A comparison of four different imaging modalities - Conventional, cross polarized, infra-red and ultra-violet in the assessment of childhood bruising.

BACKGROUND: It is standard practice to image concerning bruises in children. We aim to compare the clarity and measurements of bruises using cross polarized, infra-red (IR) and ultra-violet (UV) images to conventional images. METHODS: Children aged <11 years with incidental bruising were recruited. Demographics, skin and bruise details were recorded. Bruises were imaged by standard protocols in conventional, cross-polarized, IR and UV lights. Bruises were assessed in vivo for contrast, uniformity and diffuseness, and these characteristics were then compared across image modalities. Color images (conventional, cross polarized) were segmented and measured by ImageJ. Bruises of grey scale images (IR, UV) were measured by a 'plug in' of ImageJ. The maximum and minimum Feret's diameter, area and aspect ratio, were determined. Comparison of measurements across imaging modalities was conducted using Wilcoxon rank sum tests and modified Bland-Altman graphs. Significance was set at p < 0.05. RESULTS: Twenty five children had 39 bruises. Bruises that were of low contrast, i.e. difficult to distinguish from surrounding skin, were also more diffuse, and less uniformity in vivo. Low contrast bruises were best seen on conventional and cross-polarized images and less distinctive on IR and UV images. Of the 19 bruises visible in all modalities, the only significant difference was maximum and minimum Feret's diameters and area were smaller on IR compared to conventional images. Aspect ratios were not affected by the modality. CONCLUSIONS: Conventional and cross-polarized imaging provides the most consistent bruise measurement, particularly in bruises that are not easily distinguished from surrounding skin visually.

Optimising the measurement of bruises in children across conventional and cross polarized images using segmentation analysis techniques in Image J, Photoshop and circle diameter measurements.

BACKGROUND: Bruising is a common abusive injury in children, and it is standard practice to image and measure them, yet there is no current standard for measuring bruise size consistently. We aim to identify the optimal method of measuring photographic images of bruises, including computerised measurement techniques. METHODS: 24 children aged <11 years (mean age of 6.9, range 2.5-10 years) with a bruise were recruited from the community. Demographics and bruise details were recorded. Each bruise was measured in vivo using a paper measuring tape. Standardised conventional and cross polarized digital images were obtained. The diameter of bruise images were measured by three computer aided measurement techniques: Image J (segmentation with Simple Interactive Object Extraction (maximum Feret diameter), 'Circular Selection Tool' (Circle diameter), & the Photoshop 'ruler' software (Photoshop diameter)). Inter and intra-observer effects were determined by two individuals repeating 11 electronic measurements, and relevant Intraclass Correlation Coefficient's (ICC's) were used to establish reliability. Spearman's rank correlation was used to compare in vivo with computerised measurements; a comparison of measurement techniques across imaging modalities was conducted using Kolmogorov-Smirnov tests. Significance was set at p < 0.05 for all tests. RESULTS: Images were available for 38 bruises in vivo, with 48 bruises visible on cross polarized imaging and 46 on conventional imaging (some bruises interpreted as being single in vivo appeared to be multiple in digital images). Correlation coefficients were >0.5 for all techniques, with maximum Feret diameter and maximum Photoshop diameter on conventional images having the strongest correlation with in vivo measurements. There were significant differences between in vivo and computer-aided measurements, but none between different computer-aided measurement techniques. Overall, computer aided measurements appeared larger than in vivo. Inter- and intra-observer agreement was high for all maximum diameter measurements (ICC's > 0.7). CONCLUSIONS: Whilst there are minimal differences between measurements of images obtained, the most consistent results were obtained when conventional images, segmented by Image J Software, were measured with a Feret diameter. This is therefore proposed as a standard for future research, and forensic practice, with the proviso that all computer aided measurements appear larger than in vivo.

Agents, mechanisms and clinical features of non-scald burns in children: A prospective UK study.

AIMS: To inform childhood burn prevention by identifying demographics, clinical features and circumstances of unintentional non-scald burns. METHODS: A prospective cross-sectional study was conducted across Cardiff, Bristol and Manchester, including six emergency departments, three minor injury units and one burns unit between 13/01/2013-01/10/2015. Data collected for children aged <16 years with any burn (scald, contact, flame, radiation, chemical, electrical, friction) included: demographics, circumstances of injury and clinical features. Scalds and burns due to maltreatment were excluded from current analysis. RESULTS: Of 564 non-scald cases, 60.8% were boys, 51.1% were <3 years old, 90.1% (472/524) of burns affected one anatomical site. Contact burns accounted for 86.7% (489/564), 34.8% (137/394) of which were from objects placed at >0.6m and 76.5% (349/456) affected the hands. Hairstyling devices were the most common agent of contact burns (20.5%, 100/487); 34.1% (30/88) of hairstyling devices were on the floor. Of children aged 10-15 years, 63.7% (65/102), sustained contact burns of which 23.2% (13/56) were preparing food, and when burnt from hairstyling devices, 73.3% (11/15) were using them at the time of injury. CONCLUSIONS: Parents of toddlers must learn safe storage of hazardous items. Older children should be taught skills in safe cooking and hairstyling device use.

Ask Me! self-reported features of adolescents experiencing neglect or emotional maltreatment: a rapid systematic review.

BACKGROUND: Neglect is often overlooked in adolescence, due in part to assumptions about autonomy and misinterpretation of behaviors being part of normal adolescent development. Emotional maltreatment (abuse or neglect) has a damaging effect throughout the lifespan, but is rarely recognized amongst adolescents. Our review aims to identify features that adolescents experiencing neglect and/ or emotional maltreatment report. METHOD: A rapid review methodology searched 8 databases (1990-2014), supplemented by hand searching journals, and references, identifying 2,568 abstracts. Two independent reviews were undertaken of 279 articles, by trained reviewers, using standardised critical appraisal. Eligible studies: primary studies of children aged 13-17 years, with substantiated neglect and/ or emotional maltreatment, containing self-reported features. RESULTS: 19 publications from 13 studies were included, demonstrating associations between both neglect and emotional maltreatment with internalising features (9 studies) including depression, post traumatic symptomatology and anxiety; emotional maltreatment was associated with suicidal ideation, while neglect was not (1 study); neglect was associated with alcohol related problems (3 studies), substance misuse (2 studies), delinquency for boys (1 study), teenage pregnancy (1 study), and general victimization for girls (1 study), while emotionally maltreated girls reported more externalising symptoms (1 study). Dating violence victimization was associated with neglect and emotional maltreatment (2 studies), while emotional abuse of boys, but not neglect, was associated with dating violence perpetration (1 study), and neither neglect nor emotional maltreatment had an association with low self-esteem (2 studies). Neither neglect nor emotional maltreatment had an effect on school performance (1 study), but neglected boys showed greater school engagement than neglected girls (1 study). CONCLUSIONS: If asked, neglected or emotionally maltreated adolescents describe significant difficulties with their mental health, social relationships, and alcohol or substance misuse. Practitioners working with youths who exhibit these features should recognize the detrimental impact of maltreatment at this developmental stage, and identify whether maltreatment is a contributory factor that should be addressed.

Head injury from falls in children younger than 6†years of age.

UNLABELLED: The risk of serious head injury (HI) from a fall in a young child is ill defined. The relationship between the object fallen from and prevalence of intracranial injury (ICI) or skull fracture is described. METHOD: Cross-sectional study of HIs from falls in children (<6 years) admitted to UK hospitals, analysed according to the object fallen from and associated Glasgow Coma Score (GCS) or alert, voice, pain, unresponsive (AVPU) and CT scan results. RESULTS: Of 1775 cases ascertained (median age 18 months, 54.7% boys), 87% (1552) had a GCS=15/AVPU=alert. 19.3% (342) had a CT scan: 32% (110/342) were abnormal; equivalent to 5.9% of the overall population, 16.9% (58) had isolated skull fractures and 13.7% (47) had ICI (49% (23/47) had an associated skull fracture). The prevalence of ICI increased with neurological compromise; however, 12% of children with a GCS=15/AVPU=alert had ICI. When compared to falls from standing, falls from a person's arms (233 children (mean age 1 year)) had a significant relative OR for a skull fracture/ICI of 6.94 (95% CI 3.54 to 13.6), falls from a building (eg, window or attic) (mean age 3 years) OR 6.84 (95% CI 2.65 to 17.6) and from an infant or child product (mean age 21 months) OR 2.75 (95% CI 1.36 to 5.65). CONCLUSIONS: Most HIs from a fall in these children admitted to hospital were minor. Infants, dropped from a carer's arms, those who fell from infant products, a window, wall or from an attic had the greatest chance of ICI or skull fracture. These data inform prevention and the assessment of the likelihood of serious injury when the object fallen from is known.

A systematic review of the emotional, behavioural and cognitive features exhibited by school-aged children experiencing neglect or emotional abuse.

BACKGROUND: Interventions to minimize the long-term consequences of neglect or emotional abuse rely on prompt identification of these children. This systematic review of world literature (1947-2012) identifies features that children aged 5-14 years experiencing neglect or emotional abuse, as opposed to physical or sexual abuse, may exhibit. METHODS: Searching 18 databases, utilizing over 100 keywords, supplemented by hand searching, 13,210 articles were identified and 111 underwent full critical appraisal by two independent trained reviewers. RESULTS: The 30 included studies highlighted behavioural features (15 studies), externalizing features being the most prominent (8/9 studies) and internalizing features noted in 4/6 studies. Four studies identified attention deficit hyperactivity disorder (ADHD) associated features: impulsivity, inattention or hyperactivity. Child difficulties in initiating or developing friendships were noted in seven studies. Of 13 studies addressing emotional well-being, three highlighted low self-esteem, with a perception of external control (1), or depression (6) including suicidality (1). A negative internal working model of the mother increased the likelihood of depression (1). In assessing cognition or academic performance, lower general intelligence (3/4) and reduced literacy and numeracy (2) were reported, but no observable effect on memory (3). CONCLUSIONS: School-aged children presenting with poor academic performance, ADHD symptomatology or abnormal behaviours warrant assessment of neglect or emotional abuse as a potential underlying cause.

Patterns of burns and scalds in children.

OBJECTIVE: To describe the characteristics of childhood burns and scalds, mechanisms and agents to inform prevention. METHODS: Prospective multicentred cross-sectional study of children (<16 years) with unintentional burns/scalds from five Emergency Departments (ED), a burns assessment unit and three regional children's Burns Units. DATA COLLECTED: site, severity, distribution of the burn/scald, age, motor development of the child, agent and mechanism of the injury. Comparative analysis for children <5 and 5-16 years. RESULTS: Of 1215 children, 58% (709) had scalds, 32% (390) contact burns and 116 burns from other causes, 17.6% (214/1215) were admitted to hospital and the remaining treated in ED or burns assessment centre. 72% (878) were <5 years, peak prevalence in 1-year-olds. Commonest scald agent (<5 years) was a cup/mug of hot beverage 55% (305/554), and commonest mechanism was a pull-down injury 48% (66/554). In 5-16-year-olds, scalds were from hot water 50% (78/155) and spill injuries 76% (118/155). Scalds affected the front of the body in 96% (680/709): predominantly to the face, arms and upper trunk in <5-year-olds, older children had scalds to the lower trunk, legs and hands. Contact burns (<5 years) were from touching 81% (224/277) hot items in the home, predominant agents: hair straighteners or irons 42% (117/277), oven hobs 27% (76/277), 5-16-year-olds sustained more outdoor injuries 46% (52/113). 67% (262/390) of all contact burns affected the hands. CONCLUSIONS: Scalds to infants and toddlers who pull hot beverages over themselves or sustain burns from touching irons, hair straighteners or oven hobs are a high priority for targeted prevention.

How much do parents know about first aid for burns?

BACKGROUND: Prompt first aid reduces burn morbidity. With an estimated 19,000 children attending emergency departments (ED) with a burn or scald every year in the UK, a parent's knowledge of first aid is particularly important. This study evaluates the extent and source of this knowledge. METHODS: Parents attending the emergency and antenatal departments of a University Hospital answered a structured questionnaire detailing demographics, knowledge of burns first aid and its source. Knowledge was stratified into 4 categories: contraindicated, poor, inadequate and adequate. Individual chi-squared tests and ordered logistic regressions were performed to relate knowledge to demographic features. RESULTS: The 106 respondents (44% men) reflected a wide range of socio-economic (SE) grouping and educational level. Overall 32% had an adequate knowledge of burns first aid while 43% had poor or no knowledge. There was no significant correlation between gender, educational status or age and knowledge; however those from higher SE groups (p<0.05) and those who had undergone first aid training (p<0.01) had greater knowledge. Among 40% of parents who had undergone first aid training, 74% had adequate knowledge. The logistic regression accounting for all significant variables showed that previous first aid training was the most influential factor in knowledge of first aid (p<0.001). Interestingly, although 2/3 of parents wanted further training, 75% of those who did not had poor or no first-aid knowledge. CONCLUSIONS: Overall, the knowledge of burns first aid among parents is inadequate and correlates with lower SE groups. There was a significant association between knowledge and previous first aid training. Results suggest that targeting burns first aid training to all new parents, particularly those in low income households, would be of value.

A systematic review of abusive visceral injuries in childhood--their range and recognition.

OBJECTIVES: To define what abusive visceral injuries occur, including their clinical features and the value of screening tests for abdominal injury among abused children. METHODS: We searched 12 databases, with snowballing techniques, for the period 1950-2011, with all identified studies undergoing two independent reviews by trained reviewers, drawn from pediatrics, radiology, pediatric surgery and pathology. Of 5802 studies identified, 188 were reviewed. We included studies of children aged 0-18, with confirmed abusive etiology, whose injury was defined by computed tomography, contrast studies or at surgery/post mortem. We excluded injuries due to sexual abuse, or those exclusively addressing management or outcome. RESULTS: Of 88 included studies (64 addressing abdominal injuries), only five were comparative. Every organ in the body has been injured, intra-thoracic injuries were commoner in those aged less than five years. Children with abusive abdominal injuries were younger (2.5-3.7 years vs. 7.6-10.3 years) than accidentally injured children. Duodenal injuries were commonly recorded in abused children, particularly involving the third or fourth part, and were not reported in accidentally injured children less than four years old. Liver and pancreatic injuries were frequently recorded, with potential pancreatic pseudocyst formation. Abdominal bruising was absent in up to 80% of those with abdominal injuries, and co-existent injuries included fractures, burns and head injury. Post mortem studies revealed that a number of the children had sustained previous, unrecognized, abdominal injuries. The mortality from abusive abdominal injuries was significantly higher than accidental injuries (53% vs. 21%). Only three studies addressed screening for abdominal injury among abused children, and were unsuitable for meta-analysis due to lack of standardized investigations, in particular those with 'negative' screening tests were not consistently investigated. CONCLUSIONS: Visceral injuries may affect any organ of the body, predominantly abdominal viscera. A non-motor vehicle related duodenal trauma in a child aged

Retinal haemorrhages and related findings in abusive and non-abusive head trauma: a systematic review.

AIM: To report the retinal signs that distinguish abusive head trauma (AHT) from non-abusive head trauma (nAHT). METHODS: A systematic review of literature, 1950-2009, was conducted with standardised critical appraisal. Inclusion criteria were a strict confirmation of the aetiology, children aged <11 years and details of an examination conducted by an ophthalmologist. Post mortem data, organic disease of eye, and inadequate examinations were excluded. A multivariate logistic regression analysis was conducted to determine odds ratios (OR) and probabilities for AHT. RESULTS: Of the 62 included studies, 13 provided prevalence data (998 children, 504 AHT). Overall, retinal haemorrhages (RH) were found in 78% of AHT vs 5% of nAHT. In a child with head trauma and RH, the OR that this is AHT is 14.7 (95% confidence intervals 6.39, 33.62) and the probability of abuse is 91%. Where recorded, RH were bilateral in 83% of AHT compared with 8.3% in nAHT. RH were numerous in AHT, and few in nAHT located in the posterior pole, with only 10% extending to periphery. True prevalence of additional features, for example, retinal folds, could not be determined. CONCLUSIONS: Our systematic review confirms that although certain patterns of RH were far commoner in AHT, namely large numbers of RH in both the eyes, present in all layers of the retina, and extension into the periphery, there was no retinal sign that was unique to abusive injury. RH are rare in accidental trauma and, when present, are predominantly unilateral, few in number and in the posterior pole.

Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review.

OBJECTIVES: To identify the evidence base behind the neuroradiological features that differentiate abusive head trauma (AHT) from non-abusive head trauma (nAHT). DESIGN: Systematic review. SETTING: Literature search of 14 databases, websites, textbooks, conference abstracts and references (1970-February 2010). Studies had two independent reviews (three if disputed) and critical appraisal. PATIENTS: Primary comparative studies of children <11 years old hospitalised with AHT and nAHT diagnosed on CT or MRI. MAIN OUTCOME MEASURES: Neuroradiological features that differentiated AHT from nAHT. RESULTS: 21 studies of children predominantly <3 years old were analysed. Subdural haemorrhages (SDH) were significantly associated with AHT (OR 8.2, 95% CI 6.1 to 11). Subarachnoid haemorrhages were seen equally in AHT and nAHT and extradural haemorrhages (EDH) were significantly associated with nAHT (OR for AHT 0.1, 95% CI 0.07 to 0.18). Multiple (OR 6, 95% CI 2.5 to 14.4), interhemispheric (OR 7.9, 95% CI 4.7 to 13), convexity (OR 4.9, 95% CI 1.3 to 19.4) and posterior fossa haemorrhages (OR 2.5, 95% CI 1 to 6) were associated with AHT. Hypoxic-ischaemic injury (HII) (OR 3.7, 95% CI 1.4 to 10) and cerebral oedema (OR 2.2, 95% CI 1.0 to 4.5) were significantly associated with AHT, while focal parenchymal injury was not a discriminatory feature. SDH of low attenuation were more common in AHT than in nAHT. CONCLUSION: Multiple SDH over the convexity, interhemispheric haemorrhages, posterior fossa SDH, HII and cerebral oedema are significantly associated with AHT and should be considered together with clinical features when identifying the condition.

What are the clinical and radiological characteristics of spinal injuries from physical abuse: a systematic review.

AIM: Systematic review of 'What are the clinical and radiological characteristics of inflicted spinal injury?' METHODS: Literature search of 20 electronic databases, websites, references and bibliographies (1950-2009) using selected keywords. Critical appraisal: by two trained reviewers, (a third review, if discrepant). INCLUSION CRITERIA: primary studies of inflicted spinal injury in children <18 years, alive at presentation, with a high surety of diagnosis of abuse and sufficient detail to analyse. RESULTS: 19 studies of 25 children were included. Twelve children (median age 5 months) had cervical injury. In seven cases, the clinical signs of spinal injury were masked by respiratory symptoms and impaired levels of consciousness; six of these children had coexistent inflicted head trauma. Twelve children had thoraco-lumbar injury (median age 13.5 months), 10/12 had lesions at T11-L2, and 9/12 had fracture dislocations. All children had focal signs: 10/12 had lumbar kyphosis or thoraco-lumbar swelling, and two had focal neurology. One child had cervical, thoracic and sacral injuries. CONCLUSIONS: Spinal injury is a potentially devastating inflicted injury in infants and young children. The published evidence base is limited. However, this case series leads us to recommend that any clinical or radiological indication of spinal injury warrants an MRI. In children undergoing brain MRI for abusive head trauma, consideration should be given to including an MRI of the spine. All skeletal surveys in children with suspected abuse should include lateral views of the cervical and thoraco-lumbar spine. Further prospective comparative studies would define the discriminating features of inflicted spinal injuries.

Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review.

AIM: A systematic review of the scientific literature to define clinical indicators distinguishing inflicted (iBI) from non-inflicted brain injury (niBI). METHODS: An all language literature search of 20 electronic databases, websites, references and bibliographies from 1970-2008 was carried out. Relevant studies were independently reviewed by two trained reviewers, with a third review where required. Inclusion criteria included primary comparative studies of iBI and niBI in children aged <18 years, with high surety of diagnosis describing key clinical features. Multilevel logistic regression analysis was conducted, determining the positive predictive value (PPV) and odds ratios (OR) with p values for retinal haemorrhage, rib/long bone/skull fractures, apnoea, seizures and bruising to head/neck. RESULTS: 8151 studies were identified, 320 were reviewed and 14 included, representing 1655 children, 779 with iBI. Gender was not a discriminatory feature. In a child with intracranial injury, apnoea (PPV 93%, OR 17.06, p<0.001) and retinal haemorrhage (PPV 71%, OR 3.504, p = 0.03) were the features most predictive of iBI. Rib fractures (PPV 73%, OR 3.03, p = 0.13) had a similar PPV to retinal haemorrhages, but there were less data for analysis. Seizures and long bone fractures were not discriminatory, and skull fracture and head/neck bruising were more associated with niBI, although not significantly so. CONCLUSIONS: This systematic review shows that apnoea and retinal haemorrhage have a high odds ratio for association with iBI. This review identifies key features that should be recorded in the assessment of children where iBI is suspected and may help clinicians to define the likelihood of iBI.

What neuroimaging should be performed in children in whom inflicted brain injury (iBI) is suspected? A systematic review.

AIMS: To investigate the optimal neuroradiological investigation strategy to identify inflicted brain injury (iBI). MATERIALS AND METHODS: A systematic review of studies published between 1970-2008 in any language was conducted, searching 20 databases and four websites, using over 100 keywords/phrases, supplemented by hand-searching of references. All studies underwent two independent reviews (with disagreements adjudicated by a third reviewer) by trained reviewers from paediatrics, paediatric neuroradiology and related disciplines, using standardized critical appraisal tools, and strict inclusion/exclusion criteria. We included primary studies that evaluated the diagnostic yield of magnetic resonance imaging (MRI), in addition to initial computed tomography (CT), or follow-up CT or ultrasound in children with suspected iBI. RESULTS: Of the 320 studies reviewed, 18 met the inclusion criteria, reflecting data on 367 children with iBI and 12 were published since 1998. When an MRI was conducted in addition to an abnormal early CT examination, additional information was found in 25% (95% CI: 18.3-33.16%) of children. The additional findings included further subdural haematoma, subarachnoid haemorrhage, shearing injury, ischaemia, and infarction; it also contributed to dating of injuries. Diffusion-weighted imaging (DWI) further enhanced the delineation of ischaemic changes, and assisted in prognosis. Repeat CT studies varied in timing and quality, and none were compared to the addition of an early MRI/DWI. CONCLUSIONS: In an acutely ill child, the optimal imaging strategy involves initial CT, followed by early MRI and DWI if early CT examination is abnormal, or there are ongoing clinical concerns. The role of repeat CT imaging, if early MRI is performed, is unclear, as is the place for MRI/DWI if initial CT examination is normal in an otherwise well child.

A systematic review of the features that indicate intentional scalds in children.

BACKGROUND: Most intentional burns are scalds, and distinguishing these from unintentional causes is challenging. AIM: To conduct a systematic review to identify distinguishing features of intentional and unintentional scalds. METHODS: We performed an all language literature search of 12 databases 1950-2006. Studies were reviewed by two paediatric/burns specialists, using standardised methodology. Included: Primary studies of validated intentional or accidental scalds in children 0-18 years and ranked by confirmation of intentional or unintentional origin. Excluded: neglectful scalds; management or complications; studies of mixed burn type or mixed adult and child data. RESULTS: 258 studies were reviewed, and 26 included. Five comparative studies ranked highly for confirmation of intentional/unintentional cause of injury. The distinguishing characteristics were defined based on best evidence. Intentional scalds were commonly immersion injuries, caused by hot tap water, affecting the extremities, buttocks or perineum or both. The scalds were symmetrical with clear upper margins, and associated with old fractures and unrelated injuries. Unintentional scalds were more commonly due to spill injuries of other hot liquids, affecting the upper body with irregular margins and depth. CONCLUSIONS: We propose an evidence based triage tool to aid in distinguishing intentional from unintentional scalds, requiring prospective validation.

Which radiological investigations should be performed to identify fractures in suspected child abuse?

AIMS: To determine which radiological investigations should be performed and which children should be investigated. MATERIALS AND METHODS: An all language literature search of original articles; from 1950-October 2005. Two reviewers independently reviewed each article. A third was carried out on disagreement. Each study was assessed using standardised data extraction, critical appraisal and evidence forms. RESULTS: Thirty-four studies were included. Fifteen addressed the question: which investigation has a higher yield, skeletal surveys (SS) or bone scintigraphy (BS)? Studies gave conflicting results. Overall neither investigation is as good as the two combined. BS predominately missed skull, metaphyseal and epiphyseal fractures, whereas SS commonly missed rib fractures. Two studies showed that a repeat SS 2 weeks after the initial study provided significant additional information about tentative findings, the number and age of fractures. A comparative study evaluated additional oblique views of ribs in 73 children and showed improved diagnostic sensitivity, specificity and accuracy. Four studies addressed the diagnostic yield for occult fractures with respect to age. This was significant for children under 2-years old. CONCLUSIONS: In children under 2-years old, where physical abuse is suspected, diagnostic imaging of the skeleton should be mandatory. SS or BS alone is inadequate to identify all fractures. It is recommended that all SS should include oblique views of the ribs. This review suggests that the following options would optimize the diagnostic yield. However, each needs to be evaluated prospectively: SS that includes oblique views, SS and BS, a SS with repeat SS or selected images 2 weeks later or a BS plus skull radiography and coned views of metaphyses and epiphyses.

Are abused babies protected from further abuse?

A cohort of 69 physically abused babies under 1 year was followed for three years after the incident. Of the 49 babies who returned home following child protection investigations, 15 were further abused in the three year period, a re-abuse rate of 31%, which is grossly higher than the abuse rate in the general population.

Apnoea and brain swelling in non-accidental head injury.

AIMS: (1) To identify whether infants and young children admitted to hospital with subdural haematomas (SDH) secondary to non-accidental head injury (NAHI), suffer from apnoea leading to radiological evidence of hypoxic ischaemic brain damage, and whether this is related to a poor prognosis; and (2) to determine what degree of trauma is associated with NAHI. METHODS: Retrospective case series (1992-98) with case control analysis of 65 children under 2 years old, with an SDH secondary to NAHI. Outcome measures were presenting symptoms, associated injuries and apnoea at presentation, brain swelling or hypoxic ischaemic changes on neuroimaging, and clinical outcome (KOSCHI). RESULTS: Twenty two children had a history of apnoea at presentation to hospital. Apnoea was significantly associated with hypoxic ischaemic brain damage. Severe symptoms at presentation, apnoea, and diffuse brain swelling/hypoxic ischaemic damage were significantly associated with a poor prognosis. Eighty five per cent of cases had associated injuries consistent with a diagnosis of non-accidental injury. CONCLUSIONS: Coma at presentation, apnoea, and diffuse brain swelling or hypoxic ischaemia all predict a poor outcome in an infant who has suffered from SDH after NAHI. There is evidence of associated violence in the majority of infants with NAHI. At this point in time we do not know the minimum forces necessary to cause NAHI. It is clear however that it is never acceptable to shake a baby.

The incidence of severe physical child abuse in Wales.

OBJECTIVES: The purposes of this study were: (1) to ascertain the incidence and nature of severe physical child abuse in Wales; (2) to ascertain the incidence of all physical abuse in babies under 1 year of age; and (3) to determine whether child protection registers (CPR) accurately reflect the numbers of children who are physically abused. METHODS: This is a population-based incidence study based in Wales, UK, for 2 years from April 1996 through March 1998. Children studied were under the age of 14 with severe physical abuse consistent with the criminal law level of Grievous Bodily Harm. This included seven categories of injury (death; head injury including subdural hemorrhage; internal abdominal injury; physical injury in Munchausen Syndrome by Proxy including suffocation; fracture; burn or scald; adult bite). Cases were ascertained by a pediatrician surveillance reporting system (WPSU). A criterion for inclusion was multidisciplinary agreement that physical abuse had occurred (at case conference, strategy meeting, or Part 8 Review). The incidence of all babies under 1 year of age with physical abuse was also studied. Ascertainment of babies under the age of 1 year was undertaken from CPR as well as the WPSU. RESULTS: Severe abuse is six times more common in babies [54/100,000/year (95% CI +/- 17.2)] than in children from 1 year to 4 years of age [9.2/100,000 (95% CI +/- 3.6)]. It is 120 times more common than in 5- to 13-year-olds [0.47/100,000 (95% CI +/- 0.47)]. This is mainly because two types of serious abuse (brain injury including subdural hemorrhage and fractures) are more common in babies under the age of 1 year than older children. Using data from two sources (the WPSU and CPRs), the incidence of physical abuse in babies is 114/100,000 (CI 114 +/- 11.8) per year. This equates to 1 baby in 880 being abused in the first year of life. The largely rural Health Authority area in Wales had incidence figures for abuse in babies that were 50% of the three other predominantly urban Health Authority areas. Boys throughout the series were more at risk of being severely abused than girls (p < .025). Only 29% of the babies under 1 year of age on the CPR had actually been injured. Thirty percent of abused babies under the age of 1 year and 73% of severely abused children over the age of 1 year had caused previous concern to health professionals regarding abuse or neglect. CONCLUSIONS: Physical abuse is a significant problem in babies under the age of 1 year. Very young babies (under 6 months old) have the highest risk of suffering damage or death as a result of physical abuse. Severe abuse, in particular subdural hematoma and fracture, is much more common in babies than in older children. There is evidence of failure of secondary prevention of child abuse by health professionals, with a greater need to act on concerns regarding abuse and neglect. Interagency child protection work in partnership with parents should focus more on protecting babies under age 1 year from further abuse than on maintenance of the infant within an abusive home. The CPR is not intended as an accurate measure of children suffering abuse. It is a record of children requiring a child protection plan and must not be used as a measure of numbers of abused children.

A scoring system for bruise patterns: a tool for identifying abuse.

AIMS: To determine whether abused and non-abused children differ in the extent and pattern of bruising, and whether any differences which exist are sufficiently great to develop a score to assist in the diagnosis of abuse. METHODS: Total length of bruising in 12 areas of the body was determined in 133 physically abused and 189 control children aged 1-14 years. RESULTS: Our method of recording bruises by site, maximum dimension, and shape was easy to use. There were clear differences between cases and controls in the total length of bruises. These differences were at their greatest in the head and neck and were less notable in the limbs. A scoring system was developed using logistic regression analysis using total lengths of bruising in five regions of the body. Good discrimination between the two sets of children was achieved using this score; by including a variable that indicates whether a bruise had a recognisable shape the discrimination could be made even better. Given a prior probability of abuse the score can be used to give posterior odds of abuse, given a particular bruising pattern. CONCLUSIONS: The scoring system provides a measure that discriminates between abused and non-abused children, which should be straightforward to implement, though the results must be interpreted carefully. We do not see this score as replacing the complex qualitative analysis of the diagnosis of abuse. This clearly includes history as well as examination, but rather as the beginning of the development of an important aid in this process.