Nonaccidental trauma: clinical aspects and epidemiology of child abuse

Suspicious childhood injury: formulation of forensic opinion

Child protection paediatricians have a role as forensic experts in the context of suspicious childhood injury. The task of forensic evaluation of suspicious injury is to reach a conclusion to support legal proceedings. For each injury, one of four conclusions should be reached: 1 The injury has been caused by another person and is considered to have been inflicted. 2 The injury is adequately explained by the circumstances of the injury event provided (by the carer or other witnesses). 3 The injury is self-inflicted - has been caused by the child's own behaviour as a result of normal childhood activity (with no other person actively involved). 4 The mechanism or sequence of events leading to the injury remains indeterminate or unclear. An additional consideration is determining the extent to which an injury incident was foreseeable and therefore preventable, to form an opinion on whether lack of care (neglect) is involved. Opinions reflect a body of knowledge in forensic and medical literature of known mechanisms of injury including biomechanical aspects of tissue injury in trauma scenarios. Limitations in using research documenting injury type and prevalence at different developmental stages is discussed and in particular, the application of such research to support a conclusion that the injury must have been inflicted. Emerging recognition of research documenting injuries that overlap with those found in populations of children thought to have been physically assaulted creates some doubt on previous opinions regarding exclusivity of certain findings in children definitively indicating 'abuse'. Forensic paediatricians should remain objective, limit their opinions to what can be confidently stated and exercise caution where reasonable doubt exists and avoid speculation.

Retinal hemorrhage in abusive head trauma

Retinal hemorrhage is a cardinal manifestation of abusive head trauma. Over the 30 years since the recognition of this association, multiple streams of research, including clinical, postmortem, animal, mechanical, and finite element studies, have created a robust understanding of the clinical features, diagnostic importance, differential diagnosis, and pathophysiology of this finding. The importance of describing the hemorrhages adequately is paramount in ensuring accurate and complete differential diagnosis. Challenges remain in developing models that adequately replicate the forces required to cause retinal hemorrhage in children. Although questions, such as the effect of increased intracranial pressure, hypoxia, and impact, are still raised (particularly in court), clinicians can confidently rely on a large and solid evidence base when assessing the implications of retinal hemorrhage in children with concern of possible child abuse.