Revised Pediatric Guidelines Aid Radiologists in Detecting Child Abuse

Radiologists facing the grim task of assessing potential child abuse now have newly revised imaging guidelines as part of a new policy statement from the American Academy of Pediatrics (AAP) that more closely mirror recommendations from the American College of Radiology (ACR).

Paul K. Kleinman, M.D. Harvard Medical School

Alan S. Brody, M.D. University of Cincinnati College of Medicine

Caroline L. Hollingsworth, M.D., M.P.H. Duke University Medical Center

The 2009 AAP policy statement, "Diagnostic Imaging of Child Abuse," published in the May issue of the AAP journal, Pediatrics, was updated from the association's 2000 policy based on newer research and clinical experience, according to lead author Paul K. Kleinman, M.D., a professor of radiology at Harvard Medical School and director of musculoskeletal imaging at Children's Hospital, both in Boston. For example, new research was the impetus for new recommendations to include oblique views of the ribs to check for fractures, said Dr. Kleinman.

"A major objective of the updated version is to bring the views and recommendations in line with those of the ACR so that there is consistency," said Dr. Kleinman, an internationally recognized expert in pediatric radiology and the detection of child abuse.

The revised document also serves as a reminder of the importance of imaging in identifying the extent of physical injury when abuse is present and the necessity of elucidating all of the imaging findings that may point to an alternative diagnosis. The guidelines also emphasize the importance of close collaboration between clinician and radiologist.

"Doctors are obligated to check for abuse," said AAP statement co-author, Alan S. Brody, M.D., a professor of radiology and pediatrics at the University of Cincinnati College of Medicine and Cincinnati's Children's Hospital and Medical Center. "Questions about radiation exposure may come up. The decision to use ionizing radiation is a risk/benefit decision. The risk of cancer from a series of radiographs is extremely small. Determining whether or not someone is physically harming a child is a huge and potentially life-saving benefit."

Specifically, the updated AAP guidelines examine the use of CT, ultrasonography and MR imaging for head trauma, CT for potential abdominal trauma and the pros and cons of radiographs, CT and MR imaging for spine injuries. The review also discusses guidelines for radionuclide bone scans.

Digital Impact Acknowledged

One major change between 2000 and 2009 has been the migration from radiographs to PACS. While there were fundamental principles guiding the radiographic skeletal survey with film screen technique, "there are many more variations with digital, such as adjusting the blackness or the whiteness of the picture, which was not something you could do with film screen radiographs," Dr. Kleinman said.

The newly revised AAP recommendations, that mirror ACR standards and appropriateness criteria, charge radiology departments with providing an adequate level of diagnostic detail at the lowest radiation dose possible.

"Digital offers attractive options when it comes to brightness, magnification and the ability to share pictures with colleagues, but there is also more latitude in deciding on an appropriate technique," Dr. Kleinman said.

Dr. Brody said using PACS does not change the requirement for high-detail images. This allows radiologists to identify and interpret injuries correctly so that a child is not put back into an abusive situation and caretakers are not falsely accused of abuse.

Radiology is Important Piece of Complex Puzzle

Dr. Kleinman said the revised AAP guidelines enhance radiology's connection to a new subspecialty recently approved by AAP, child abuse pediatricians, which "has given us a new opportunity to build consensus," he said. "Working closely with radiologists, these physicians strive to find an accurate diagnosis for the protection of children at risk and assist social and legal bodies of assessment.

"Child abuse is a complex problem," Dr. Kleinman added. "It is challenging to be able to make an accurate diagnosis and differentiate from conditions that may simulate or mimic it, as in cases of bone disease, and exclude them."

"Radiologists see patterns of injury that correlate with abuse," said Caroline L. Hollingsworth, M.D., M.P.H., an assistant professor of radiology and pediatrics at Duke University Medical Center in Durham, N.C., and chair of the pediatrics subcommittee of the RSNA Education Exhibits Committee. "We can offer a very important piece of the puzzle."

Imaging can play an important role in what she said is an underreported issue. For example, radiology can help with general dating of some injuries. When radiologists are asked to estimate when an injury occurred, "We can say: 'It's older than two weeks,' but we can't say 'Last Thursday,'" said Dr. Hollingsworth.

Radiologists must remind others of the judicious use of CT and try not to over-image children when the suspicion of child abuse is low, Dr. Hollingsworth said. Radiologists also must be aware of potential diseases that mimic abuse, as in cases of bone disease, and exclude them. "We can help clinicians guide those parents," Dr. Hollingsworth said.

Clinician, Radiologist Collaboration Urged

In the revised guidelines, researchers emphasize the importance of close collaboration between clinician and radiologist and stress that diagnostic imaging of suspected inflicted injury in infancy and childhood should be performed with at least the same rigor used in evaluating accidental trauma and naturally occurring disease.

"To be confident that the imaging studies are acquired and interpreted in a thorough and informed manner, clinicians charged with reporting and providing evidence in cases of suspected abuse should work in close collaboration with radiologists experienced in pediatric imaging," the authors concluded.

Dr. Brody said he thinks the revised AAP document is so important that it should be posted on radiologists' walls so they can refer to it on a regular basis.

"These are guidelines for events that, happily, don't come up that often in general practice. They should be handy when needed," he said.