Source: Weihmiller SN, Buonomo C, Bachur R. Risk stratification of children being evaluated for intussusception. Pediatrics. 2011; 127(2): e296– e303; doi: 10.1542/peds.2010-2432To determine risk factors for intussusception and to develop a clinical decision tree, investigators from Children’s Hospital, Boston performed a prospective cohort study. Children ages 1 month to 6 years presenting to the emergency department (ED) with suspected intussusception between December 2008 and January 2010 were eligible for study enrollment. Treating physicians provided clinical evaluation and management and completed a standardized questionnaire regarding history and physical examination findings prior to the completion of advanced imaging (ultrasound, CT scan, or air enema) on study patients. Plain radiographs of the abdomen were categorized as positive, suspicious, or negative using predefined criteria. Intussusception was defined as visualization of the intussusception at air enema or operative intervention. Parents of children were contacted by telephone at least two weeks after the ED visit to confirm that no cases of intussusception were missed, and medical records were reviewed when telephone contact was not successful. Study data were entered in a recursive partitioning model for clinical decision tree development. (For an explanation of recursive partitioning, see AAP Grand Rounds, October 2009;22:39.) The goal of the analysis was to identify children at low risk for intussusception based on clinical findings.About 68% of eligible patients were enrolled during the study period. Data were analyzed on 310 enrolled children, 38 (12.3%) of whom had intussusception. Significant predictors of intussusception were male gender (P=.007), age over 6 months (P=.04), bilious emesis (P=.002), lethargy by history (P=.001), and positive or possibly positive abdominal radiographs (P<.001).These and other clinical findings were used for the clinical decision tree development. With this analysis, patients could be considered low risk if they were in one of two low risk categories: a) negative radiograph and age 5 months or younger (0/31 = 0%); or b) negative radiograph, age over 5 months, no bilious vomiting but with diarrhea (1/54 = 1.9%). This low risk rule had a sensitivity of 97% (95% CI, 86%–100%) and negative predictive value of 99% (95% CI, 93%–100%).The authors conclude that abdominal radiographs should be obtained for all children with possible intussusception, and that patients with certain clinical characteristics may be at low risk of intussusception.Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.Intussusception can be a challenging diagnosis because of the variable penetrance of clinical signs and symptoms.1 For pediatric providers, tools which aid in identification of children at low risk of intussusception could greatly assist with appropriate utilization of advanced imaging such as ultrasound, which is not available 24 hours per day at many facilities, or air contrast enema, which is invasive and requires the presence of a radiologist and availability of a pediatric surgeon.Other investigators have attempted to develop low risk prediction rules for intussusception using retrospective data, with limited success. 2,3 Although clinicians in the current study may have had knowledge of the abdominal radiographs (but not advanced imaging) prior to recording their clinical findings, the prospective design enhanced the ability to develop a clinical prediction algorithm. It is notable that the abdominal radiographs were interpreted by experienced pediatric radiologists who were not blinded to the patient’s clinical data.The evolution of quality clinical decision rules involves both development and validation.4 It is important to recognize that the 95% confidence intervals of the sensitivity and negative predictive values in the current study are wide. Due to the potential morbidity and mortality associated with intussusception, these decision rules require prospective validation, preferably with a larger sample of children in a variety of clinical settings, prior to clinical use. In the meantime, abdominal radiographs remain the key first step in determining the risk of intussusception in young children.While this report is thought-provoking, there are a few important caveats. First, 23% of the children with intussusception had negative radiographs, and 54% had only “suspicious” findings such as “paucity of bowel gas in a specific quadrant.” Second, since none of the 35 patients younger than 6 months had intussusception, the utility of the radiograph or other findings in this age group cannot adequately be tested. Finally, of the 275 children 6 months or older in whom intussusception was suspected, only 54 (20%) met the classification of “low risk,” and one of the items used to classify a patient as low risk, diarrhea, can be a nebulous component of the history. Thus, in most instances “ruling out” intussusception without “advanced imaging in a child at risk” will continue to be difficult.
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