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Child abuse linked to faith or belief (CALFB) is a worldwide issue that is linked to serious short-term and long-term consequences and even death. Children affected by CALFB may have undergone multiple abuses - such as ritual starvation, beatings, burns, stabbings and drowning - prompting concern in hospitals, schools and communities, including in emergency and primary care settings. Nurses have an important role in safeguarding children and young people, and their role in identifying and responding to CALFB is often challenging. This article uses a 'competemility' (cultural competence and cultural humility) approach to raise awareness of CALFB reporting and investigations in the UK. It examines medical evidence and psychosocial indicators of this form of abuse and explains the metaphorical language and thoughts associated with reported beliefs. The article aims to support nurses to be culturally sensitive to CALFB and to explore how they can contribute to preserve the safety of children in familial and community settings.

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, …

Good child protection systems and processes require reliable and accurate data. A retrospective study of the case records of 452 children referred to a major UK children’s tertiary centre for suspected child maltreatment was undertaken to determine whether routinely collected data on a child’s journey through the child protection system, together with a study of related multidimensional factors, can be used to develop an enhanced dataset to protect children in the UK and in other countries. Child maltreatment was substantiated in 65% of referred cases, with the vast majority of referrals coming from children living in the most deprived neighbourhoods in the country. Domestic violence and abuse, and the child’s previous involvement with statutory bodies was associated with case substantiation. Physical abuse predominated, with soft tissue injuries, including dog bites, and burns. Burns were related almost exclusively to supervisory neglect. There were also cases of medical neglect. Emotional abuse was associated with exposure to domestic violence and abuse, and to self-harm. The strengths and weaknesses for single centre data systems were explored, concluding with a recommendation to establish an agreed national and international minimum data set to protect children from maltreatment.

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 …

ObjectivesTo determine any change in referral patterns and outcomes in children (0-18) referred for child protection medical examination (CPME) during the covid-19 pandemic compared to previous years.DesignRetrospective observational study, analysing routinely collected clinical data from CPME reports in a rapid response to the pandemic lockdown.SettingBirmingham Community Healthcare NHS Trust, which provides all routine CPME for Birmingham, England, population 1.1 million including 288,000 children.ParticipantsChildren aged under 18 years attending CPME during an 18 week period from late February to late June during the years 2018, 2019, and 2020.Main Outcome MeasuresNumbers of referrals, source of disclosure and outcomes from CPMEResultsThere were 78 CPME referrals in 2018, 75 in 2019 and 47 in 2020, this was a 39.7% (95%CI 12.4-59.0) reduction in referrals from 2018 to 2020, and a 37.3% (95%CI 8.6-57.4) reduction from 2019 to 2020. There were fewer CPME referrals initiated by school staff in 2020, 12(26%) compared to 36 (47%) and 38 (52%) in 2018 and 2019 respectively. In all years 75.9% of children were known to social care prior to CPME, and 94% of CPME concluded that there were significant safeguarding concerns.ConclusionsSchool closure due to covid-19 may have harmed children as child abuse has remained hidden. There needs to be either mandatory attendance at schools in future or viable alternatives found. There may be a significant increase in safeguarding referrals when schools fully re-open as children disclose the abuse they have experienced at home.Article summary: Strengths and Limitations of the StudyThis is a highly robust study: we obtained CPME reports for 97% of CPME referrals during the study period.We ensured consistency of data extraction by double reviewing every report, with further consensus discussions for the few cases that raised uncertainties.The team extracting the data comprised highly experienced paediatricians with expertise in child abuse.One weakness is that we only considered minor injuries from outpatient CPME, excluding those admitted to hospital, so our findings do not include those with more serious NAI, however they would be taken to hospital for treatment due to the severity of their injuries.

ObjectiveTo describe a safeguarding decision pathway for the assessment of osteopenic fractures in non-ambulant children with cerebral palsy.MethodLiterature review and consensus practice of a child safeguarding team, including clinicians and social workers.ConclusionLow-energy fractures of the lower limb in non-ambulant children with cerebral palsy are relatively common and explained by the presence of reduced bone strength, in the absence of any other unexplained injuries or safeguarding concerns.

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

There is now a strong evidence base for the characteristics of inflicted injury. Professionals within the multidisciplinary team and the courts are increasingly relying on other features such as the child's presentation to help determine whether child maltreatment has occurred. These features are somewhat subjective in nature, with little or no evidence to assist the clinician, particularly where there is uncertainty surrounding the possibility of child maltreatment. This paper will examine further evidence on the physical signs of child maltreatment, focussing on primary research on bruising, sentinel injuries, occult rib fractures and conditions that mimic physical injury such as the resurgence in the use of cupping as a remedy for childhood illness. It will also examine emerging evidence on a child's presentation, including history, response to injury and time to seek medical attention. If uncertainty surrounding the causation of an injury remains following advice and peer review, this must be acknowledged and stated unequivocally.

Child maltreatment and intentional injuries are major public health challenges, incurring huge costs for both individuals and society. Violence is an abuse of power comprising acts of commission and omission, and can have lasting consequences for survivors. It includes abuse in the home and collective violence, resulting in children being orphaned or abandoned, forced to become child soldiers, ‘street kids’ or trafficked for domestic work or sexual exploitation. In addition to physical violence, emotional abuse can involve bullying and seeing or hearing the ill treatment of another, such as a child witnessing intimate partner violence. Child maltreatment rates are higher in countries affected by war, famine, social inequality, and economic transition and in communities with marginalised indigenous and disabled groups. Comprehensive interventions, based on child rights principles, are needed that focus on prevention, detection, and intervention.

Objectives - In line with a national policy to move care ‘closer to home’, a specialist children's hospital in the National Health Service in England introduced consultant-led ‘satellite’ clinics to two community settings for general paediatric outpatient services. Objectives were to reduce non-attendance at appointments by providing care in more accessible locations and to create new physical clinic capacity. This study evaluated these satellite clinics to inform further development and identify lessons for stakeholders. Methods - Impact of the satellite clinics was assessed by comparing community versus hospital-based clinics across the following measures: (1) non-attendance rates and associated factors (including patient characteristics and travel distance) using a logistic regression model; (2) percentage of appointments booked within local catchment area; (3) contribution to total clinic capacity; (4) time allocated to clinics and appointments; and (5) clinic efficiency, defined as the ratio of income to staff-related costs. Results - Satellite clinics did not increase attendance beyond their contribution to shorter travel distance, which was associated with higher attendance. Children living in the most-deprived areas were 1.8 times more likely to miss appointments compared with those from least-deprived areas. The satellite clinics’ contribution to activity in catchment areas and to total capacity was small. However, one of the two satellite clinics was efficient compared with most hospital-based clinics. Conclusions - Outpatient clinics were relocated in pragmatically chosen community settings using a ‘drag and drop’ service model. Such clinics have potential to improve access to specialist paediatric healthcare, but do not provide a panacea. Work is required to improve attendance as part of wider efforts to support vulnerable families. Satellite clinics highlight how improved management could contribute to better use of existing capacity.

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 …

Setting: England, Wales and Scotland. Patients : 1958 birth cohort. Exposure : Experience of abuse during childhood, measured prospectively by parent and teacher interviews and retrospectively by self-report. Outcomes: Markers of socioeconomic function at 45–50 years. Follow-up period: 50 years from birth. Patient follow-up: Surveys sent out at 45 and 50 years of age. All forms of childhood maltreatment result in poorer socioeconomic outcomes at 50 years of age (summarised in table 1). Sexual abuse had the greatest effect, with neglect also having a significant impact. Adjusting for cognition …

Human bite marks in children are relatively common but are either not recognized as such or, when suspected, not subjected to rigorous forensic assessment. When a human bite mark on a child is identified, the explanation generally given is that it was either self-inflicted or the result of being bitten by another child. Adjudication on whether it is a child or adult bite mark must not be attempted, as there is insufficient evidence to determine this by inspection. However, the bite may show sufficient, unique dental characteristics to identify a perpetrator. Thus, it is vital that a forensic odontologist is involved from the outset. This paper describes the characteristics of human bite marks and emphasises the key role of forensic odontology in possible perpetrator identification.

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.

The joint agency approach should be used to investigate all unexpected child deaths Practitioners should ensure that final case discussions are not unduly delayed so that parents do not have to wait several months for information on the cause of their child's death. All bereaved parents should be given the opportunity to have a follow-up appointment with the paediatrician responsible for managing sudden unexpected death in children.

There is a growing evidence-base for physical signs of child maltreatment. However, health professionals sometimes find themselves in situations that are not clear cut, particularly when there is one suspicious injury in an otherwise normal child in a family where there are no risk factors for maltreatment present. This paper highlights such situations and guides the clinician through uncertainty to a consideration of whether or not the explanation for an injury is reasonably possible. This will be done by discussing the location, configuration and patterns of injury arising from low level falls, stairway falls, climbing into the bathtub, pacifiers or bottles, and being bitten by another child; explanations often proffered for an injury. The location of bruising in disabled children and young people will also be discussed. If uncertainty surrounding the causation of an injury remains following advice and peer review, this must be acknowledged and stated unequivocally.

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. …

A case is presented of a child who was initially diagnosed with osteogenesis imperfecta following a skull fracture. However, she later presented with multiple fractures and soft tissue injuries which were considered to be due to non-accidental injury. It can be perplexing distinguishing accidental and non-accidental injury in children where a bone fragility disorder has been suspected. A combination of a careful review of the history, a thorough examination and expert review of the radiology is imperative. DNA testing can be helpful. Multidisciplinary case review, taking into account the social history and any concerns professionals have about the family, is invaluable in informing a difficult diagnosis. In this context, there is a definite role for other agencies in challenging the diagnosis or exclusion of non-accidental injury. Professionals should be willing to challenge the exclusion of non-accidental injury when such exclusion is not evidence based. Copyright © 2009 John Wiley & Sons, Ltd.

Recent high-profile cases have made paediatricians very aware of the serious implications of either missing or wrongly diagnosing non-accidental injury. Subdural fluid collections in non-mobile infants usually represent haemorrhage caused by non-accidental injury. We report a 6-month-old male who presented to the Accident and Emergency Department of Birmingham Heartlands Hospital with bilateral subdural fluid collections and skin ulcers resembling cigarette burns. Non-accidental injury was considered to be the most likely diagnosis. However, while under observation in hospital, the child's neurological condition deteriorated with progressive cerebral infarctions, and serial photographs of the skin lesions showed failure to heal. The revised diagnosis, confirmed histologically, was Degos disease, an extremely rare and often fatal occlusive vasculopathy. The child was treated palliatively and died 8 weeks after presentation. This report informs doctors of a new simulator of non-accidental injury to be considered in infants with otherwise unexplained subdural fluid collections.

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.

Papillon–Lefevre syndrome is characterised by palmoplantar keratoderma, periodontitis and pyogenic infections. We describe the first case of brain abscess in a child with this syndrome. We highlight the importance of recognising any associated diagnosis, however rare or apparently irrelevant, in an acutely and critically ill child.

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.

A survey of West Midlands paediatricians in 2001 identified 24 cases of symptomatic vitamin D deficiency in children less than 5 years of age. The overall incidence was 7.5 per 100 000 children per year with notable differences in incidence per ethnic group.

Fifty cases of Sudden Infant Death Syndrome (SIDS) have been selected randomly from a group of 511 such cases studied since 1973. In addition, thiamine levels from 12,613 babies screened during the study period are also reviewed in relation to SIDS deaths. Despite exhaustive post-mortem analysis, few indications to causation are apparent. When compared with the control group, a five-fold increase in mean thiamine levels was noted in SIDS victims. However, the interpretation of thiamine screening data requires further detailed investigation. The results of this study suggest the value of adoption of a uniform basic protocol for the examination of SIDS and non-SIDS babies, along with the establishment of a central register of these deaths.