Abstract
The highly variable practices observed regarding the early detection and diagnostic workup of suspected child physical abuse contribute to suboptimal care and could be partially related to discrepancies in clinical guidelines. To systematically evaluate the completeness, clarity, and consistency of guidelines for child physical abuse in high-income countries. For this systematic review, national or regional guidelines that were disseminated from 2010 to 2020 related to the early detection and diagnostic workup of child physical abuse in infants aged 2 years or younger by academic societies or health agencies in high-income countries were retrieved. The definitions of sentinel injuries and the recommended diagnostic workup (imaging and laboratory tests) for child physical abuse were compared. Data were analyzed from July 2020 to February 2021. Within the 20 included guidelines issued in 15 countries, 168 of 408 expected statements (41%) were missing and 10 statements (4%) were unclear. Among 16 guidelines characterizing sentinel injuries, all of them included skin injuries, such as bruises, hematoma, or burns, but only 8 guidelines (50%) included intraoral injuries and fractures. All 20 guidelines agreed on the indication for radiological skeletal survey, head computed tomography, and head magnetic resonance imaging but differed for those of bone scintigraphy, follow-up skeletal survey, spinal magnetic resonance imaging, cranial ultrasonography, chest computed tomography, and abdominal ultrasonography and computed tomography. Additionally, 16 guidelines agreed on exploring primary hemostasis and coagulation but not on the tests to perform, and 8 guidelines (50%) mentioned the need to investigate bone metabolism. These findings suggest that guidelines for the diagnosis of child physical abuse in infants were often clear but lacked completeness and were discrepant on major issues. These results may help identify priorities for well-designed original diagnostic accuracy studies, systematic reviews, or an international consensus process to produce clear and standardized guidelines to optimize practices and infant outcomes.
Highlights
Physical abuse is estimated to occur in 4% to 16% of the population younger than 18 years in highincome countries,[1] and the World Health Organization has considered child physical abuse (CPA) an international priority and has developed a vast program of CPA prevention.[2]
16 guidelines agreed on exploring primary hemostasis and coagulation but not on the tests to perform, and 8 guidelines (50%) mentioned the need to investigate bone metabolism. These findings suggest that guidelines for the diagnosis of child physical abuse in infants were often clear but lacked completeness and were discrepant on major issues
Early detection of CPA based on sentinel injuries,[14] alone or interpreted with the help of clinical decision rules, such as the TEN-4 rule,[15] and accurate diagnostic workup with imaging and laboratory tests are of paramount importance
Summary
Physical abuse is estimated to occur in 4% to 16% of the population younger than 18 years in highincome countries,[1] and the World Health Organization has considered child physical abuse (CPA) an international priority and has developed a vast program of CPA prevention.[2]. To help physicians optimize the detection and diagnosis of CPA and consider differential diagnoses, clinical guidelines have been developed by academic societies and health agencies. Despite these efforts at standardization, several studies reported suboptimal practices by health care practitioners. Our objective was to systematically investigate the completeness, clarity, and consistency of clinical guidelines for the early detection and diagnostic workup of CPA that were issued by academic societies and health agencies in high-income countries
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