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ARTICLES: Joanne N. Wood, Cindy W. Christian, Cynthia M. Adams, and David M. Rubin Skeletal Surveys in Infants With Isolated Skull Fractures Pediatrics 2009; 123: e247-e252 [Abstract] [Full text] [PDF]

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Please Do Not Stop Performing Skeletal Surveys or Making Referrals to Child Protective Services in I

Rachel P. Berger, Daniel M. Lindberg, Brigham & Women's Hospital   (9 March 2009)

Please Do Not Stop Performing Skeletal Surveys or Making Referrals to Child Protective Services

Rachel P. Berger, Daniel Lindberg   (13 March 2009)

Please Do Not Stop Performing Skeletal Surveys or Making Referrals to Child Protective Services in I 9 March 2009
Rachel P. Berger, Pediatrician Children's Hospital of Pittsburgh, Daniel M. Lindberg, Brigham & Women's Hospital Send letter to journal: Re: Please Do Not Stop Performing Skeletal Surveys or Making Referrals to Child Protective Services in I rachel.p.berger{at}gmail.com Rachel P. Berger, et al.	We read with interest the recent study by Dr. Wood and colleagues related to the use of skeletal surveys in infants with isolated skull fractures.1 Their goals of decreasing radiation risk, cost and the stress associated with referrals to Child Protective Services (CPS) are laudable, but we are very concerned that the conclusions as stated in the abstract and summary boxes are not supported by their data. If these recommendations were incorporated into clinical practice, they could potentially place infants at risk. Based on the results of their study, the authors conclude that ‘skeletal surveys rarely added additional information beyond the history and physical findings, to support a report to child protective services.’ The issue of whether or not to report cases to child protective services (CPS) was not the question addressed by the authors. The authors sought to answer the question of how often a skeletal survey demonstrated additional fractures in infants with a known skull fracture. If the authors had found that the rate of additional fractures identified by skeletal survey was high, one might reasonably conclude that isolated skull fractures in infants have a high rate being inflicted. The converse is not true - a low rate of additional fractures does not imply that skull fractures in infants are rarely, if ever, due to abuse. The way in which the conclusion is stated has a danger of being misinterpreted by the casual reader who could easily imply that if an infant with a skull fracture has a normal skeletal survey, there is no need to report the case to CPS. Despite years of education, the myth persists that a referral to CPS is equivalent to a diagnosis of child abuse. This belief not only minimizes the investigative function of CPS, it prevents doctors from reporting even when the concern for abuse is high.2 A report to CPS is statement of a concern for abuse and a request for further assessment. This assessment almost always includes a visit to the home, an evaluation of the siblings, and a check of whether there have been prior concerns of abuse or neglect. None of this information is available to the physician, yet all can be critical in making an assessment about whether or not an infant with a skull fracture is safe and whether or not the injury is likely to be the result of abuse. Clearly, it is not necessary for CPS to be notified of every infant with a skull fracture, but neither should a report be limited to infants with other fractures seen on skeletal survey - as implied by the abstract. We are also very concerned by the statement that ‘in infants with simple or complex skull fractures….skeletal surveys…may not be warranted.’ The authors analyzed a sample of 40 0-3 month olds, 42 3-9 month olds and 42 9-12 month olds. The possibility of a skull fracture being the result of an accident in a walking 11-month who falls down the stairs is far different than the same skull fracture an 11-week old without a history of trauma. With this sample size, the upper limit of the 95% CI is 4% if there are no cases in a given age group and 7% if there is one case. In a brief review of cases at Children’s Hospital of Pittsburgh, the rate of additional fractures on skeletal survey in infants meeting the same inclusion criteria was 3.5% (3/86). The question of whether an incidence of 3 or 4%, for example, justifies performing a given test is complex. A low incidence alone is not enough to state that the screening test is not warranted. The proportion of lumbar punctures which reveal bacterial meningitis, for example, is below 3% as is the proportion of head CTs in children with mild head trauma which show significant intracranial injury. It is highly unlikely, however, that we would recommend limiting the number of lumbar punctures or head CTs because of a single study which identified several high risk characteristics of the children with a positive screening test. The risk of re-abuse, re-injury and/or death in an infant with missed abuse is well-recognized.3, 4 Given this risk, the standard for limiting the performance of skeletal surveys in infants with skull fractures, should be no different than our standard for other medical conditions with similarly severe complications if the diagnosis is missed. We agree with authors that there may well be ways to identify the subset of infants who do not need to undergo skeletal survey - and indeed the fact that only 41% of infants with a skull fracture underwent skeletal survey suggests that physicians may already have identified these children. We disagree, however, with the conclusions stated in the abstract and summary box and strongly believe that the results of this study are inadequate to recommend a change in practice and have the potential to put infants at risk. References: 1. Wood JN, Christian CW, Adams CM, Rubin DM. Skeletal surveys in infants with isolated skull fractures. Pediatrics 2009;123(2):e247-52. 2. Flaherty EG, Sege RD, Griffith J, et al. From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics 2008;122(3):611-9. 3. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. Jama 1999;281(7):621-6. 4. Alexander R, Crabbe L, Sato Y, Smith W, Bennett T. Serial abuse in children who are shaken. Am J Dis Child 1990;144(1):58-60. Conflict of Interest: None declared
Please Do Not Stop Performing Skeletal Surveys or Making Referrals to Child Protective Services 13 March 2009
Rachel P. Berger, Pediatrician Children's Hospital of Pittsburgh, Daniel Lindberg Send letter to journal: Re: Please Do Not Stop Performing Skeletal Surveys or Making Referrals to Child Protective Services rachel.p.berger{at}gmail.com Rachel P. Berger, et al.	We read with interest the recent study by Dr. Wood and colleagues related to the use of skeletal surveys in infants with isolated skull fractures.1 Their goals of decreasing radiation risk, cost and the stress associated with referrals to Child Protective Services (CPS) are laudable, but we are very concerned that the conclusions as stated in the abstract and summary boxes are not supported by their data. If these recommendations were incorporated into clinical practice, they could potentially place infants at risk. Based on the results of their study, the authors conclude that ‘skeletal surveys rarely added additional information beyond the history and physical findings, to support a report to child protective services.’ The issue of whether or not to report cases to child protective services (CPS) was not the question addressed by the authors. The authors sought to answer the question of how often a skeletal survey demonstrated additional fractures in infants with a known skull fracture. If the authors had found that the rate of additional fractures identified by skeletal survey was high, one might reasonably conclude that isolated skull fractures in infants have a high rate being inflicted. The converse is not true - a low rate of additional fractures does not imply that skull fractures in infants are rarely, if ever, due to abuse. The way in which the conclusion is stated has a danger of being misinterpreted by the casual reader who could easily imply that if an infant with a skull fracture has a normal skeletal survey, there is no need to report the case to CPS. Despite years of education, the myth persists that a referral to CPS is equivalent to a diagnosis of child abuse. This belief not only minimizes the investigative function of CPS, it prevents doctors from reporting even when the concern for abuse is high.2 A report to CPS is statement of a concern for abuse and a request for further assessment. This assessment almost always includes a visit to the home, an evaluation of the siblings, and a check of whether there have been prior concerns of abuse or neglect. None of this information is available to the physician, yet all can be critical in making an assessment about whether or not an infant with a skull fracture is safe and whether or not the injury is likely to be the result of abuse. Clearly, it is not necessary for CPS to be notified of every infant with a skull fracture, but neither should a report be limited to infants with other fractures seen on skeletal survey - as implied by the abstract. We are also very concerned by the statement that ‘in infants with simple or complex skull fractures….skeletal surveys…may not be warranted.’ The authors analyzed a sample of 40 0-3 month olds, 42 3-9 month olds and 42 9-12 month olds. The possibility of a skull fracture being the result of an accident in a walking 11-month who falls down the stairs is far different than the same skull fracture an 11-week old without a history of trauma. With this sample size, the upper limit of the 95% CI is 4% if there are no cases in a given age group and 7% if there is one case. In a brief review of cases at Children’s Hospital of Pittsburgh, the rate of additional fractures on skeletal survey in infants meeting the same inclusion criteria was 3.5% (3/86). The question of whether an incidence of 3 or 4%, for example, justifies performing a given test is complex. A low incidence alone is not enough to state that the screening test is not warranted. The proportion of lumbar punctures which reveal bacterial meningitis, for example, is below 3% as is the proportion of head CTs in children with mild head trauma which show significant intracranial injury. It is highly unlikely, however, that we would recommend limiting the number of lumbar punctures or head CTs because of a single study which identified several high risk characteristics of the children with a positive screening test. The risk of re-abuse, re-injury and/or death in an infant with missed abuse is well-recognized.3, 4 Given this risk, the standard for limiting the performance of skeletal surveys in infants with skull fractures, should be no different than our standard for other medical conditions with similarly severe complications if the diagnosis is missed. We agree with authors that there may well be ways to identify the subset of infants who do not need to undergo skeletal survey - and indeed the fact that only 41% of infants with a skull fracture underwent skeletal survey suggests that physicians may already have identified these children. We disagree, however, with the conclusions stated in the abstract and summary box and strongly believe that the results of this study are inadequate to recommend a change in practice and have the potential to put infants at risk. References: 1. Wood JN, Christian CW, Adams CM, Rubin DM. Skeletal surveys in infants with isolated skull fractures. Pediatrics 2009;123(2):e247-52. 2. Flaherty EG, Sege RD, Griffith J, et al. From suspicion of physical child abuse to reporting: primary care clinician decision-making. Pediatrics 2008;122(3):611-9. 3. Jenny C, Hymel KP, Ritzen A, Reinert SE, Hay TC. Analysis of missed cases of abusive head trauma. Jama 1999;281(7):621-6. 4. Alexander R, Crabbe L, Sato Y, Smith W, Bennett T. Serial abuse in children who are shaken. Am J Dis Child 1990;144(1):58-60. Conflict of Interest: None declared