Adequacy of the Diagnostic Workup of Suspected Physical Abuse in Young Children: An Audit in the Paris Metropolitan Area
Background: When child physical abuse (CPA) is suspected in young children, an adequate diagnostic workup is crucial to confirm the diagnosis and to rule out other possible causes. To standardize and optimize the diagnostic workup of CPA, academic societies and health agencies have developed national and international clinical guidelines. These guidelines notably recommend systematically performing 3 key tests when CPA is suspected: a radiological skeletal survey in all young children under 2 years old, head computed tomography or magnetic resonance imaging, and an eye fundus examination when abusive head trauma is suspected, in children < 1 to 2 years old, depending on the guidelines. Additional tests are recommended, for example to investigate bone fragility or bleeding disorders, to explore alternative explanations for the injuries. However, studies in North America and surveys in Europe, including France, have shown that adherence to these guidelines varies. We aimed to audit the actual practices in Paris area hospitals and evaluate their adherence to current clinical guidelines.
Methods: We used specific discharge codes suggesting CPA in the Assistance Publique-Hôpitaux de Paris clinical data warehouse to identify children under 2 years old hospitalized for suspected CPA in 2018–19 in 7 university hospitals. We systematically reviewed the electronic medical records to confirm the suspected CPA. We then compared the observed proportion of tests performed to what is expected according to national and international guidelines.
Results: Among the 97 included children (median age 5 months), 60% had intracranial injuries, 40% skin injuries, and 30% skeletal injuries; 8% died. At least one of the key recommended tests was not performed in 14 (14%) of children. Bone metabolism tests (to investigate bone fragility) were performed in 33% of the 43 children with at least one unexplained fracture. Coagulation tests were performed in 82% of the 76 children with bruises or internal bleeding.
Conclusions: Practices observed in the Paris metropolitan university hospitals for the diagnostic workup for suspected CPA were better than those reported in other studies but not always consistent with guidelines. Obstacles to the complete implementation of guidelines, such as physician’s nonadherence, must be identified and overcome.
https://www.sciencedirect.com/science/article/pii/S1876285925000919
By Flora Blangis
Photo credit: Renaud, Insights Imaging 2013
