, et al
Parental recognition of shunt failure: a prospective single-institution study
J Neurosurg Pediatr.
; doi:

Investigators from the University of Alabama and the Children’s Hospital of Alabama sought to evaluate parental ability to predict cerebrospinal fluid (CSF) shunt failure. They prospectively asked the parents of children with CSF shunts for hydrocephalus if they thought the shunt was failing at the time of presentation to the emergency department (ED), neurosurgery clinic, or inpatient neurosurgery consultation service. A diagnosis of shunt malfunction was either confirmed intraoperatively or excluded if the shunt was not revised within 1 week of presentation. For the analysis, the predictive ability of parental assessment was compared to that of CT or radiographic shunt series. In addition, the assessments by “experienced” parents – those with children with at least 3 previous shunt malfunctions – was compared to those by parents whose child had fewer shunt failures.

Data were collected on a total of 199 encounters in 149 parent-child dyads; a shunt failure was diagnosed at 71 encounters (35.7%). Parental predictions of shunt failure had a positive predictive value (PPV) of 41%, negative predictive value (NPV) of 79%, sensitivity of 83%, specificity of 34%, and accuracy of 52%. The assessments of “experienced” parents of 63 children were significantly worse, with a PPV of 29% and accuracy of 41%. Parental prediction was significantly inferior to head CT and shunt series (PPV 84%, NPV 85%, specificity 88%, accuracy 85%).

The authors conclude that although parents had difficulty diagnosing shunt failure, the high NPV and sensitivity of parental prediction may make parental response a clinically useful screening tool to rule out shunt failure.

Dr Bollo has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.

CSF shunts have a high rate of failure, and shunt malfunction is associated with significant morbidity if it is not diagnosed and treated rapidly. Shunt malfunction is a common diagnostic challenge facing pediatricians, ED physicians, and pediatric neurosurgeons. Head CT and shunt series are normal or unchanged in a significant proportion of patients. There is no “gold-standard” test to establish the diagnosis. Parents of children with shunts are often asked by practitioners to not simply report signs and symptoms but also interpret them in the context of past experience with an individual patient.

The present study demonstrates that parents are better at ruling out shunt malfunction than predicting it. Parental impression demonstrated a high sensitivity but low specificity for shunt failure. Of interest, the predictions of “experienced” parents were significantly less accurate than those of “inexperienced” parents, although sensitivity to detection of shunt failure increased with parental experience. This contrasts with work by Kim and colleagues, likely reflecting methodological differences between the 2 studies. Kim et al used a visual-analog scale for parents that was...

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