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OBJECTIVES: Only 4% of brief resolved unexplained events (BRUE) are caused by a serious underlying illness. The American Academy of Pediatrics (AAP) guidelines do not distinguish patients who would benefit from further investigation and hospitalization. We aimed to derive and validate a clinical decision rule for predicting the risk of a serious underlying diagnosis or event recurrence. METHODS: We retrospectively identified infants presenting with a BRUE to 15 children’s hospitals (2015–2020). We used logistic regression in a split-sample to derive and validate a risk prediction model. RESULTS: Of 3283 eligible patients, 565 (17.2%) had a serious underlying diagnosis (n = 150) or a recurrent event (n = 469). The AAP’s higher-risk criteria were met in 91.5% (n = 3005) and predicted a serious diagnosis with 95.3% sensitivity, 8.6% specificity, and an area under the curve of 0.52 (95% confidence interval [CI]: 0.47–0.57). A derived model based on age, previous events, and abnormal medical history demonstrated an area under the curve of 0.64 (95%CI: 0.59–0.70). In contrast to the AAP criteria, patients >60 days were more likely to have a serious underlying diagnosis (odds ratio:1.43, 95%CI: 1.03–1.98, P = .03). CONCLUSIONS: Most infants presenting with a BRUE do not have a serious underlying pathology requiring prompt diagnosis. We derived 2 models to predict the risk of a serious diagnosis and event recurrence. A decision support tool based on this model may aid clinicians and caregivers in the discussion on the benefit of diagnostic testing and hospitalization (https://www.mdcalc.com/calc/10400/brief-resolved-unexplained-events-2.0-brue-2.0-criteria-infants).

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Rat bite fever is a systemic illness most commonly caused by Streptobacillus moniliformis that is classically characterized by fever, rash and migratory polyarthritis. Here, we highlight the highly variable clinical presentations of rat bite fever in children and the importance of maintaining a high degree of suspicion so appropriate treatment can be promptly initiated.