Development of Guidelines for Skeletal Survey in Young Children With Fractures

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Rates of performing skeletal survey (SS) for young children presenting with fractures and at risk for abuse vary substantially across providers, with disparities associated with patients' characteristics. Lack of consensus regarding indications for SS also contributes to this variation. WHAT THIS STUDY ADDS:The results of this study provide a set of explicit consensus guidelines, based on the literature and on the knowledge of experts from several medical specialties, for identifying children with fractures who should undergo an initial SS.abstract OBJECTIVE: To develop guidelines for performing initial skeletal survey (SS) in children ,24 months old with fractures, based on available evidence and collective judgment of experts from diverse pediatric specialties. METHODS:Following the Rand/UCLA Method, a multispecialty panel of 13 experts applied evidence from a literature review combined with their own expertise in rating the appropriateness of performing an SS for 525 clinical scenarios involving fractures in children ,24 months old. After discussion on the initial ratings, panelists rerated SS appropriateness for 240 revised scenarios and deemed that SSs were appropriate in 191 scenarios. The panelists then assessed in which of those 191 scenarios SSs were not only appropriate, but also necessary. RESULTS:Panelists agreed that SS is "appropriate" for 191 (80%) of 240 scenarios rated and "necessary" for 175 (92%) of the appropriate scenarios. Skeletal survey is necessary if a fracture is attributed to abuse, domestic violence, or being hit by a toy. With few exceptions, SS is necessary in children without a history of trauma. In children ,12 months old, SS is necessary regardless of the fracture type or reported history, with rare exceptions. In children 12 to 23 months old, the necessity of obtaining SS is dependent on fracture type. CONCLUSIONS:A multispecialty panel reached agreement on multiple clinical scenarios for which initial SS is indicated in young children with fractures, allowing for synthesis of clinical guidelines with the potential to decrease disparities in care and increase detection of abuse. Pediatrics 2014;134:45-53

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.…”

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

“…Details on the application of the Rand methodology to identify scenarios in which SSs are inappropriate, appropriate, or necessary for children ,2 years was previously described by Wood and colleagues. 17 The Rand methodology, a modified Delphi process, informs clinical decision-making by combining expert opinion with evidence from the literature to qualify the benefit-harm ratio of tests and screening procedures for varying clinical scenarios. Unlike similar consensus methods, Rand methodology provides the experts with an opportunity to discuss their judgments, and has been shown to have high content, construct, and predictive validities for developing appropriateness criteria.…”

“…21 Per Rand protocol, we (1) compiled literature reviews on bruising, SSs, and suspected abuse; (2) generated a set of clinical scenarios characterizing children with bruising for whom SS might be considered; and (3) convened a panel of medical experts (Fig 1). 17 The subsequent sequential phases of scenario rating are as follows: (1) panelists rated the appropriateness of SS for each clinical scenario (Round 1); (2) panelists reviewed the Round 1 ratings and made revisions to scenarios during a moderated discussion; (3) panelists re-rated the appropriateness of SS for the revised scenarios (Round 2); (4) we categorized SS as appropriate, uncertain, or inappropriate for respective scenarios based on Round 2 ratings; (5) panelists rated the necessity of SS in scenarios for which SS was categorized as appropriate (Round 3); and (6) we categorized scenarios for which SS was deemed appropriate as necessary or unnecessary for SS based on Round 3 ratings. The Children's Hospital of Philadelphia's Institutional Review Board exempted this study as non-human subjects research.…”

“…Figure previously published in Wood et al 17 Based on consensus at the conference, we modified some bruise location categories. We also condensed groups of multiple scenarios with similar ratings into single scenarios.…”

Evaluation of Child Maltreatment in the Emergency Department Setting

“…The AAP recently published consensus guidelines on when a skeletal survey is necessary, and comments that it is always reasonable to obtain the films if suspicion is high. 47 Cases of confessed abuse, injury during domestic violence, delayed care, or injury attributed to impact from a toy or other object should prompt a skeletal survey on an age-dependent basis.…”