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.

Are referrals to occupational therapy for developmental coordination disorder appropriate?

AIMS: To assess children referred to the Occupational Therapy Service in Gwent with a presumptive diagnosis of developmental coordination disorder (DCD) in order to investigate the appropriateness of their referral. METHODS: Non-urgent referrals to the occupational therapy team for children with coordination difficulties in Gwent between June 2001 and February 2002 were studied. RESULTS: Eighty nine children, aged 5-10 years, were identified. Thirteen children who would not meet the DCD criteria were excluded. This left 76 children, 67 of whom were actually assessed. If the 15th centile for the Movement ABC is used, 26 children met and 41 failed one of the four criteria in DSM IV (38%). If the 5th centile is used, 21 children met and 46 failed one of the four criteria in the DSM (31%). Of the major groups of referrers, school nurses did the best with 48% success rate; better than the paediatricians with 32%. The worst success rate was in educational psychologists and teachers, with only 20% of cases referred actually having DCD. These differences did not quite reach statistical significance. CONCLUSIONS: Less than a third of referrals to occupational therapy for DCD actually have the diagnosis. This suggests that referrers need further training and guidance. This includes a knowledge and understanding of the DSM IV criteria and their interpretation. This would reduce the number of time consuming, unnecessary assessments being done. A triage procedure with a checklist would be a good way forward and we hope to devise one to assist referrers with this process.

Head injury and limb fracture in modern playgrounds.

There were no serious head injuries in modern Cardiff municipal playgrounds with safety surfaces over five years injury surveillance. The literature suggests serious head injuries did occur before the introduction of safety surfaces.

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.

Short report: Is regional paediatric surveillance useful? Experience in Wales.

The Welsh Paediatric Surveillance Unit was established in 1994 to monitor the incidence and prevalence of a number of uncommon disorders of childhood in Wales. Its work complements that of the British Paediatric Surveillance Unit. Information from consultant paediatricians is obtained by means of a monthly card return system; return rate is over 90%.

Social deprivation and the causes of stillbirth and infant mortality.

AIMS: To investigate the relation between social deprivation and causes of stillbirth and infant mortality. METHODS: Stillbirths and infant deaths in 6347 enumeration districts in Wales were linked with the Townsend score of social deprivation. In 1993-98 there were 211 072 live births, 1147 stillbirths, and 1223 infant deaths. Poisson regression analysis was used to estimate the magnitude of effect for associations between the Townsend score and categories of death by age and the causes of death. The relative risk of death between most and least deprived enumeration districts was derived. RESULTS: Relative risk of combined stillbirth and infant death was 1.53 (95% CI 1.35 to 1.74) in the most deprived compared with the least deprived enumeration districts. The early neonatal mortality rate was not significantly associated with deprivation. Sudden infant death syndrome showed a 307% (95% CI 197% to 456%) increase in mortality across the range of deprivation. Deaths caused by specific conditions and infection were also associated with deprivation, but there was no evidence of a significant association with deaths caused by placental abruption, intrapartum asphyxia, and prematurity. CONCLUSIONS: Collaborative public health action at national and local level to target resources in deprived communities and reduce these inequalities in child health is required. Early neonatal mortality rates and deaths from intrapartum asphyxia and prematurity are not significantly associated with deprivation and may be more appropriate quality of clinical care indicators than stillbirth, perinatal, and neonatal mortality rates.

Subdural haemorrhages in infants: population based study.

OBJECTIVES: To identify the incidence, clinical outcome, and associated factors of subdural haemorrhage in children under 2 years of age, and to determine how such cases were investigated and how many were due to child abuse. DESIGN: Population based case series. SETTING: South Wales and south west England. SUBJECTS: Children under 2 years of age who had a subdural haemorrhage. We excluded neonates who developed subdural haemorrhage during their stay on a neonatal unit and infants who developed a subdural haemorrhage after infection or neurosurgical intervention. MAIN OUTCOME MEASURES: Incidence and clinical outcome of subdural haemorrhage in infants, the number of cases caused by child abuse, the investigations such children received, and associated risk factors. RESULTS: Thirty three children (23 boys and 10 girls) were haemorrhage. The incidence was 12.8/100 000 children/year (95% confidence interval 5.4 to 20.2). Twenty eight cases (85%) were under 1 year of age. The incidence of subdural haemorrhage in children under 1 year of age was 21.0/100 000 children/year and was therefore higher than in the older children. The clinical outcome was poor: nine infants died and 15 had profound disability. Only 22 infants had the basic investigations of a full blood count, coagulation screen, computed tomography or magnetic resonance imaging, skeletal survey or bone scan, and ophthalmological examination. In retrospect, 27 cases (82%) were highly suggestive of abuse. CONCLUSION: Subdural haemorrhage is common in infancy and carries a poor prognosis; three quarters of such infants die or have profound disability. Most cases are due to child abuse, but in a few the cause is unknown. Some children with subdural haemorrhage do not undergo appropriate investigations. We believe the clinical investigation of such children should include a full multidisciplinary social assessment, an ophthalmic examination, a skeletal survey supplemented with a bone scan or a skeletal survey repeated at around 10 days, a coagulation screen, and computed tomography or magentic resonance imaging. Previous physical abuse in an infant is a significant risk factor for subdural haemorrhage and must be taken seriously by child protection agencies.

Procedures, placement, and risks of further abuse after Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.

OBJECTIVES: To investigate outcome, management, and prevention in Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation. DESIGN: Ascertainment through British Paediatric Surveillance Unit and questionnaires to responding paediatricians. SETTING: The UK and Republic of Ireland, September 1992 to August 1994. SUBJECTS: Children under 14 years diagnosed with the above. MAIN OUTCOME MEASURES: Placement and child protection measures for victims and siblings; morbidity and reabuse rates for victims; abuse of siblings; prosecution of perpetrators. RESULTS: Outcome data for 119 with median follow up of 24 months (range 12 to 44 months). No previously diagnosed factitious disease was found to have been caused by genuine disease. Forty six children were allowed home without conditions at follow up. Children who had suffered from suffocation, non-accidental poisoning, direct harm, and those under 5 years were less likely to go home. Twenty seven (24%) children still had symptoms or signs as a result of the abuse at follow up; 108/120 were originally on a child protection register and 35/111 at follow up. Twenty nine per cent (34/118) of the perpetrators had been prosecuted and most convicted; 17% of the milder cases of Munchausen syndrome by proxy allowed home were reabused. Evidence in siblings suggests that in 50% of families with a suffocated child and 40% with non-accidental poisoning there would be further abuse, some fatal. CONCLUSIONS: This type of abuse is severe with high mortality, morbidity, family disruption, reabuse, and harm to siblings. A very cautious approach for child protection with reintroduction to home only if circumstances are especially favourable is advised. Paediatric follow up by an expert in child protection should also occur.

A case-control study of somatic and behavioural symptoms in sexually abused boys.

OBJECTIVES: To ascertain how often sexually abused boys present with somatic and behavioural symptoms. DESIGN: A case-control study. SETTING: A primary school in South Wales where a male teacher had been convicted of sexually abusing boys since 1981. The police investigation started in 1993 and he was convicted in 1994. A similar large primary school where abuse had not taken place. SUBJECTS: All 107 boys who had been identified by a police inquiry to have been subject to sexual abuse by a single teacher in a single primary school; 107 age matched controls. MAIN OUTCOME MEASURES: Symptoms that might have had a somatic or behavioural basis reported in general practice, hospital, and school health records. RESULTS: Somatic and behavioural complaints were uncommon in both cases and controls. There was no significant difference between the numbers of cases and controls who had presented with somatic and behavioural complaints (18 cases v 25 controls). However the difference between the cases and controls with symptoms lasting over a year was significant (p < 0.05). There were no differences in the nature of reported symptoms between the control and abused groups. CONCLUSIONS: This suggests that extensive investigation for possible abuse is not indicated where are short lived somatic symptoms but it should be considered as a possible diagnosis where symptoms are long standing.

Epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.

A two year prospective study was performed to determine the epidemiology of Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation in the UK and the Republic of Ireland. Cases were notified to the British Paediatric Association Surveillance Unit from September 1992 to August 1994 if a formal case conference had been held for the first time during that period to discuss any of the above conditions. A total of 128 cases were identified: 55 suffered Munchausen syndrome by proxy alone, 15 poisoning, and 15 suffocation; 43 suffered more than one type of abuse. The majority of children were aged under 5 years, the median age being 20 months. On 85% of occasions the perpetrator was the child's mother. In 42% of families with more than one child, a sibling had previously suffered some form of abuse. Eighty five per cent of notifying paediatricians considered the probability of their diagnosis as virtually certain before a case conference was convened. The commonest drugs used to poison were anticonvulsants; opiates were the second commonest. Sixty eight children suffered severe illness of whom eight died. The combined annual incidence of these conditions in children aged under 16 years is at least 0.5/100,000, and for children aged under 1, at least 2.8/100,000.

Children and cycle helmets: the case for.

The question of cycle helmets for children should be an easy one for society to decide upon. There is good experimental evidence from case control studies that they help prevent injuries (Thompson, Rivara & Thompson 1989; Spaite et al. 1991; McDermott et al. 1993; Malmaris et al. 1994; Thomas et al. 1994). Commonsense also suggests that they should be effective. So why has there been so much controversy? I suggest that there are three reasons for this. Many cyclists feel that their cycling is part of their personal freedom. They also feel that cycling, with the exercise that it gives, is healthy. Therefore, anything that cyclists see as discouraging people from taking exercise and enjoying personal freedom is wrong. Many cyclists view helmets as a major discouragement to cycling and therefore something to be opposed. There is also the mis-apprehension that each injury needs one preventive solution. Therefore, anyone who is for helmets is against bicycle lanes and separation of bicycles from traffic. This is not the case with other injuries that children receive. For instance, no one would seriously suggest that just because a house has a smoke alarm that there should be no flame-resistant upholstery. Neither would anyone seriously suggest that just because one has traffic calming there should be no additional work carried out against drivers who consume too much alcohol. There is also the mistaken belief that any injury control solution should be completely effective. No one expects seat belts to completely stop injuries to car passengers, so why should be expect helmets to completely prevent cycle injuries. We have personal experience in the difficulties experienced during cycle helmet campaigns in our work in Wales. We used cycle helmets as our first campaign in our Safe Child Penarth initiative (Kemp, Gibbs & Silbert 1994). However, every time we published a piece in the local paper we had letters from Penarth cyclists saying that helmets were unnecessary. These problems were confounded by the publishing during our campaign of the Policy Institute report (Policy Studies Institute 1993). This report, funded by a Cyclists' organization, put all their fears in a form that they could easily use.

Child health surveillance: development of a multicentre course and its evaluation.

With increasing numbers of general practitioners wishing to provide child health surveillance during the 1980s and the expected further increase with the 1990 General Practice Contract, a course in child health surveillance was developed. The content of the course was determined by a needs assessment of Welsh general practitioners in combination with the expectations of paediatricians already involved in educating doctors in community child health. A multicentre course with prepared materials was developed. Teaching methods reflected adult learning needs, included practical clinical competencies and was centred in small groups each led by local tutors. The course was held annually on three occasions, with 220 participants in total. The materials and teaching methods were highly acceptable to the participants, and evaluation demonstrated a significant increase in knowledge and confidence. All participants reached the required clinical competence, six after further teaching. The content, teaching methods, and evaluation methods were altered in the light of feedback, resulting in a 'stand alone' course with built-in evaluation, which is now being provided by local tutors. This study has demonstrated the feasibility of providing a course for large numbers of doctors, using predominantly small-group teaching and discussion with local tutors. We are grateful to all the participants and especially the tutors.