Follow-up protocol was useful for children whose parents attended emergency departments after partner violence, substance abuse or a suicide attempt.

AIM: This was a one-year follow-up of families referred to support services after the parents visited the emergency department due to intimate partner violence, substance abuse or a suicide attempt. Its aim was to evaluate the well-being of any children. METHODS: Data on families identified a year earlier by the Amsterdam protocol were gathered from child protective services and parent and child self-reports in two Dutch regions from 2012-2015. RESULTS: We included 399 children (52%) boys with a median age of eight years (range 1-18) in the study using child protective services data. Of the 101 families who participated in the first measurement, 67 responded one year after the parent's emergency department visit. The results showed that 20% of the children had no or minor problems, voluntary support services were involved in 60% of cases and child protective services were involved in 20%. Compared to their first assessment a year earlier, the children's psychosocial problems had not increased, but this could have been an underestimation due to selective responses. CONCLUSION: The Amsterdam protocol was valuable in referring families to voluntary support services, but given the ongoing problems in some families, professionals need to carefully monitor whether support services are sufficiently effective.

Assessments carried out by a child abuse and neglect team in an Amsterdam teaching hospital led to interventions in most of the reported cases.

AIM: This study described cases of child abuse and neglect (CAN) that were reported to the multiagency CAN team at the Emma Children's Hospital in Amsterdam and the resulting interventions. METHODS: We carried out a retrospective review of all cases that were reported to the CAN team from 1 January 2010 to 31 December 2012. RESULTS: There were 27 prenatal cases, 92 referrals based on parental characteristics and 523 children. Overall, 1.2% of the children visiting the emergency department of our hospital, attending the outpatients department or being admitted were reported to the team. More than half of the referrals (55.1%) were confirmed as CAN. The most common diagnoses were as follows: witnessing intimate partner violence, physical neglect and emotional abuse. If CAN was confirmed an intervention was offered in 98.3% of cases. If a CAN diagnosis was undetermined or rejected, the figures were still 83.5% and 64.2%, respectively. CONCLUSION: Our results showed that CAN affected more than one in every 100 children visiting our hospital, and the expertise of our hospital-based CAN Team led to an intervention in the majority of the reported cases. The broad scope of problems that were encountered underlined the importance of a multidisciplinary CAN team.

Parents' Opinion About a Routine Head-to-Toe Examination of Children as a Screening Instrument for Child Abuse and Neglect in Children Visiting the Emergency Department.

INTRODUCTION: To improve detection of child abuse and neglect (CAN), many emergency departments use screening methods. Apart from diagnostic accuracy, possible harms of screening methods are important to consider, especially because most children are not abused and do not benefit from screening. We performed a systematic literature review to assess parents' opinions about CAN screening, in which we could only include 7 studies, all reporting that the large majority of participating parents favor screening. Recently, a complete physical examination (called "top-toe" inspection [TTI], a fully undressed inspection of the child) was implemented as a CAN screening method at the emergency department of a teaching hospital in The Netherlands. This study describes parents' opinions about the TTI. METHODS: We used a questionnaire to assess parents' opinions about the TTI of their children when visiting the emergency department. During the study period, 1000 questionnaires were distributed by mail. RESULTS: In total, 372 questionnaires were returned (37%). A TTI was performed for 194 children (52%). The overall attitude of parents whose children underwent a TTI was positive; 77.3% of the respondents found the TTI acceptable, and 1.5% (N = 3) found it unacceptable. Seventy percent of the respondents agreed with the theorem that all children who visit the emergency department should have a TTI performed, and 7.3% (N = 14) disagreed. DISCUSSION: Contrary to what is commonly believed, both in our systematic literature review and in our questionnaire study, the majority of participating parents agree with screening for CAN in general and with the TTI specifically. Sharing the results of this study with ED personnel and policy makers could take away prejudices about perceived disagreement of parents, thereby improving implementation of and adherence to CAN screening.

Results of the implementation of a new screening protocol for child maltreatment at the Emergency Department of the Academic Medical Center in Amsterdam.

OBJECTIVE: This study examines the results of the implementation of a new screening protocol for child maltreatment (CM) at the Emergency Department (ED) of the Academic Medical Center in Amsterdam, The Netherlands. This protocol consists of adding a so called 'top-toe' inspection (TTI), an inspection of the fully undressed child, to the screening checklist for child maltreatment, the SPUTOVAMO. DESIGN: We collected data from all patients 0-18 years old directly after introduction (February 2010) and 9 months later. Outcome measures were: completion of the screening and reasons for non-adherence. Data were collected on age, gender, reason for visiting the ED (defined by International Classification of Disease, ICD), presence of a chronic illness, type of professional performing the TTI and admission during week or weekend days. RESULTS: In February 560 and in November 529 paediatric patients were admitted. In February the complete screening protocol was performed in 42% of all children, in November in 17%. A correlation between completion of the SPUTOVAMO and having a TTI performed was found. Older age and presence of a chronic illness influenced the chance of having both SPUTOVAMO and TTI performed negatively. The completion rate of SPUTOVAMO was influenced by ICD code. Completion of TTI was influenced by type of investigator. The best performing professional was the ED physician followed by the paediatrician followed by the ED nurse. The reasons for not performing a TTI were not documented. Refusal of the TTI by a patient or parent was reported three times. CONCLUSION: Implementation of this new screening protocol for CM was only mildly successful and declined in time. A negative correlation between older child age and having a chronic illness and completion of the screening was found. A practical recommendation resulting from this study could be that, if CM screening protocols prove to be effective in detecting CM, regular training sessions have to be held. Filling out the checklist is something that could be performed by ED nurses. Performing a TTI is perhaps easier for the ED physicians to make part of their daily routine.

Age determination of subdural hematomas with CT and MRI: a systematic review.

OBJECTIVES: To systematically review the literature on dating subdural hematomas (SDHs) on CT and MRI scans. METHODS: We performed a systematic review in MEDLINE, EMBASE and Cochrane to search for articles that described the appearance of SDHs on CT or MRI in relation to time between trauma and scanning. Two researchers independently screened the articles, assessed methodological quality and performed data extraction. Medians with interquartile ranges were calculated. Differences were tested with a Mann-Whitney U or Kruskal-Wallis H test. RESULTS: We included 22 studies describing 973 SDHs on CT and 4 studies describing 83 SDHs on MRI. Data from 17 studies (413 SDHs) could be pooled. There were significant differences between time intervals for the different densities on CT (p<0.001). Time interval differed significantly between children and adults for iso- and hypodensity (p=0.000) and hyperdensity (p=0.046). Time interval did not differ significantly between abused and non-abused children. On MRI, time intervals for different signal intensities on T1 and T2 did not differ significantly (p=0.108 and p=0.194, respectively). CONCLUSIONS: Most time intervals of the different appearances of SDHs on CT and MRI are broad and overlapping. Therefore CT or MRI findings cannot be used to accurately date SDHs.

Postmortem CT compared to autopsy in children; concordance in a forensic setting.

OBJECTIVES: The aim of this study is to assess the accuracy of postmortem CT (PMCT) in determining the cause of death in children who underwent a forensic autopsy because of a suspected nonnatural death. METHODS: We selected forensic pediatric autopsies at the Netherlands Forensic Institute, whereby the subject underwent PMCT between 1-1-2008 and 31-12-2012. Cause of death was independently scored by a radiologist and a pathologist. Cause of death was classified (1) in categories being natural, unnatural, and unknown; (2) according to the ICD-10; and (3) according to institutional classification. RESULTS: In the study period, 189 pediatric forensic autopsies were performed. Fifteen were excluded because of putrefaction. Of the remaining 174 autopsies, 98 (56%) underwent PMCT. PMCT and autopsy identified the same category in 69/98 cases (70%, kappa 0.49). They identified the same cause of death in 66/98 cases (67%, kappa 0.5) using ICD-10; in 71/98 (72%, kappa 0.62) using a forensic classification. PMCT performed better in unnatural deaths (59-67 % agreement) than in natural deaths (0 % agreement). If no cause of death was detected with autopsy, PMCT failed to identify a cause of death in 98% (39/40). CONCLUSIONS: Pediatric PMCT does identify the majority of unnatural causes of death, but does not identify new diagnoses (true positives) if no cause of death is found during autopsy. Diagnostic accuracy in natural deaths is low. KEY POINTS: • The case mix is an important predictor for the concordance between PMCT and autopsy. • In case of an unnatural death, 72--81% of PMCT results matches autopsy results. • In case of a natural death, 0% of PMCT results matches autopsy results. • If no cause of death is identified with autopsy, 98% of PMCT results concurs.

Age determination of subdural hematomas: survey among radiologists.

Abusive head trauma is a severe form of child abuse. One important diagnostic finding is the presence of a subdural hematoma. Age determination of subdural hematomas is important to relate radiological findings to the clinical history presented by the caregivers. In court this topic is relevant as dating subdural hematomas can lead to identification of a suspect. The aim of our study is to describe the current practice among radiologists in the Netherlands regarding the age determination of subdural hematomas in children. This is a cross-sectional study, describing the results of an online questionnaire regarding dating subdural hematomas among pediatric and neuro-radiologists in the Netherlands. The questionnaire consisted of sociodemographic questions, theoretical questions and eight pediatric cases in which the participants were asked to date subdural hematomas based on imaging findings. Fifty-one out of 172 radiologists (30 %) filled out the questionnaire. The percentage of participants that reported it was possible to date the subdural hematoma varied between 58 and 90 % for the eight different cases. In four of eight cases (50 %), the age of the subdural hematoma as known from clinical history fell within the range reported by the participants. None of the participants was "very certain" of their age determination. The results demonstrate that there is a considerable practice variation among Dutch radiologists regarding the age determination of subdural hematomas. This implicates that dating of subdural hematomas is not suitable to use in court, as no uniformity among experts exists.

Pneumomediastinum and soft tissue emphysema in pediatric hanging.

Postmortem computed tomography (CT) is increasingly being used as a tool in forensic pathology. The exact value of postmortem imaging in detecting specific conditions has not yet been established, but in specific cases, it can be used as a diagnostic tool demonstrating findings that remain undetected during autopsy, as in this case. Pneumomediastinum and soft tissue emphysema were detected with postmortem CT in a 3-year-old girl after hanging. It was not found during autopsy. This radiological finding matches 3 adult cases previously described. It is assumed that in this case, the first reported in a child, hanging was the most likely cause as well. In the adult cases, it was interpreted as a vital sign; the person must have been alive to create a pressure gradient causing rupture of the alveoli. This case demonstrates one of the added values of postmortem imaging, the possibility of demonstrating findings that remain undetected during autopsy.

Insufficient evidence for the use of a physical examination to detect maltreatment in children without prior suspicion: a systematic review.

BACKGROUND: Although it is often performed in clinical practice, the diagnostic value of a screening physical examination to detect maltreatment in children without prior suspicion has not been reviewed. This article aims to evaluate the diagnostic value of a complete physical examination as a screening instrument to detect maltreatment in children without prior suspicion. METHODS: We systematically searched the databases of MEDLINE, EMBASE, PsychINFO, CINAHL, and ERIC, using a sensitive search strategy. Studies that i) presented medical findings of a complete physical examination for screening purposes in children 0-18 years, ii) specifically recorded the presence or absence of signs of child maltreatment, and iii) recorded child maltreatment confirmed by a reference standard, were included. Two reviewers independently performed study selection, data extraction, and quality appraisal using the QUADAS-2 tool. RESULTS: The search yielded 4,499 titles, of which three studies met the eligibility criteria. The prevalence of confirmed signs of maltreatment during screening physical examination varied between 0.8% and 13.5%. The designs of the studies were inadequate to assess the diagnostic accuracy of a screening physical examination for child maltreatment. CONCLUSIONS: Because of the lack of informative studies, we could not draw conclusions about the diagnostic value of a screening physical examination in children without prior suspicion of child maltreatment.

[Neonaticide: frequently suspected, seldom proven]. / Neonaticide: vaak vermoed, zelden bewezen.

OBJECTIVE: To present an overview of pathological findings on neonaticide in the Netherlands. DESIGN: Retrospective descriptive study. METHOD: We analyzed all autopsy reports on neonates from the Netherlands Forensic Institute for the period 1994-2011. We collected data on gestational age, how the body had been discovered and autopsy results. RESULTS: We included details of 78 victims; 61 (78%) had been born at full term and 17 (22%) prematurely. Half of the victims were girls, 40% were boys and in 10% the state of the body meant that it was not possible to determine the sex. Minimal, moderate and severe putrefaction was observed in 29 bodies (37%), 15 bodies (19%) and 34 bodies (44%), respectively. In the cases with moderate or severe decomposition it was not possible to determine with certainty whether the child had been born alive and, if applicable, the cause of death. Of the remaining 29 cases with minimal decomposition, 1 had been stillborn; a possible cause of death could be determined in 12 cases. CONCLUSION: In the Netherlands 4 to 5 forensic autopsies are performed annually in cases of suspected neonaticide. In most cases decomposition is already too advanced to be able to determine whether there was any sign of life at birth and to establish the cause of death, if applicable.

Abusive head trauma in young children in the Netherlands: evidence for multiple incidents of abuse.

AIM: We investigated the prevalence of risk factors for and the prevalence of prior abuse in abusive head trauma victims in the Netherlands. METHODS: We performed a retrospective file review of all abusive head trauma cases in the Netherlands in which forensic medical expertise was requested by the courts, between 2005 and 2010. Outcome measures were risk factors and indicators for prior abuse. RESULTS: Eighty-nine cases were included; 62% boys, median age 3.5 months. Impact trauma was found in 48% of cases, with a male perpetrator in 79%. Prematurity, dysmaturity and twins/triplets were found in 27%, 23% and 10% of cases, respectively, maternal age under 20 years in 17%. Of the parents, 60% had completed only primary or secondary education, 38% of the families were known to child welfare authorities. There was evidence for prior abuse in 81% of the cases. CONCLUSION: The high number of families with prior abuse indicates that both the healthcare system and child welfare authorities failed to protect some of the children that have been in their care. Our results highlight the importance of training healthcare and child welfare professionals in recognizing physical abuse, as well as the importance of optimizing abusive head trauma prevention strategies.

Prevalence of child sexual abuse in pediatric patients with chronic abdominal pain.

BACKGROUND AND OBJECTIVES: A history of sexual abuse is to be found in approximately 40% of all adult patients with gastrointestinal complaints. Data on the prevalence of child sexual abuse (CSA) in children with chronic abdominal pain (CAP) are lacking. The objective of this systematic review is to determine the prevalence of CSA in pediatric patients with CAP. METHODS: We conducted a systematic literature search in the electronic databases MEDLINE, EMBASE, PsychInfo, and ERIC. Reference lists of relevant articles were scanned for additional citations. We selected case-control, cohort and cross-sectional studies investigating the prevalence of CSA in children with CAP, ages 0 to 18 years. Data were extracted from relevant studies, which were assessed for methodological quality by 2 independent reviewers. Prevalence of CSA was the main outcome measure. RESULTS: The literature search yielded a total of 269 articles. Only 2 studies met our inclusion criteria, reporting CSA in 2.1% and 8.0% of children (age range 4-21 years) with CAP. Both studies were conducted in small groups (n = 48 and n = 50) without control group(s) and did not use standardized or validated instruments for diagnosing CSA. CONCLUSIONS: According to existing data, the prevalence of a history of CSA in pediatric patients with CAP is lower than in adult patients; however, no well-designed studies have been conducted in children. Future research is required to determine a reliable prevalence of CSA in children with CAP.

New hospital-based policy for children whose parents present at the ER due to domestic violence, substance abuse and/or a suicide attempt.

Child maltreatment is a major social problem with many adverse consequences, and a substantial number of maltreated children are not identified by health care professionals. In 2010, in order to improve the identification of maltreated children in hospitals, a new hospital-based policy was developed in Amsterdam, The Netherlands. This policy was adapted from another policy that was developed in The Hague, the Netherlands, in 2007. In the new Amsterdam policy, all adults presenting at the emergency department due to domestic violence, substance abuse, and/or a suicide attempt are asked whether they have any children in their care. If this is the case, parents are urged to visit the outpatient pediatric department together with all of their children. During this visit, problems are evaluated and voluntary referrals can be arranged to different care organizations. If parents refuse to cooperate, their children are reported to the Dutch Child Abuse Counseling and Reporting Centre. The two aims of this study are to describe (1) characteristics of the identified families and (2) the referrals made to different voluntary and involuntary care organizations during the first 2 years after implementation of the policy. Data were collected from medical records. One hundred and six children from 60 households were included, of which 68 children because their mother was a victim of domestic violence. Referrals to care organizations were arranged for 99 children, of which 67 on a voluntary basis. The Amsterdam policy seems successful in arranging voluntary support for the majority of identified children.

[A boy with an abdominal mass]. / Een jongen met een zwelling in de buik.

A 11-year-old boy presented with an abdominal mass in the right upper abdomen. As a newborn he was analyzed for this mass, diagnosed as an adrenal hemorrhage. Abdominal X-ray and CT revealed a fetus-in-fetu, which was removed surgically.

Educational paper: imaging child abuse: the bare bones.

Fractures are reported to be the second most common findings in child abuse, after skin lesions such as bruises and contusions. This makes careful interpretation of childhood fractures in relation to the provided clinical history important. In this literature review, we address imaging techniques and the prevailing protocols as well as fractures, frequently seen in child abuse, and the differential diagnosis of these fractures. The use of a standardised protocol in radiological imaging is stressed, as adherence to the international guidelines has been consistently poor. As fractures are a relatively common finding in childhood and interpretation is sometimes difficult, involvement of a paediatric radiologist is important if not essential. Adherence to international guidelines necessitates review by experts and is therefore mandatory. As in all clinical differential diagnoses, liaison between paediatricians and paediatric radiologists in order to obtain additional clinical information or even better having joint review of radiological studies will improve diagnostic accuracy. It is fundamental to keep in mind that the diagnosis of child abuse can never be solely based on radiological imaging but always on a combination of clinical, investigative and social findings. The quality and interpretation, preferably by a paediatric radiologist, of radiographs is essential in reaching a correct diagnosis in cases of suspected child abuse.

Abusive head trauma Part II: radiological aspects.

UNLABELLED: Abusive head trauma (AHT) is a relatively common cause of neurotrauma in young children. Radiology plays an important role in establishing a diagnosis and assessing a prognosis. Computed tomography (CT), followed by magnetic resonance imaging (MRI) including diffusion-weighted imaging (DWI), is the best tool for neuroimaging. There is no evidence-based approach for the follow-up of AHT; both repeat CT and MRI are currently used but literature is not conclusive. A full skeletal survey according to international guidelines should always be performed to obtain information on possible underlying bone diseases or injuries suspicious for child abuse. Cranial ultrasonography is not indicated as a diagnostic modality for the evaluation of AHT. If there is a suspicion of AHT, this should be communicated with the clinicians immediately in order to arrange protective measures as long as AHT is part of the differential diagnosis. CONCLUSION: The final diagnosis of AHT can never be based on radiological findings only; this should always be made in a multidisciplinary team assessment where all clinical and psychosocial information is combined and judged by a group of experts in the field.

Educational paper: Abusive Head Trauma part I. Clinical aspects.

UNLABELLED: Abusive Head Trauma (AHT) refers to the combination of findings formerly described as shaken baby syndrome. Although these findings can be caused by shaking, it has become clear that in many cases there may have been impact trauma as well. Therefore a less specific term has been adopted by the American Academy of Pediatrics. AHT is a relatively common cause of childhood neurotrauma with an estimated incidence of 14-40 cases per 100,000 children under the age of 1 year. About 15-23% of these children die within hours or days after the incident. Studies among AHT survivors demonstrate that approximately one-third of the children are severely disabled, one-third of them are moderately disabled and one-third have no or only mild symptoms. Other publications suggest that neurological problems can occur after a symptom-free interval and that half of these children have IQs below the 10th percentile. Clinical findings are depending on the definitions used, but AHT should be considered in all children with neurological signs and symptoms especially if no or only mild trauma is described. Subdural haematomas are the most reported finding. The only feature that has been identified discriminating AHT from accidental injury is apnoea. CONCLUSION: AHT should be approached with a structured approach, as in any other (potentially lethal) disease. The clinician can only establish this diagnosis if he/she has knowledge of the signs and symptoms of AHT, risk factors, the differential diagnosis and which additional investigations to perform, the more so since parents seldom will describe the true state of affairs spontaneously.

Current techniques in postmortem imaging with specific attention to paediatric applications.

In this review we discuss the decline of and current controversies regarding conventional autopsies and the use of postmortem radiology as an adjunct to and a possible alternative for the conventional autopsy. We will address the radiological techniques and applications for postmortem imaging in children.