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Listening to a child is a paramount activity, yet, the ‘silence is defeaning’.1 The importance of hearing the voice of the child or young person who is traumatised, and the importance of justice to survivors, cannot be overstated. This applies particularly to survivors of child sexual abuse (CSA) where report of maltreatment might well influence the legal process. The article by Marchant et al 2 notes that imprecations to health professionals to listen and hear the child’s voice are not accompanied by explanations on how to do this ‘practically, well or safely’. They provide guidance on how to do this, through expertise gained through Triangle Services for Children, an independent organisation enabling children and young people to communicate, especially in legal proceedings. The authors use the ‘Opening Doors’ framework that ‘draws on what is known about children’s memory and children’s testimony’. One author (Ruth Marchant) died in December 2018. She was an experienced forensic interviewer who brought considerable expertise and humility to bear, particularly with very young children.3 There is potential difficulty in how a paediatrician might enable a child to tell their story and how that might impact on the child’s need for justice that is duly recognised by the authors of this timely and important paper. This commentary provides both paediatric (GD) and legal (RP) insight into this tension. This will inevitably reflect the situation within England and will reflect the situation in other jurisdictions. The authors of Opening Doors have ‘reframed’ the term ‘disclosure’ for reasons that, within the ‘Opening Doors’ framework, and with its specific meaning in the legal system, seem valid. This article will adopt ‘report of maltreatment’ which is used in HM Government guidance instead of ‘disclosure’. CSA is associated with adverse effects on physical and mental health that, without effective intervention, …

There is emerging evidence of increase in injuries to children associated with abuse or neglect during the lockdown in response to the COVID-19 pandemic.1 We report an increase in the numbers of children under 16 years, during the COVID-19 lockdown period, with safeguarding concerns, and who were admitted under neurosurgery for head/spinal injuries following falls from height. Retrospective analysis of referrals from our hospital to children’s social care (CSC) from 1 April to 30 June 2020 was compared with data from the same period in 2018 and 2019. Children admitted with neurosurgical trauma, including falls out of buildings during school closure, were analysed. Referral to CSC and multiagency strategy meetings were used as an indicator of verifiable safeguarding concerns, justified by established organisational processes for convening strategy meetings after individualised case review, when there is risk of significant harm. During …

Objectives Describe cases of female genital mutilation (FGM) presenting to consultant paediatricians and sexual assault referral centres (SARCs), including demographics, medical symptoms, examination findings and outcome. Design The well-established epidemiological surveillance study performed through the British Paediatric Surveillance Unit included FGM on the monthly returns. Setting All consultant paediatricians and relevant SARC leads across the UK and Ireland. Patients Under 16 years old with FGM. Interventions Data on cases from November 2015 to November 2017 and 12 months later meeting the case definition of FGM. Main outcome measures Returns included 146 cases, 103 (71%) had confirmed FGM and 43 (29%) did not meet the case definition. There were none from Northern Ireland. Results The mean reported age was 3 years. Using the WHO classification of FGM, 58% (n=60) had either type 1 or type 2, 8% (n=8) had type 3 and 21% (n=22) had type 4. 13% (n=13) of the cases were not classified and none had piercings or labiaplasty. The majority, 70% had FGM performed in Africa with others from Europe, Middle East and South-East Asia. There were few physical and mental health symptoms. Only one case resulted in a successful prosecution. Conclusions There were low numbers of children presenting with FGM and in the 2 years there was only one prosecution. The findings may be consistent with attitude changes in FGM practising communities and those at risk should be protected and supported by culturally competent national policies

The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) has recently published what they purported to be a systematic review of the literature on ‘isolated traumatic shaking’ in infants, concluding that ‘there is limited evidence that the so-called triad (encephalopathy, subdural haemorrhage, retinal haemorrhage) and therefore its components can be associated with traumatic shaking’. This flawed report, from a national body, demands a robust response. The conclusions of the original report have the potential to undermine medico-legal practice. We have conducted a critique of the methodology used in the SBU review and have found it to be flawed, to the extent that children’s lives may be put at risk. Thus, we call on this review to be withdrawn or to be subjected to international scrutiny.

Background Sexually transmitted infections in children ought to raise concerns about sexual abuse. It is not known how frequently they are identified in the UK and Ireland, nor how well they are investigated. Aims To measure the incidence, mode of presentation, investigations and child protection procedures among children under 13 years and over 12 months of age presenting with infections of Neisseria gonorrhoea , Treponema pallidum , Chlamydia trachomatis or Trichomonas vaginalis in the UK and Republic of Ireland. Methods National surveillance study over 25 months through the British Paediatric Surveillance Unit. All consultant paediatricians in the UK and Republic of Ireland reported laboratory confirmed infections followed by a confidential questionnaire covering clinical details, investigation results and child protection outcomes. Results Fifteen cases were reported, giving an overall incidence of these infections of 0.075 cases per 100 000 children per year. Most were identified because they presented with symptoms. Five cases presented with ophthalmic infection. Laboratory investigation and screening for other infections was adequate in most cases. Although only three cases of sexual abuse were confirmed in court or case conference, abuse was suspected in a further seven cases based on clinical factors, family or social history. Conclusions Sexually transmitted infections in children, although rare, are generally well investigated. The findings support current guidance on the management of sexually transmitted infection in young children and the need to maintain a high index of suspicion for sexual abuse. Isolated ophthalmic infection with N gonorrhoeae and C trachomatis occurs beyond infancy, but the mode of transmission is unclear.

I asked a 13-year-old girl whether she had been cut. She replied, “That's horrible isn't it”, a rhetorical question to which I nodded assent. She felt that it was an appropriate question to ask, given the clinical context. The next morning I read, “Cameron in crackdown on summer surge of FGM cases” (from The Observer , Sunday 14 June 2015). New laws aimed at preventing young girls being taken abroad to undergo what the prime minister described as the “cruel and barbaric practice” of female genital mutilation (FGM) were to be “fast-tracked within weeks, amid fears that the number of cases could soar during the summer holidays”. The headline and story is revealing in a number of respects: it is one of a number of articles, particularly in the lead up to the historic Girl Summit in London in July 2014, that reflect increasing community, professional and political concern over the practice of ‘FGM/cutting’. It signals government determination to eradicate this practice yet does so in a tone and language that might be construed as hostile to the very communities and their activists who put FGM onto the front pages in the first place. Later that week, I was sent a link to the West Midlands Police and Crime Panel press release, which announced that, between January and November 2014, 118 cases of FGM had been referred to the West Midlands Police, and that, while there had been “no reports to West Midlands Police of mutilation in the area”, there had been some intelligence to suggest girls “are brought to Birmingham to be cut”. Is there a ‘summer surge’ when at-risk children and young people from practising communities are more vulnerable? Is there a risk that some of those children will be sent to Birmingham to be cut? Are these …

We welcome scientific debate around the recognition of abusive head trauma. The Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) report concludes, ‘ There is limited scientific evidence that the triad and therefore its components can be associated with traumatic shaking. ’1 We have provided a methodological critique of the SBU report2 which we hope provides points for others to consider when interpreting it. …

BackgroundIn response to a resurgence of symptomatic cases of vitamin D deficiency in a high-risk predominantly ethnic minority population, a programme of universal rather than targeted vitamin D supplementation was begun with a public awareness campaign about the importance of vitamin D.ObjectiveTo evaluate the effectiveness of this programme in reducing case numbers.MethodsCases of symptomatic vitamin D deficiency in children under 5 years resident in a primary care trust catchment area presenting at local hospitals were identified through laboratory records of low vitamin D levels which were cross-checked against medical records to confirm the diagnosis. Comparisons were made of the case incidence rate, level of public knowledge and vitamin supplement uptake rate at the onset of the programme in 2005 and 4 years later.ResultsThe number of cases of symptomatic vitamin D deficiency in those under 5 years fell by 59% (case incidence rate falling from 120/100 000 to 49/100 000) despite the supplement uptake rate rising only to 17%. Public awareness of vitamin D deficiency rose to near universal levels.ConclusionsA programme of universal rather than targeted Healthy Start vitamin D supplementation for pregnant and lactating women and young children has led to a substantial decrease in cases of symptomatic vitamin D deficiency in a high-risk population. Supplementation was also started at a younger age than in the national programme. This approach has implications for the delivery of vitamin D supplementation programmes in similar populations.

The National Health Service (NHS) is embarking on significant changes. The new Health and Social Care Act comes into force on 1 April 2013 alongside increasing demographic challenges and capacity pressures. While costs are set to soar, finances are increasingly constrained so that the effective delivery of integrated out-of-hospital care coordinated around the needs of the child and family is vital. The case report1 illustrates how families’ lives are turned upside down when sustaining complex care at home. Adverse medical outcomes may partly reflect the difficulties connecting secondary health and social care. Previous failings in safeguarding show the dangers of a disconnected system and it is critical that the new commissioning arrangements should encourage integration. There has been a fourfold increase in young patients on Home Parenteral Nutrition (PN) since 1993 with a mean of 13.7 children per million.2 Young mothers are over-represented since teenage pregnancy is a risk factor for low birth weight and preterm delivery. Short bowel syndrome due to necrotising enterocolitis as a cause for intestinal failure has increased. Maternal age less than 20 years is also associated with gastroschisis and a near tripling of gastroschisis cases has led to more children requiring Home PN.3 Home PN requires technical competencies and strict adherence to daily routines. Recurrent catheter related blood steam infection with late presentation is a risk factor for intestinal failure associated liver disease. Intestinal transplantation is offered when PN has reached its limits due to life-threatening complications such as recurrent infections. Care routines continue to be demanding after transplantation. If parents are unable to maintain strict …

The implications for sexual abuse investigation of genital herpes in a child are uncertain because of a lack of good quality research evidence. The incidence, presenting features, history of exposure, indicators of child maltreatment and outcomes of child protection investigations in children with genital herpes are described.Ascertainment of all cases of genital herpes in children11 years of age first presenting to paediatricians in the UK and Ireland from April 2007 to April 2009 conducted through the British Paediatric Surveillance Unit.23 cases were notified. The incidence of confirmed and all reported cases was 0.091 and 0.13 per 100,000 children per year, respectively. Of the 16 virologically confirmed cases, 12 were female, 11 were5 years of age, 14 had herpes simplex type 1, eight were tested for other sexually transmitted infections (STIs), and only one had a full STI screen. Three cases had other clinical features suggestive of sexual abuse. Six cases were referred for child protection investigation, but no sexual abuse was substantiated.Genital herpes in children under 11 years is rare. Almost a third of children diagnosed with genital herpes did not have appropriate virological investigation and few were screened for other STIs. Around a quarter of cases were referred to child protection agencies for further investigation, which limits any inferences in this study about mode of transmission in children. Sexual abuse guidance should emphasise the need for thorough assessment and investigation in cases of genital herpes in children.

Aims National radiology standards for investigation of suspected physical abuse (PA) in under 1 year olds recommend that a head CT should be performed alongside other investigations. Clinicians express anxiety regarding the radiation dose to the infant brain. This audit looks at adherence to guidelines and whether clinical indicators can be refined. Methods This audit, in two teaching hospitals, identified infants who underwent investigation for suspected PA (January 2005–2008). Standardised data were extracted from case and radiology records and entered into an anonymised database. Presenting neurological symptoms (seizure, vomiting, apnoea, altered or loss of consciousness and altered behaviour) and neurological signs (focal neurology, bulging fontanelle or enlarging head circumference) plus documented injuries were recorded. Cases were allocated a level of concern of PA; high (unexplained fracture, bruising or head injury), medium (sibling, thermal injury) or low (clear accidental/medical cause). Results 180 children were identified: 89 (49%) underwent CT head scan (58 high, 20 medium, 11 low risk). 91 had no CT (15 high, 36 medium, 40 low risk), of which 12 had neurological symptoms/signs and 35 had associated injuries suggestive of PA. 31/89 (35%) children who had CT showed intracranial injury (ICI). [Table 1][1] identifies the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for ICI on CT in children with neurological symptoms/signs and in children with neurological symptoms/signs or facial/head bruising. View this table: Abstract P4 Table 1 Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for intracranial injury (ICI) on CT for children with neurological symptoms/signs and for children with neurological symptoms/signs or facial/head bruising Conclusions This audit shows clinicians do not wholly follow radiological standards. Clinical decisions to perform a head CT were directly related to the level of perceived risk of PA. Of concern, some high risk cases with neurological symptoms/signs had no CT. Our data shows that should neurological symptoms/signs be used as a predictor of ICI the sensitivity is 81% and specificity 83%. If facial/head bruising is added as an indicator the sensitivity would rise to 100% and specificity falls. We acknowledge an element of selection bias in this data. However, the findings reflect current clinical practice and identify strong clinical indicators for ICI in suspected PA in infancy. [1]: #T1

Background 63% of all childhood thermal injuries affect children under 3 years old and many would advocate that they represent an element of neglect, ‘failure to protect a child from physical, harm or danger, to ensure adequate supervision, access to appropriate medical care or treatment’. This study explores factors associated with thermal injury to identify possible indicators of childhood neglect. Methods Data regarding markers of possible neglect were collected from children 24 h to presentation for children with a partial-thickness-burn or worse (significant burn), known to social services. Cases referred to child protection services were compared with those that were not. Results 1031 cases included in the study, 82%(846) had a superficial-partial-thickness burn or worse, late presentation: 24% (203/846) presented > 24 h post injury. lack of supervision: 23.5% of children were unsupervised at the time of injury. First aid: 25.5% received no, inadequate or detrimental first aid in the home, 12.6% were known to social services. Regarding the number of risk factors in each child with a significant burn: 39% had one, 29% had two 11% had three and 13.6% had four risk factors. 104 cases were referred to child protection services. With the exception of injury severity and ‘known to social services’ there was no significant difference in the number or nature of risk factors or age group between those referred and those not. 4/104 cases of abuse were substantiated. Conclusions This study shows that there is no difference between the markers of possible neglect between children referred to CP services and those that are not. We would advocate that all of these children need some degree of secondary prevention. A needs-assessment tool could be administered in EDs to identify three groups of young children who (1) those who need simple injury prevention advice, (2) those who require additional prevention advice on appropriate first aid/supervision etc. (3) those who have multiple needs and may require assessment for a child-in-need or child protection assessment.

To compare the clinical characteristics associated with sudden infant death syndrome (SIDS) and explained sudden unexpected deaths in infancy (SUDI).Three year population based, case control study with parental interviews for each death and four age matched controls.Five regions in England (population,17 million; live births,470,000).SIDS: 325 infants; explained SUDI: 72 infants; controls: 1,588 infants.In the univariate analysis, all the clinical features and health markers at birth, after discharge from hospital, during life, and shortly before death, significant among the infants with SIDS were in the same direction among the infants who died of explained SUDI. In the multivariate analysis, at least one apparent life threatening event had been experienced by more of the infants who died than in controls (SIDS: 12% v 3% controls; odds ratio (OR) = 2.55; 95% confidence interval (CI), 1.02 to 6.41; explained SUDI: 15% v 4% controls; OR = 16.81; 95% CI, 2.52 to 112.30). Using a retrospective illness scoring system based on "Baby Check", both index groups showed significant markers of illness in the last 24 hours (SIDS: 22% v 8% controls; OR = 4.17; 95% CI, 1.88 to 9.24; explained SUDI: 49% v 8% controls; OR = 31.20; 95% CI, 6.93 to 140.5).The clinical characteristics of SIDS and explained SUDI are similar. Baby Check might help identify seriously ill babies at risk of sudden death, particularly in high risk infants.