Development of Hospital-Based Guidelines for Skeletal Survey in Young Children With Bruises

Abstract

OBJECTIVE: To develop guidelines for performing an initial skeletal survey (SS) for children ,24 months of age presenting with bruising in the hospital setting, combining available evidence with expert opinion. METHODS:Applying the Rand/UCLA Appropriateness Method, a multispecialty panel of 10 experts relied on evidence from the literature and their own clinical expertise in rating the appropriateness of performing SS for 198 clinical scenarios characterizing children ,24 months old with bruising. After a moderated discussion of initial ratings, the scenarios were revised. Panelists re-rated SS appropriateness for 219 revised scenarios. For the 136 clinical scenarios in which SS was deemed appropriate, the panel finally assessed the necessity of SS.RESULTS: Panelists agreed that SS is "appropriate" for 62% (136/219) of scenarios, and "inappropriate" for children $12 months old with nonpatterned bruising on bony prominences. Panelists agreed that SS is "necessary" for 95% (129/136) of the appropriate scenarios. SS was deemed necessary for infants ,6 months old regardless of bruise location, with rare exceptions, but the necessity of SS in older children depends on bruise location. According to the panelists, bruising on the cheek, eye area, ear, neck, upper arm, upper leg, hand, foot, torso, buttock, or genital area necessitates SS in children ,12 months. CONCLUSIONS:The appropriateness and necessity of SS in children presenting for care to the hospital setting with bruising, as determined by a diverse panel of experts, depends on age of the child and location of bruising. WHAT'S KNOWN ON THIS SUBJECT:Bruising is common in young victims of physical abuse as well as in cases of accidental trauma. There is uncertainty regarding which young children with bruising require evaluation with skeletal survey for possible abuse. WHAT THIS STUDY ADDS:The results of this study provide guidelines, based on the literature and knowledge of experts, for identifying children ,24 months presenting for care in the hospital setting with bruises, who should and should not undergo skeletal survey.

Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage

“…13 This methodology was previously used to identify scenarios in which SS is appropriate and necessary for children <2 years old with fractures or bruises. 14,15 RAM is a modified Delphi process that informs clinical decision-making by combining the evidence from a systematic review of the literature with clinical expertise to determine the benefitharm ratio of tests and screening procedures for various clinical scenarios. Unlike similar consensus methods, RAM provides experts with an opportunity to discuss their clinical judgments with each other and modify scenarios accordingly.…”

Home accident or physical abuse: Evaluation of younger children presenting with trauma, burn and poisoning in the Pediatric Emergency Department

“…The frequency of abuse alters between 18-24% in patients with trauma in different studies. 11,14,15 These studies focused on more well-known trauma such as head trauma and fractures related to abuse; however, in our study, not only traumas but also burns and poisonings that might be related to abuse were taken into consideration. Gencer et al 13 found the rate of the suspected abuse or definitive abuse as 16% investigating the abuse in any kind of home accidents including falling down, foreign object ingestion, intoxication, burn, electrical shock and others.…”

“…For all these reasons, training the physicians dealing with children will improve their ability in diagnosing the abuses in the early period and may reduce the recurrences and deaths. [9][10][11] In recent medical literature, medical evaluation of child abuse has received careful consideration because of specialists' increased awareness. [1][2][3]5,9 When abuse is suspected concerning the patients' history and/or physical examination, patients should be evaluated by screening methods, and they should be directed to the specialists.…”

Kindesmisshandlung aus pädiatrischer Sicht

“…beeinträch-tigen) unterschieden werden. Bestimmte Formen der Kindesmisshandlung haben als spezifische Syndrome Eingang in die medizinische Fachliteratur gefunden ("Battered Child-Syndrom", "Shaken Baby Syndrome" (SBS) und das "Münchhausen-by-proxy-Syndrom" [8, 22,23] Bei Kopfverletzungen ist im Notfall immer die zerebrale Computertomographie (cCT) die Methode der ersten Wahl; in weniger dringlichen Fällen kann bzw. sollte eine cerebrale Kernspintomografie (cMRT) zur Reduktion der Strahlenbelastung durchgeführt werden.…”