Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Gastroesophageal reflux 
Treatment: Inpatient stay 

Summary: The patient is a female infant. She presented to the ED at five weeks of age for evaluation of apnea. The day prior while sitting in a sling, she turned purple and became unresponsive for a few seconds. She had been fed fifteen minutes prior. She presented to the ED at that time where she was monitored for an hour and then discharged. She was taken to the pediatric clinic where her physical examination was unremarkable and she was sent home. In the afternoon, she had another episode of turning purple while being held, just after feeding, lasting a few seconds. She was taken back to the same ED where she was monitored and discharged. She presented to the second ED later in the day for additional evaluation. 

The patient's laboratory studies revealed mild metabolic acidosis (CO2 [carbon dioxide] 21), normal glucose (91), normal WBC (white blood cell) count (6.5), and urinalysis only with large blood. Overnight, she had multiple episodes of spitting up. She also had not had a bowel movement for three days until a large stool was passed in the morning following a glycerine suppository. The spitting up episodes were considered likely secondary to gastroesophageal reflux, so the mother was encouraged to decrease the frequency of feedings and thicken them. 

BRUE, or brief resolved unexplained event, has replaced the term ALTE, or acute life-threatening event. It is defined as brief self-resolved event occurring in an infant less than a year of age, associated with one or more of the following: cyanosis or pallor; absent, decreased, or irregular breathing; marked change in tone; and/or altered level of responsiveness. BRUE is a diagnosis of exclusion. Infants that present for evaluation can be categorized as either high risk or low risk based on careful and detailed history and physical exam. Any abnormalities on exam may place the infant into a higher risk category, with consideration for child abuse if there are inconsistencies in the story or exam, cardiac arrhythmia in the presence of positive family history, and infection if there is fever. 

To be considered lower risk, the infant must be older than 60 days, gestational age greater than or equal to 32 weeks and post-conceptional age greater than or equal to 45 weeks, this must be the first event, the event must have lasted less than a minute, not requiring CPR, with no concerning historical or exam findings. While hospitalization overnight or longer for monitoring and evaluation may not be indicated for lower risk infants, hospitalization and further testing may be indicated for high risk infants. Concerning signs that would warrant hospitalization include toxic appearance, lethargy or respiratory distress at the time of the event, bruising or other evidence of trauma, history of multiple events in the past 24 hours, history of clinically significant events or unexpected death of a sibling, history that raises suspicion for the possibility of child maltreatment, and dysmorphic features or known syndrome. 

This infant presented to the hospital for evaluation after two brief episodes of turning purple after feeding. She had been to multiple institutions prior and discharged. She was admitted for evaluation following a mini sepsis work-up. The results were not available until after admission, but were benign. After observation in the hospital, the BRUE was considered most likely secondary to be the result of gastroesophageal reflux. Symptoms of spitting up were significant improved after changes were made to her feedings. She was discharged after a period of observation. Based on the risk criteria above, she would be considered low risk. While it was not unreasonable to monitor her in the hospital, she was overall hemodynamically stable with no evidence of impending sepsis, and did not require acute inpatient admission. She could have been safely managed at a lower level of care such as observation.