Does cardiopulmonary resuscitation cause rib fractures in children? A systematic review☆
Section snippets
Background
Fractured ribs in children less than 3 years old have a high specificity for child abuse (Barsness et al., 2003, Bulloch et al., 2000; Cadzow & Armstrong, 2000; Garcia, Gotschall, Eichelberger, & Bowman, 1990; Leventhal, Thomas, Rosenfield, & Markowitz, 1993; McClelland & Heiple, 1982; Schweich & Fleisher, 1985; Strouse & Owings, 1995; Thomas, 1977). One study gives a positive predictive value of 95% that a rib fracture in children less than 3 years of age is an indicator of abuse (Barsness et
Objectives
The purpose of this study was thus to conduct a systematic review to address the following questions: (i) Does cardiopulmonary resuscitation cause rib fractures in children? (ii) If so, what are the frequency and characteristics of these fractures, and can they be differentiated from rib fractures arising from physical child abuse?
Criteria for considering studies for this review
The inclusion criteria were studies of children aged up to 18 years:
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with no underlying bone disease;
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who had external closed cardiac massage (CPR);
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where the occurrence of associated rib fractures was recorded.
We excluded review articles, expert opinion, consensus guidelines, and studies that were significantly methodologically flawed on critical appraisal. We also excluded studies with mixed adult and child subjects where the paediatric data could not be separated.
Search strategy
We conducted a literature
Description of studies
At the end of the review process, six studies met the inclusion criteria and had satisfactorily excluded important confounders, such as pre-existing bone disease, as listed above (Betz & Liebhardt, 1994; Bush, Jones, Cohle, & Johnson, 1996; Feldman & Brewer, 1984; Price, Rush, Perper, & Bell, 2000; Ryan, Young, & Wells, 2003; Spevak, Kleinman, Belanger, Primack, & Richmond, 1994). These studies, which are summarised in Table 2, represent data on a total of 923 children aged 0–14 years.
Methodological quality
The
Discussion
Individual studies within this review demonstrate that 98–100% of children who undergo cardiopulmonary resuscitation do not develop rib fractures as a consequence.
The retrospective nature, the small numbers of cases included to detect a rare complication, and the different methods used to identify rib fractures in the individual studies contribute to considerable heterogeneity, and are limitations to the final conclusions of the systematic review. The population of interest is children under 3
Acknowledgements
The authors thank our specialist reviewers: M. Barber, P. Barnes, M. Bhal, A. Butler, J. Bowen, R. Brooks, S. Datta, R. Frost, C. Graham, S. Harrison, M. James-Ellison, A. Maddocks, S. Morris, A. Mott, A. Naughton, C. Norton, H. Payne, L. Price, I. Prosser, P. Thomas, E. Webb, C. Woolley.
References (42)
- et al.
Pediatric injuries from cardiopulmonary resuscitation
Annals of Emergency Medicine
(1996) - et al.
Paediatric life support. An advisory statement by the paediatric life support working group of the international liaison committee on resuscitation
Resuscitation
(1997) Unexplained pneumoperitoneum in association with basic cardiopulmonary resuscitation efforts
Resuscitation
(1993)- ASSIA...
- et al.
The positive predictive value of rib fractures as an indicator of nonaccidental trauma in children
Journal of Trauma: Injury, Infection and Critical Care
(2003) - et al.
Rib fractures in children—resuscitation or child abuse?
International Journal of Legal Medicine
(1994) - et al.
Cause and clinical characteristics of rib fractures in infants
Pediatrics
(2000) - et al.
Rib fractures in infants: Red alert! The clinical features, investigations and child protection outcomes
Journal of Paediatrics and Child Health
(2000) - Caredata...
- ChildDate...
Child abuse, cardiopulmonary resuscitation and rib fractures
Pediatrics
Rib fractures in children: a marker of severe trauma
The Journal of Trauma
Characteristics of child abuse by anteroposterior manual compression versus cardiopulmonary resuscitation: case reports
American Journal of Forensic Medicine and Pathology
Oblique radiographs of the chest in nonaccidental trauma
Emergency Radiology
Mechanical factors associated with posterior rib fractures: laboratory and case studies
Pediatric Radiology
Factors affecting visualization of posterior rib fractures in abused infants
American Journal of Roentgenology
Fractures of the rib head in abused infants
Radiology
Post-mortem diagnosis and age estimation of infants’ fractures
International Journal of Legal Medicine
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This work was supported by the National Society for the Prevention of Cruelty to Children (UK).