Standard protocol requires radiologists to perform both skull radiography and volume CT imaging on pediatric patients with suspected nonaccidental injuries (NAIs), but the former technique could be outdated and more trouble than it’s worth, U.K.-based researchers reported this March.

Guidelines for the radiologic investigation of children with NAIs were implemented by the Royal College of Radiologists and the Royal College of Paediatrics and Child Health in 2008, but the decade of space between the issuing of those guidelines and present-day imaging capabilities means procedures have evolved, corresponding author Ruth E. Brown and colleagues wrote in Clinical Radiology. Still, clinicians stick to the 2008 guidelines, which stipulate that pediatric patients presenting with suspected NAIs must undergo a skeletal survey that includes both a skull x-ray and CT brain exam.

“The references provided for this statement are from studies performed in 1980 and 1986,” Brown and co-authors said in the study. “Since this time, there have been radical changes in CT imaging, including the introduction of volumetric CT imaging as standard practice on CT head studies nationally. With the advances in CT imaging quality, is it still necessary to perform both CT and radiographic imaging of the skull?”

Though children with suspected NAI typically present with bruising and cutaneous injury, it’s common to see skeletal injuries in the emergency department, too, Brown et al. wrote. Radiological imaging is a key tool—especially in children under 2 years old—for diagnosing the source and severity of those injuries.

Skull x-rays can be beneficial in some cases—in one meta-analysis, the sensitivity and specificity of a skull radiograph for predicting the presence of intracranial hemorrhage was 38 percent and 95 percent, respectively. But those statistics pale in comparison to the sensitivity and specificity specs of computed tomography, which are approaching 100 percent.

The researchers conducted a study comprising 94 patients, all between 24 days and 23 months old, who came to their hospital’s emergency department between August 2014 and July 2016. All children were victims in investigations for suspected NAI, and clinicians followed 2008 protocol in each case, using both CT scans and skull radiography to identify injuries.

According to the study, Brown’s team found no additional findings on skull x-rays that hadn’t already been identified with CT imaging. Since no single case showed an added benefit from skull radiographs, though, the authors were unable to statistically prove radiographs were an irrelevant addition to the process.

“Did skull radiograph imaging provide clinical diagnoses that were missed with contemporaneous CT?” Brown and colleagues wrote. “The present findings support the theory that skull radiographs do not identify any skull fractures that cannot be identified already with CT, and thus there is no clinically significant advantage of the inclusion of skull radiographs in the skeletal survey.”

The authors said more research is needed to draw more definitive conclusions.