Adequacy of the Diagnostic Workup of Suspected Physical Abuse in Young Children: An Audit in the Paris Metropolitan Area

Abstract

Objective

An adequate diagnostic workup of suspected child physical abuse (CPA) is crucial for an accurate diagnosis and to consider differential diagnoses. We aimed to audit the actual practices in Paris area hospitals and evaluate their adherence to current clinical guidelines.

Methods

We used specific discharge codes suggesting CPA in the Assistance Publique-Hôpitaux de Paris clinical data warehouse to identify cases of young children <2 years old hospitalized for suspected CPA in 2018–19 in 7 university hospitals. We systematically reviewed the electronic medical records to confirm the suspected CPA. We compared the observed proportion of the diagnostic tests performed to that expected according to current national and international clinical guidelines.

Results

Among the 97 included children (median age 5 months), 60% had intracranial injuries, 40% skin injuries, and 30% skeletal injuries; 8% died. At least one of the key diagnostic tests (radiological skeletal survey, eye fundus examination, and head computed tomography or magnetic resonance imaging) expected to be performed systematically according to guidelines was not performed in 14 (14%) of children. Bone metabolism investigation was performed in 33% of the 43 children with ≥1 unexplained fracture(s). Hemostasis and coagulation investigations were performed in 82% of the 76 children with bruises or internal bleeding.

Conclusions

Practices observed in the Paris area university hospitals for the diagnostic workup of suspected CPA were not always consistent with guidelines, thus leading to risk of misdiagnosis. Obstacles to the complete implementation of guidelines, such as physician’s nonadherence, must be identified and overcome.