Skeletal Surveys in Young Infants with Bruising: An Opportunity to Improve Quality of Care
Kristin G Crichton1, Sandra Spencer1, Kathi Makoroff2, Eugene Izsak3, Paul McPherson4, Lori Vavul-Roediger5, Grace Kim6, Jonathan Thackeray5
1Nationwide Children's Hospital, Columbus, OH;2Cincinnati Children's Hospital Medical Center, Cincinnati, OH;3Promedica Toledo Children's Hospital, Toledo, OH;4Akron Children's Hospital, Akron, OH;5Dayton Children's Hospital, Dayton, OH;6UH Rainbow Babies and Children’s Hospital, Cleveland, OH
Background (issue): Sentinel injuries, minor injuries in infants concerning for non-accidental trauma, appear more frequently in children who are victims of abuse. Bruising has been reported to be the most common type of sentinel injury and the workup, when bruising is identified, is extremely variable. Despite the American Academy of Pediatrics’ recommendations, providers do not consistently obtain skeletal surveys on young infants with bruising to identify occult fractures. We aim to determine which patient factors, if any, are associated with completion of a skeletal survey in infants less than six months of age who present with bruising.
Methods: Six children’s hospitals identified all patients under the age of six months with bruising via a retrospective chart review. Demographic and clinical data were collected for each patient, including whether or not a skeletal survey was completed.
Findings: A total of 367 infants younger than six months old with bruising were identified, 142 (38.7%) of which had skeletal surveys completed. Infants who had skeletal surveys were significantly younger, more likely to have public insurance, and more likely to be seen in the emergency department than infants who did not.
Conclusions (implications for practice): Fewer than 40% of infants with bruises had a skeletal survey completed with significant disparities based on age, insurance status, and site of evaluation. Provider bias in the evaluation of infants with bruising may lead to missed abuse. This study highlights an opportunity to improve medical provider education on the approach to infants with bruising and thus improve detection of potential child abuse.
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