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C. Hobbs, J. Price, A. Thomas. RCPCH, London, UK
AimsTo collect information about current UK practice in the medical examination of children in whom sexual abuse is suspected.
MethodsTwo questionnaires were sent out to 383 named and designated doctors in child protection. The second detailed questionnaire was additionally sent to forensic medical examiners (FMEs) who examine children.
ResultsWith regard to colposcope use, of 249 replies from questionnaire 1, 133 had dedicated use, 32 shared use and 75 no access. 158 paediatricians, 88 FMEs and 2 others replied to questionnaire 2. 64/181 respondents indicated that the colposcope was sited in a dedicated area. Of 211 doctors who examined children, 142 made hand drawings, 199 used body plans, 11 used still film photography, 46 still digital photography and 52 videophotography. 88 photographed all findings, normal or abnormal and 36 only abnormal findings. Of 248 respondents, Paediatricians examined alone (110), FMEs examined alone (73), paediatricians and FMEs examined jointly (192), 2 paediatricians examined jointly (85), or a paediatrician examined with another doctor (mainly GUM/Gynae) (7). Sexually transmitted infections were sampled for by 192 (where specified, selective in 131, routinely for all children in 16). 129 respondents had difficulty recruiting staff to examine these children. Professional support included peer review (90), attendance at a training course (57), a trusted colleague (86) or nothing (34). Only 35 respondents indicated that SpRs were involved in seeing sexually abused children in their area.
ConclusionsImprovements in practice and service provision have slowly taken place since the last survey in 1996. This area of paediatric practice requires further strengthening by increasing staffing resources, universal training at SpR and Consultant level and enhanced support systems for medical staff.
C. Kirk, A. Lucas‐Herald, J. Mok. Royal Hospital for Sick Children, Edinburgh, UK
IntroductionChild protection guidelines highlight the importance of medical assessments for children suspected to have been abused. However, the contribution of the medical examination to the outcome for the child has not been evaluated.
AimTo review the findings and immediate outcome of medical examinations generated from child protection referrals over a 4‐year period.
MethodRetrospective review of all examinations performed between January 2002 and March 2006. Examination findings, follow‐up and outcome for each child were collated in a database.
ResultsThere were 4549 child protection referrals during this period, of which 860 (18%) proceeded to a medical examination. 742 (86%) case notes were reviewed. Of the medical examinations, 381 (51.3%) were for alleged physical abuse, 262 (35.3%) for sexual abuse, 20 (2.6%) for neglect and 79 (10.6%) were either a combination or other forms of abuse. 15 (2%) examinations were considered to be “diagnostic of abuse” and 352 (47%) described signs that were supportive of the alleged abuse. In 102 (13.7%) occasions other causes for concern were identified, despite the examination being unable to support the initial allegation. Of those examinations that were diagnostic or supportive of abuse 157 (43%) proceeded to case conference and the child was placed on the child protection register or in long‐term foster care in 149 (94%) of these. Of the remaining examinations, 182 (48%) identified other health concerns. 618 (91%) children were followed up, the majority by community paediatricians.
ConclusionIn this review 549 (73%) out of 742 examinations showed signs supportive of abuse or highlighted other 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 health and welfare needs of vulnerable children.
H. Smith1, V. Coupes2. 1Central Manchester and Manchester Children's Hospitals, Manchester, UK; 2Fairfield General Hospital, Bury, Manchester, UK
AimsTo identify the prevalence of harbinger injuries in infants and children who suffer serious physical abuse, to record the nature and timing of those injuries and the action taken, and to record the outcome of children suffering serious physical abuse.
MethodsRetrospective record review of children (16 years and under) presenting to the Child Protection team at a tertiary Children's Hospital with GBH‐level injuries agreed to have been caused by abuse over a five year period. These were then analysed by one reviewer for demographic details, details of the presenting injury and details of any previous injury.
ResultsForty three notes were reviewed and the age range was 11 days to 4 years. 24/43 were boys and 37/43 were under 12 months. 35 had suffered head injuries at presentation. An account suggesting previous (harbinger) injury was documented for 13/43—11 of these were non‐mobile infants with bruising, 8 of whom had bruising to the head and neck, 1 to the torso and 2 to upper limbs. Eight harbinger injuries had been seen by clinicians, but only one had undergone further investigation and referral to Social Services. Six children died, of whom 3 had previous injuries documented.
ConclusionsSerious abuse may be preceded by less severe assaults leaving apparently minor bruising. The presence of bruising in a non‐mobile infant should always lead to paediatric assessment with critical consideration of any explanation offered. There should be a low threshold for proceeding to skeletal survey and brain imaging.
S. Maguire1, S. Rajaram1, M. Mann1, T. Jaspan2, N. Stoodley3, A. Kemp1. 1Cardiff University, Cardiff, UK; 2Queen's Medical Centre, Nottingham, UK; 3Bristol Children's Hospital, Bristol, UK
BackgroundNon‐accidental head injury has the highest morbidity and mortality of any abusive injury. Who should be investigated, what modality should be used and when are prevailing clinical questions.
AimTo define the optimal neuroradiological investigation strategy for detecting and defining the extent of inflicted traumatic brain injury.
MethodsAn all language literature search of 13 databases, from 1970. Included: studies of children <18 years with inflicted brain injury confirmed on neuro‐imaging. Excluded: studies with mixed adult and child data, of outcome or prognostic indicators or postmortem imaging. All studies underwent two independent reviews, by a panel of paediatricians/paediatric neuroradiologists.
ResultsOf 196 studies reviewed, 13 were included, representing 318 children aged 0–4 years (mean age 6.3 months). Six compared the additional benefit of MRI to early CT, showing new information in 65%. One study confirmed the role of early CT in detecting acute interhemispheric bleeds. Two studies compared diffusion weighed imaging (DWI) with conventional MRI, showed enhanced detection of cerebral ischaemia in 14/17 children. Two studies addressed the benefits of follow‐up CT in 26 cases (1.5 days to six months later) and gave increased information about evolving ischaemia in 11/12 cases, an enlarging SDH in one, and an alteration in surgical (4), medical (2) or legal outcome (4) in the remainder. One study demonstrated positive neuroradiology in 19/51 neurologically asymptomatic children, with a high suspicion of physical abuse. There is no study of serial MRI up to 2–3 months post event. Three studies looked at the role of ultrasound, validating its complementary role in detection of contusional tears, and a limited role as a follow‐up investigation.
ConclusionsThe conclusions of this review are limited by varying timing, imaging techniques, clinical indications and radiological interpretation. The published data suggest that CT and MRI have complementary roles. The optimal strategy to fully delineate inflicted brain injury is either early CT scan with early MRI and DWI or CT scan and a follow up CT scan. Neuro‐imaging is justified in an infant where physical abuse is strongly suspected even in the absence of neurological symptoms. These recommendations need validating in a prospective study using current radiological techniques.
L. Coles. Cardiff University, Cardiff, UK
Aims(1) Find out the barriers and facilitating factors for the prevention of accidental and non‐accidental head injury (NAHI), including from shaking. (2) Develop prevention strategies and tools for community practitioners and parents to learn about the risks and consequences of not protecting babies' heads.
MethodThis qualitative study had ethical approval and used semi‐structured interviews based on the research aims. Nine focus groups with a purposive sample of 70 mothers, fathers and health visitors were held in urban settings and a prison. The criteria for participants reflected risks for accidental and NAHI: areas of deprivation and social isolation, being single and unemployed, having multiple partners, substance abuse, crime and low literacy.
ResultsNew fathers, unlike mothers, were often excluded from learning about handling babies safely and coping with triggers for abuse, such as persistent crying, when in contact with health services. Fathers showed motivation to learn, an awareness of masculinity as potentially harmful to a vulnerable baby, and a sense of responsibility when handling their newborn. Confidence was gained from the sidelines by observation of how others managed. Intervention strategies to engage the hard to reach groups to prevent head injuries were suggested by mothers and fathers. These offered some solutions to the barriers of working preventatively that were raised by health visitors. Service barriers need resolving. A protecting babies' heads teaching toolbox, with leaflets for parents and a practice guide for professionals, has been published by the CPHVA with support from the NSPCC from this study and our previous research.
ConclusionsMale carers are responsible for 75% of NAHI in babies yet in this study of a risk group most were excluded from learning opportunities about handling babies safely and learning the dangers of shaking. Parents were imaginatively able to suggest solutions for engaging this hard‐to‐reach group. A limitation is that this qualitative research can only be generalised to similar contexts. However, generalisation on a theoretical level can be made in that prevention of accidental and NAHI cannot be universal unless there are changes in service and practice to include fathers.
A. De1, O. P. Srivastava2, S. Skinner1. 1Luton and Dunstable Hospital, Luton, UK; 2Luton Primary Care Trust, Luton, UK
IntroductionWith the growing concern of maternal substance abuse, the Advisory Council on the Misuse of Drugs recommends ways to identify these vulnerable children to prevent further harm. We surveyed our practices against the given recommendations in the local unitary area.
Aims(1) to determine the ease of identification of newborns of problem drug users from antenatal and postnatal health recording system; (2) to identify the adequacy of existing health surveillance system in respect of information recording and information sharing to address and assess the immediate and future needs of these children.
MethodsRetrospective case record analysis of hospital and community child health records in the English unitary authority of Luton Borough Council. Cases were neonates born to mothers with history of substance abuse identified perinatally. Cases were identified from the neonatal unit admission register who had one or more of following admission/discharge diagnoses: neonatal drug withdrawal, maternal substance abuse, admitted for foster care/adoption/social reasons, unbooked pregnancy and baby on social services' at‐risk register. Case identification period was February 2000–2 and Community Child Health Records analysis period February 2000–4.
ResultsTwenty eight neonates were identified by the search criteria of which 12 babies were born to substance‐abusing mothers. Eight (67%) cases were known antenatally, women were single (9/12) or multiple (3/12) drug users, adverse socio‐domestic factors were noted in 9, antenatally social services were involved in 4. Paediatricians were notified in 2 cases, antenatal planning meeting took place in none. Nine babies needed treatment, 5 babies were discharged home on medication. Four babies were discharged to foster care. Nine out of 10 cases attended at least 1 hospital follow‐up appointment but only 58% completed 2‐year health surveillance check. 16.6% cases were uncontactable by 2 years of age.
ConclusionPitfalls in current health recording and surveillance system and lack of information sharing result in underdetection of problem drug users antenatally and leads to failure of effective multi‐agency planning and management of these women and newborns.
A. M. Slade, C. R. Tapping. Leeds General Infirmary, Leeds, UK
AimsTo examine paediatricians' views on smacking children as a form of discipline.
MethodsA quantitative and qualitative questionnaire was sent to 15 Paediatric departments between October‐December 2005. Their willingness to participate was obtained via email asking Consultants for their support. Questionnaires were then distributed during one of their meetings. 87 subjects were identified; 32 Consultants, 23 Specialist Registrars, 28 Senior House Officers, and 4 Pre‐Registration House Officers. Responses were categorised and data analysed using χ2 tests.
Results90% of respondents were smacked and 71% would smack their child. Factors associated with a higher tendency to smack were having children, being male, senior grade and being surgically trained. Being smacked also meant subjects were more likely to smack their child (p<0.001). 48% thought smacking was effective, and 64% did not think it had a life‐long effect on the child. Although most paediatricians (61%) had witnessed evidence of smacking in their professional lives, 67% did not view it as abuse and 69% did not wish the government to ban smacking completely. 64% felt it was ultimately a parent's right to smack their child. Only 63% could list alternatives to smacking, with junior staff citing the least.
ConclusionsPaediatricians' views on smacking are affected by their own experiences as children, parents and professionals. Their different views may influence the advice given on discipline to parents and the decision to investigate cases of suspected child abuse. For example, those that smack will find it harder to criticise others for doing the same. This could lead to incidences of suspected abuse being accepted as parental discipline by some, and result in cases of abuse being under diagnosed with detrimental consequences. Providing information on alternative disciplinary methods may mean fewer people smack and this in turn may reduce rates of non‐accidental injury. This is particularly important given that the government's current standpoint on smacking is unclear and that paediatricians differ in opinions about the effectiveness of smacking and the need for its complete ban.
K. Aucharaz, D. Smith. York Hospital NHS Trust, York, UK
AimsThere is a perception that staff may be reluctant to become involved in child protection (CP) work because of fear of criticism, fear of confrontation, professional complaint and media publicity. We aimed to study the actual pattern of issues that most concern staff and how these have been addressed in training. We also aimed to study whether perceived difficulties were actually experienced and whether administrative as well as clinical staff were affected.
MethodWe compared our practise with the local children safeguarding board recommendations for good practice in staff training and support. An audit questionnaire was given to all members of a UK general hospital paediatric department. This examined staff training, support, frequency of involvement, court attendance, confidence in recognising different forms of abuse and the pattern of issues which caused most concern when approaching CP work.
Result120 questionnaires were returned. Training experience was overall good (>94% at least level 1) but a wide range of different training methods were reported from diverse backgrounds of staff. CP work was a frequent part of both administrative and clinical staff work with 38.3% involved in at least one case per month. Many staff (33.7%) did not have an identified mentor for CP work. 36% of the staff attending court had no specific training. Staff were more confident in their ability to recognise physical abuse and neglect than emotional, sexual and factitious induced illness abuse. Fear of complaint was reported but not ranked highly in a table of different concerns when approaching CP cases. Staff were most highly concerned about factors of the distress of the children involved and the importance of establishing the correct diagnosis.
ConclusionsAll grades of clinical and administrative staff are affected by CP issues, which they find stressful. Staff training needs regular updates and should address attending case conferences and court hearings. CP training should include training in recognising and managing the emotional stress associated with involvement in cases. Recent publicity has highlighted the issue of fear of professional criticism; however, the issue that most concerns staff is the distress of the abused children.