daily body weight gains higher than the mean (112 heifers). Heifer birth weight, breed, birth season, dam body weight at calving, calving interval, and genotypes were used as predictors. From among the analyzed models, the neural network with 8 neurons in a single hidden layer (root mean squared error equal to 0.4471) and the tree with an error coefficient of 0.4076 were selected. These classifiers correctly detected 20 out of 27 heifers with daily body weight gains below the mean. In the case of heifers with daily body weight gains above the mean, neural networks correctly classified 17 out of 23 individuals, whereas decision tree only 14. Breed, leptin genotype and combined genotype turned out to be the most important variables contributing to the determination of body weight gains class for both types of classifiers.

Impact of cria protection strategy on post-natal survival and growth of alpacas (Vicugna pacos)

A 2×4 factorial arrangement was performed including two levels of garlic powder (0 and 0.5%) and four levels of lead acetate (0, 300, 600 and 900 mg/kg diet).One hundred twenty unsexed 1-week-old Ross broiler chicks were randomly distributed to 8 dietary treatment groups (15 birds each).Each treatment was subdivided to 3 replicates and each replicate contained 5 chicks.Growth performance and carcass traits were studied.Obtained results showed that final live body weight, daily body weight gain, feed conversion ratio and survival rate were significantly (p<0.01)improved while, daily feed intake was significantly (p<0.01)decreased with dietary garlic supplementation.Lead acetate significantly (p< 0.01) impaired live body weight, body weight gain and feed conversion.The interaction between lead levels and garlic supplementation showed that dietary garlic supplementation reversed these deleterious effects of lead intoxication on growth performance traits.Giblets percentage was significantly decreased with dietary supplementation by garlic and lead acetate at different levels, while, carcass and dressing were not affected significantly.These results suggested that garlic supplementation at 0.5% in broiler chicks diets can promotes growth performance traits and reverse the inhibitory effects of lead intoxication on such traits.

Proportional Partnership Format of Animal Husbandry Department of Kupang State Agricultural Polytechnic is be applied in pigs fattening in order to improve feed management and maintenance of pigs at Syaloom Farmers Group in Tuatuka Kelurahan of East Kupang. This experiment aims to determine the effect(s) of Poliagro complete feed on linear body sizes (body length, chest circumference, height) and daily body weight gain between female and male pigs. Experimental farm method was used in the experiment in which 10 pigs are used (consist of 3 males and 7 females). Data was analysis using descriptive statistics and t-student test to compare variables of both groups by using IBM-SPSS software version 21. The results showed that after 5 months, the average linear sizes of male group (body length, chest circumference and height) were 29.33 ± 0.57; 77.67 ± 2.51 and 94.33 ± 4.04in sequentially order. While the linear sizes of the female pig's were 27.67 ± 1.53; 75.67 ± 3.21and 90.67 ± 1.52. The mean of daily weight gain of male pigs was 0.49 ± 0.01 kg/head/day and the females ones 0.46 ± 0.02 kg/head/day. Statistical analysis showed that there were no differences in linear body sizes and daily body weight gain between male and female pigs that were fed Poliagro pellet fee.

The study was conducted to evaluate the effect of supplementing Lactobacillus casei and vitamin C on growth performance of New Zealand White rabbits affected by heat stress during summer seasons between March and May in Kerala state, India. Twenty four two month old rabbits (average body weight 0.91kg) were distributed to four groups of six rabbits each. The treatments were control group (C) fed basal diet alone, L group fed basal diet along with Lactobacillus casei (106 colony forming units per g of feed), V group fed basal diet along with ascorbic acid (200 mg per kg feed), and LV group fed basal diet along with L. casei and ascorbic acid at the same rate as in V and L. The Temperature humidity index (THI) values in the rabbitry and rabbit fecal cortisol values (n=6 per group) were estimated to assess the heat stress level in rabbits. As per THI values, animals were exposed to stress (THI > 27.8) in the afternoon hours during the entire experimental period. The V, L and VL rabbits had lower mean cortisol level than control during the period of very severe and severe heat stress (1-9th experimental week- March and April). The groups did not differ for body weights during the period of very severe and severe heat stress (March and April). The V, L and VL rabbits had similar 21 week final weights but those of the L and VL rabbits were 25.52% and 32.29% higher than the control. The rabbits in the V, L and VL group showed 38.51%, 49.19% and 61.13% (P<0.05) higher overall mean daily body weight gain and 23.89%, 31.48%, 40.33% higher overall mean feed efficiency than the control. Dietary supplementation of the probiotic or ascorbic acid did not affect (P>0.05) the overall feed intake. Cost of production (Rupees) per kilogram live weight on feed basis was lowest for VL animals followed by L and V animals respectively.