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

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.