Non-accidental injury in children--an update.

The abuse of children is a universal problem. It affects children from all social classes, racial and religious groups. Child abuse involves acts of commission or omission which directly or indirectly result in harm to the child and prevent a normal development into healthy adulthood. Those responsible may be members of a family, a community or an institution. The prevalence of child abuse and neglect is difficult to measure since events tend to be unreported because they happen behind closed doors. The majority of children who have been physically abused present with soft tissue injuries, thermal injuries and fractures. This article is focused on the physical abuse of children with particular emphasis on fractures.

Incidence and demography of non-accidental head injury in southeast Scotland from a national database.

BACKGROUND: This study utilized an existing national database of cases of non-accidental head injury (NAHI; also called inflicted traumatic brain injury [inflicted TBI] and shaken baby syndrome [SBS]) in Scotland to report the incidence, confidence intervals, and demography of such cases in Southeast Scotland. METHODS: This prospective population-based study was conducted from January 1998 to September 2006. Data from the Lothian region of Scotland, where there is known full ascertainment of infant head injuries, including NAHI, have been used to calculate the incidence rate for this region of Scotland, with government statistics providing the normal annual infant population as the denominator. A new Scottish Index of Multiple Deprivation (SIMD), which assesses a very focused area (data zone population size=750) and provides novel information about social demography for education, housing, employment, health, crime, income, and geographic accessibility to services, was applied to the identified cases of NAHI during this study period. RESULTS: The mean incidence of NAHI in southeast Scotland for 8.75 years was 33.8/100,000 infants per year. The cases of NAHI were mostly located in the lowest 1 (or 2) quintiles for all SIMD domains (education, housing, employment, health, crime, income), although they had good accessibility to medical and other community services. CONCLUSIONS: The incidence rates from this prospective study for NAHI are considerably higher than other published UK surveys and are not considered to reflect a cluster effect. The perpetrators in this study fit a strongly skewed profile aggregating to the lowest socioeconomic groups in the community.

Epidemiology of oronasal hemorrhage in the first 2 years of life: implications for child protection.

BACKGROUND: Epistaxis in childhood is common but unusual in the first years of life. Oronasal blood has been proposed as a marker of child abuse. METHODS: We performed a retrospective review of all hospital notes of children in the Lothian region of Scotland who were <2 years of age and in whom facial blood had been recorded over a 10-year period. RESULTS: There were 77,173 accident and emergency department attendances with 58,059 admissions during the 10-year study period in children <2 years of age; 16 cases of nose bleed and 3 cases of hemoptysis were recorded. All cases of hemoptysis were associated with significant bouts of coughing and respiratory infections. Epistaxis in 8 cases was associated with visible trauma and in 4 cases with thrombocytopenia (secondary to malignancy in 3). In 2 cases, an associated apparent life-threatening event was described, and in 2 cases there was a coincident upper respiratory tract infection. Review of previous and subsequent history suggested 7 cases of "accidental" injury that might have been caused by abuse. These cases are described here. All children who presented with this problem to the accident and emergency department had been admitted for observation or management. CONCLUSIONS: Epistaxis is rare in the accident and emergency department and hospital in the first 2 years of life and is often associated with injury or serious illness. The investigation of all cases should involve a pediatrician with expertise in child protection.

The epidemiology of fractures in children.

A retrospective study of all paediatric fractures presenting to hospital in Edinburgh, Scotland in 2000 was undertaken. It showed that the incidence of fractures was 20.2/1000/year and that 61% of children's fractures occurred in males. Analysis of paediatric fractures shows that there are six basic fracture distribution curves with six fractures showing a bimodal distribution but most having a unimodal distribution affecting younger or older children. The incidence of fractures increases with age with falls from below bed height (<1m) being the commonest cause of fracture. The majority of fractures in children involve the upper limb. Lower limb fractures are mainly caused by twisting injuries and road traffic accidents. The incidence of fractures in cyclists and pedestrians remains relatively high whereas the incidence in vehicle occupants is low suggesting that road safety programs have been successful. Similar programs should be instituted for young cyclists. The importance of accident prevention programmes in the home is also highlighted.

Older children and adolescents surviving with vertically acquired HIV infection.

This article describes the characteristics of children infected vertically with HIV surviving 10 years or more who were enrolled in the prospective European Collaborative Study. Thirty-four of 187 infected children were identified with a median age of 11.4 years (range, 10.1-15.9 years). Factors examined included clinical status, immunologic and virologic characteristics, type of antiretroviral therapy, and psychosocial characteristics. By 10 years of age, 6 (18%) children had progressed to Class A as determined by the system of the U.S. Centers for Disease Control and Prevention (CDC), 17 (52%) to class B, 7 (21%) to class C, and 3 (9%) had remained asymptomatic. At 73% (904 of 1234) of scheduled clinic visits, these children had no symptoms of HIV disease. Most children were in CDC immune categories 1 (18, 56%) or 2 (11, 34%) at their last visit. Three quarters (24 patients) were on combination therapy with three or more drugs, although 3 children had never received any antiretroviral therapy. Nineteen (56%) children were living with at least 1 parent and the mothers of 13 (38%) children had died. Most (77%) children had been told about their HIV infection. Children infected vertically with HIV who have survived their first 10 years are mainly free of serious symptoms. As they enter adolescence, additional services are needed including support with disclosure to others, therapy, and sexual health.