title: Development of hospital-based guidelines for skeletal survey in young children with bruises.
abstract: 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.
authors.affiliation: Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Leonard Davis Institute of Health Economics and Departments of Pediatrics and woodjo@email.chop.edu.
authors.forename: Joanne N
authors.initials: JN
authors.lastname: Wood
authors.affiliation: Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and.
authors.forename: Oludolapo
authors.initials: O
authors.lastname: Fakeye
authors.affiliation: Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and.
authors.forename: Valerie
authors.initials: V
authors.lastname: Mondestin
authors.affiliation: Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Leonard Davis Institute of Health Economics and Departments of Pediatrics and.
authors.forename: David M
authors.initials: DM
authors.lastname: Rubin
authors.affiliation: Biostatistics and Epidemiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Russell
authors.initials: R
authors.lastname: Localio
authors.affiliation: Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Leonard Davis Institute of Health Economics and Departments of Pediatrics and.
authors.forename: Chris
authors.initials: C
authors.lastname: Feudtner
mesh_terms: D001930:Brain Injuries / Q000175:diagnosis* / Q000209:etiology*; D002140:California; D002648:Child; D002649:Child Abuse / Q000175:diagnosis*; D003288:Contusions / Q000175:diagnosis* / Q000209:etiology*; D003299:Cooperative Behavior; D003697:Delphi Technique; D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital; D005260:Female; D050723:Fractures, Bone / Q000175:diagnosis* / Q000209:etiology*; D006748:Hospital Departments; D006785:Hospitals, University; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D033183:Interdisciplinary Communication; D008297:Male; D010372:Pediatrics; D010808:Physical Examination / Q000379:methods*; D015397:Program Evaluation; D014947:Wounds and Injuries / Q000175:diagnosis / Q000209:etiology
keywords: bruise; child abuse; child maltreatment; skeletal survey; trauma