Related Experiment Video
Updated: Mar 24, 2026
Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation
Published on: October 15, 2021
Development of Guidelines for Skeletal Survey in Young Children With Intracranial Hemorrhage
Christine Weirich Paine1, Philip V Scribano2, Russell Localio3
1Division of General Pediatrics and PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and painec@email.chop.edu.
Insights
Skeletal surveys are recommended for nearly all young children with intracranial hemorrhage to detect abuse-related injuries. These guidelines aim to reduce variations in evaluating these critical cases.
Area of Science:
- Pediatric Medicine
- Radiology
- Forensic Medicine
Background:
- Intracranial hemorrhage (ICH) in young children presents diagnostic challenges.
- There is significant variation in the use of skeletal surveys (SS) for evaluating additional injuries.
- Guidelines are needed to standardize SS evaluation for ICH in children under 24 months.
Purpose of the Study:
- To develop guidelines for initial skeletal survey (SS) in children under 24 months with ICH.
- To combine existing literature evidence with expert opinion for SS appropriateness.
- To address uncertainty in identifying children with ICH who require SS for abuse-related injuries.
Main Methods:
- Utilized the RAND/UCLA Appropriateness Method with a 12-expert multispecialty panel.
- Rated the appropriateness of SS for 216 scenarios involving children <24 months with ICH.
- Revised and re-rated 74 scenarios after moderated discussion to determine necessity of SS.
Main Results:
- Skeletal survey (SS) was deemed appropriate in 85% of scenarios and necessary in all appropriate cases.
- SS is necessary for infants <6 months and children <24 months with non-tiny subdural hemorrhage and skull fracture.
- Necessity of SS for epidural hemorrhage in children 6-23 months depends on age, trauma history, and clinical presentation.
Conclusions:
- Clinical guidelines support near-universal SS evaluation for children under 24 months with ICH.
- Implementation of these detailed, validated guidelines may reduce care variations and disparities.
- Standardized evaluation protocols are crucial for accurate diagnosis and management of pediatric ICH.
Background And Objective:
As evidenced by the variation and disparities in evaluation, there is uncertainty in determining which young children with intracranial hemorrhage (ICH) should undergo evaluation with skeletal survey (SS) for additional injuries concerning for abuse. We aimed to develop guidelines for performing initial SS in children <24 months old presenting with ICH by combining available evidence from the literature with expert opinion.
Methods:
Using the RAND/UCLA Appropriateness Method, a multispecialty panel of 12 experts used the literature and their own clinical expertise to rate the appropriateness of performing SS for 216 scenarios characterizing children <24 months old with ICH. After a moderated discussion of initial ratings, the scenarios were revised. Panelists re-rated SS appropriateness for 74 revised scenarios. For the 63 scenarios in which SS was deemed appropriate, the panel rated the necessity of SS.
Results:
Panelists concluded that SS is appropriate for 85% (63), uncertain for 15% (11), and inappropriate for 0% of scenarios. Panelists determined that SS is necessary in all scenarios deemed appropriate. SS was deemed necessary for infants <6 months old and for children <24 months old with subdural hemorrhage that is not tiny and under a skull fracture. For children 6 to 23 months old with epidural hemorrhage, necessity of SS depended on the child's age, history of trauma, signs/symptoms, and ICH characteristics.
Conclusions:
The resulting clinical guidelines call for near-universal evaluation in children <24 months old presenting with ICH. Detailed, validated guidelines that are successfully implemented may decrease variation and disparities in care.
