Jacqueline Mok

Lack of agreement on colour description between clinicians examining childhood bruising

INTRODUCTION In child protection cases clinicians are often asked to describe and age bruises. This paper looks at both intra- and inter-observer variability in the description of childhood bruising. METHODS Fifty-eight bruises on 44 children were described by three observers, the bruises were then photographed and the same observers described the bruises at a later date. The descriptions were compared and classified in terms of complete, partial, or no agreement, both between observers and between the in vivo and photographic descriptions. RESULTS Complete agreement on colour description between two observers in vivo occurred in 27% of descriptions in vivo and 24% of photographs. Only 31% of descriptions completely agreed with the later description of a photograph of the same bruise. CONCLUSIONS This marked variability in colour description, severely questions the practice of estimating the age of bruises especially from clinical photographs as evidence in child protection proceedings.

The dental practitioner and child protection in Scotland.

Objectives To identify from general dental practitioners: undergraduate and postgraduate training experience in child protection; numbers of suspected cases of child physical abuse; reasons for failing to report suspicious cases of child physical abuse; knowledge of local child protection protocols and procedures for referral.Materials and methods Postal questionnaires were sent to 500 randomly selected general dental practitioners in Scotland, with a further 200 sent to a random sample of the original 500 to increase response rate.Results Sixty-one per cent (306) of the original 500 questionnaires, and 35% (69) of the second random mail shot of 200 questionnaires were returned. Only 19% could remember any undergraduate training and 16% had been to a postgraduate lecture or seminar in child protection. Twenty-nine per cent of dentists had seen at least one suspicious case in their career. Only 8% of suspicious cases were referred on to the appropriate authorities. Reasons for failure to refer revealed that 11% were concerned about a negative impact on their practice, 34% feared family violence towards the child, 31% feared violence directed against them, and 48% feared litigation. Only 10% of dentists had been sent a copy of the local child protection guidelines on commencing work and only 15% had seen their Area Child Protection Committee (ACPC) Guidelines via any route.Conclusions Due to lack of training or clear guidelines for dentists in Scotland, most practitioners were unsure what to do in the event of a suspicion of child abuse. Twenty-one per cent of dentists had encountered suspicious cases but failed to take any action. Dentists overwhelmingly requested appropriate training. This training should address dental competence in assessment of suspicious indicators and involve dentists in inter-agency child protection training.

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 77173 accident and emergency department attendances with 58059 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.

Child protection medical assessments: why do we do them?

Introduction Child protection guidelines highlight the importance of medical assessments for children suspected of having been abused. Aim To identify how medical assessments might contribute to a diagnosis of child abuse and to the immediate outcome for the child. Method Review of all notes pertaining to medical assessments between January 2002 and March 2006. Results There were 4549 child protection referrals during this period, of which 848 (19%) proceeded to a medical examination. 742 (88%) case notes were reviewed. Of the medical examinations, 383 (52%) were for alleged physical abuse, 267 (36%) for sexual abuse and 20 (3%) for neglect. 258 (67%) of the physical abuse cases were considered to have diagnostic or supportive findings as compared to 61 (23%) of the sexual abuse cases (χ2=146.31, p<0.001). In diagnostic or supportive examinations or where other potentially abusive concerns were identified, 366 (73%) proceeded to further multi-agency investigation and 190 (41%) to case conference. 131 (69%) of these resulted in the registration of the child on the child protection register. Other health concerns were identified in 121 (31%) of physical and 168 (63%) of sexual abuse cases. Conclusion In this case series, 465 (63%) out of 742 examinations showed signs diagnostic or supportive of alleged abuse or highlighted other abusive concerns. This endorses the view that medical examination is an important component in the assessment of child abuse as it provides information to support or refute an allegation and helps to identify the health and welfare needs of vulnerable children.

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.

The needs of children whose mothers have HIV infection

AIM To ascertain the psychological, social, and educational needs of children born to mothers with HIV infection. METHODS Review of case records of 120 children and 86 mothers. RESULTS The cohort of 120 children were born to 92 women, and followed up for a median duration of 48 months (mean (SD) 51.1 (34.1), range 0.3–132). Sixteen children were infected with HIV, 15 were of indeterminate status, and 89 uninfected. Eighty one children (68%) were cared for by their birth mother, of whom 52% were single women and 23 (38% of 61) known to have symptomatic HIV disease. Twenty five mothers of 32 children had died; the child’s mean (SD) age at maternal death was 66.9 months (37.7) (range 4–128). Compared with uninfected children, more infected children knew of their mother’s diagnosis (31% v 5%) and mothers were also more likely to disclose their own illness to educational authorities (77%v 13%). A larger proportion of infected children had special educational needs (69% v 13%). Only 33 children (28%) were known not to be receiving any support from the voluntary or statutory agencies. CONCLUSION The results highlight the multiple needs of children living with maternal HIV infection, which require dedicated resources and commitment from health, education, and social work agencies and the voluntary sector. We propose the model of chronic illness as the standard of care for these children.

MYCOPLASMA PNEUMONIAE INFECTION A Retrospective Review of 103 Hospitalised Children

Abstract. The clinical aspects of Mycoplasma pneumoniae infection in 103 children under 12 years admitted to hospital over an eight‐year period were reviewed retrospectively. Respiratory illnesses occurred in 87 (85 %) cases. The prevalence of lower respiratory tract involement was similar in both pre‐school and school children. Cough was the commonest symptom at all ages. Coryzal symptoms and wheeze were common in pre‐school children. Most infants had signs of pharyngitis or otitis media. Non‐specific symptoms—fever, lethargy, malaise, anorexia and vomiting—were common accompaniments in children older than one year of age. Non‐respiratory illnesses in 16 (15%) patients included gastroenteritis, convulsions, non‐specific skin rashes and limb pains. The duration of stay in hospital ranged from two to 30 days (median five days) with apparent clinical recovery and resolution of chest X‐ray abnormalities within three months in 78 (76 %) patients seen for review.

Violence against children: the UN Report

> Understand that one person can do something about violence but many people can stop violence. > > No violence against children is justifiable; all violence against children is preventable. In November 2006 the UN issued the Secretary-General’s Report1 on violence against children. In a joint initiative, the Office of the High Commissioner on Human Rights (OHCHR), the United Nations Children’s Fund (UNICEF) and the World Health Organization (WHO) have led the first global attempt to describe the scale and impact of all forms of violence against children. It follows the previous study2 by Graca Machel (wife of Nelson Mandela) on violence against children in armed conflict. It is therefore relevant to the UK and to the work of paediatricians who see the results of this violence in children’s lives, and is essential reading both in its wealth of statistics and its global overview of how to prevent violence. We review the report to bring out its implications for UK paediatricians, who are much concerned with the impact of violence and have a central role to play in its prevention. Paediatricians are key players in the management of child abuse and in protecting children from harm. Can they also take a high profile role in the prevention of violence and the promotion of non-violent policies? The independent expert appointed to lead the study is Dr Paulo Pinheiro and his concept for the study outlines the objectives and methodology.3 The research covered the magnitude of violence, the causes both locally and nationally, and strategies for prevention. The methods used included information obtained from international and national organisations, regional consultations, field visits and wide discussion with children and young people. The last was a strong feature of the study and adds to its value; children’s comments are provided below. New research was …

The epidemiology of oro-nasal haemorrhage and suffocation in infants admitted to hospital in Scotland over 10 years

Objective To estimate the incidence of oro-nasal haemorrhage (ONH) and suffocation in infancy and to investigate their aetiology and overlap. Setting A 10-year retrospective hospital based study from Scotland, UK. Methods The hospital notes of all infants presenting with ONH or suffocation identified through the Information Services Division of the Scottish Health Service were reviewed by three paediatric consultants, two with child protection expertise. The hospital-based incidences of haemorrhages from different sites were calculated and the causes ascertained. When trauma was involved, a decision was made whether it was likely to have been accidental. Results 7 cases of suffocation and 88 of ONH were recorded at hospital discharge over 10 years. This gives an incidence of ONH of 1.62 (1.30 to 1.99)/10 000 live births (95% CI) which consists of haemorrhage arising from nose or mouth (N/M), n=65 (1.19/10 000 (0.92 to 1.52)); haematemesis, n=11 (0.20/10 000 (0.10 to 0.36)); haemoptysis, n=3 (0.06/10 000 (0.1 to 0.16)) and pulmonary haemorrhage, n=9 (0.17/10 000 (0.08 to 0.31)). No suffocation cases were recorded as having a coincident ONH, but five ONH cases were probably caused by airway obstruction. 40 of 65 cases of N/M were associated with trauma, which in 15 cases were thought to be probable abuse; four were associated with coagulation abnormalities. 2/3 haemoptysis cases, 2/11 haematemesis cases and 8/65 N/M cases were associated with a coincident respiratory tract infection, though in 4/8 of these cases, there was an associated apparent life-threatening event. Conclusions Haemorrhage from the N/M is rare in infancy. Trauma is commonly involved and child protection concerns often poorly explored. Pulmonary haemorrhage and several cases of ONH were associated with probable airway obstruction. Information, in cases of ONH, is in general recorded badly, and an investigation and management plan are suggested.

The joint paediatric–forensic examination in child abuse

The investigation of alleged child abuse should be multi-professional and coordinated to minimize distress to the child and family. Much attention has focused on the joint interview process, with less prominence being given to the medical component of the initial investigation. No standard practice exists in the United Kingdom regarding the conduct of the medical examination or in the training requirements of the doctors who perform the examination. We present a model of practice which has evolved in Edinburgh and the Lothians, drawing on the combined expertise and experience of paediatricians and police surgeons, which has operated for over 2 years; and propose a formal accreditation process for doctors who wish to specialize in the field of child abuse.