Which radiological investigations should be performed to identify fractures in suspected child abuse?

AIMS

To determine which radiological investigations should be performed and which children should be investigated.

MATERIALS AND METHODS

An all language literature search of original articles; from 1950-October 2005. Two reviewers independently reviewed each article. A third was carried out on disagreement. Each study was assessed using standardised data extraction, critical appraisal and evidence forms.

RESULTS

Thirty-four studies were included. Fifteen addressed the question: which investigation has a higher yield, skeletal surveys (SS) or bone scintigraphy (BS)? Studies gave conflicting results. Overall neither investigation is as good as the two combined. BS predominately missed skull, metaphyseal and epiphyseal fractures, whereas SS commonly missed rib fractures. Two studies showed that a repeat SS 2 weeks after the initial study provided significant additional information about tentative findings, the number and age of fractures. A comparative study evaluated additional oblique views of ribs in 73 children and showed improved diagnostic sensitivity, specificity and accuracy. Four studies addressed the diagnostic yield for occult fractures with respect to age. This was significant for children under 2-years old.

CONCLUSIONS

In children under 2-years old, where physical abuse is suspected, diagnostic imaging of the skeleton should be mandatory. SS or BS alone is inadequate to identify all fractures. It is recommended that all SS should include oblique views of the ribs. This review suggests that the following options would optimize the diagnostic yield. However, each needs to be evaluated prospectively: SS that includes oblique views, SS and BS, a SS with repeat SS or selected images 2 weeks later or a BS plus skull radiography and coned views of metaphyses and epiphyses.

Are abused babies protected from further abuse?

A cohort of 69 physically abused babies under 1 year was followed for three years after the incident. Of the 49 babies who returned home following child protection investigations, 15 were further abused in the three year period, a re-abuse rate of 31%, which is grossly higher than the abuse rate in the general population.

Head injury and limb fracture in modern playgrounds

There were no serious head injuries in modern Cardiff municipal playgrounds with safety surfaces over five years injury surveillance. The literature suggests serious head injuries did occur before the introduction of safety surfaces.

The incidence of severe physical child abuse in Wales

OBJECTIVES

The purposes of this study were: (1) to ascertain the incidence and nature of severe physical child abuse in Wales; (2) to ascertain the incidence of all physical abuse in babies under 1 year of age; and (3) to determine whether child protection registers (CPR) accurately reflect the numbers of children who are physically abused.

METHODS

This is a population-based incidence study based in Wales, UK, for 2 years from April 1996 through March 1998. Children studied were under the age of 14 with severe physical abuse consistent with the criminal law level of Grievous Bodily Harm. This included seven categories of injury (death; head injury including subdural hemorrhage; internal abdominal injury; physical injury in Munchausen Syndrome by Proxy including suffocation; fracture; burn or scald; adult bite). Cases were ascertained by a pediatrician surveillance reporting system (WPSU). A criterion for inclusion was multidisciplinary agreement that physical abuse had occurred (at case conference, strategy meeting, or Part 8 Review). The incidence of all babies under 1 year of age with physical abuse was also studied. Ascertainment of babies under the age of 1 year was undertaken from CPR as well as the WPSU.

RESULTS

Severe abuse is six times more common in babies [54/100,000/year (95% CI +/- 17.2)] than in children from 1 year to 4 years of age [9.2/100,000 (95% CI +/- 3.6)]. It is 120 times more common than in 5- to 13-year-olds [0.47/100,000 (95% CI +/- 0.47)]. This is mainly because two types of serious abuse (brain injury including subdural hemorrhage and fractures) are more common in babies under the age of 1 year than older children. Using data from two sources (the WPSU and CPRs), the incidence of physical abuse in babies is 114/100,000 (CI 114 +/- 11.8) per year. This equates to 1 baby in 880 being abused in the first year of life. The largely rural Health Authority area in Wales had incidence figures for abuse in babies that were 50% of the three other predominantly urban Health Authority areas. Boys throughout the series were more at risk of being severely abused than girls (p < .025). Only 29% of the babies under 1 year of age on the CPR had actually been injured. Thirty percent of abused babies under the age of 1 year and 73% of severely abused children over the age of 1 year had caused previous concern to health professionals regarding abuse or neglect.

CONCLUSIONS

Physical abuse is a significant problem in babies under the age of 1 year. Very young babies (under 6 months old) have the highest risk of suffering damage or death as a result of physical abuse. Severe abuse, in particular subdural hematoma and fracture, is much more common in babies than in older children. There is evidence of failure of secondary prevention of child abuse by health professionals, with a greater need to act on concerns regarding abuse and neglect. Interagency child protection work in partnership with parents should focus more on protecting babies under age 1 year from further abuse than on maintenance of the infant within an abusive home. The CPR is not intended as an accurate measure of children suffering abuse. It is a record of children requiring a child protection plan and must not be used as a measure of numbers of abused children.

Differences in protein kinase C and estrogen receptor alpha, beta expression and signaling correlate with apoptotic sensitivity of MCF-7 breast cancer cell variants

Widespread use of MCF-7 human breast cancer cells as a model system for breast cancer has lead to variations in these cells between different laboratories. Although several reports have addressed these differences in terms of proliferation and estrogenic response, differences in sensitivity to apoptosis have just begun to be described. Based on the possible differences in apoptotic sensitivity that may arise due to the existence of MCF-7 cell variants, we determined the relative sensitivity of MCF-7 cell variants from three established laboratories (designated M, L and N) to known inducers of apoptosis. Consistent with our previous studies we demonstrate that differences exist among these variants in regards to tumor necrosis factor alpha (TNF)-induced cell death and inhibition of proliferation in a dose-dependent manner. To establish if the difference in apoptotic susceptibility was specific to TNF, the three MCF-7 cell variants were tested for their response to other known inducers of apoptosis: okadaic acid, staurosporine and 4-hydroxy-tamoxifen. Viability and DNA fragmentation analysis revealed a similar pattern of resistance to apoptosis by all agents in the MCF-7 M variant. The MCF-7 L variant was resistant to okadaic acid and 4-hydroxy-tamoxifen but not staurosporine. In contrast, MCF-7 N cells were sensitive to induction of apoptosis by all agents. The role of both protein kinase C (PKC) and estrogen signaling in the regulation of cell survival prompted investigation of these pathways as a mechanism for differential sensitivity of MCF-7 cell variants to apoptosis. While both estrogen receptor alpha (ERalpha) and ERbeta were expressed in MCF-7 M and N cells, the absence of ERbeta in MCF-7 L cells correlated with decreased estrogen responsiveness of the L variant. Variations in estrogenic responsiveness and PKC isoform expression may account for the enhanced susceptibility of both the L and N variants to staurosporine.

Procedures, placement, and risks of further abuse after Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation

OBJECTIVES

To investigate outcome, management, and prevention in Munchausen syndrome by proxy, non-accidental poisoning, and non-accidental suffocation.

DESIGN

Ascertainment through British Paediatric Surveillance Unit and questionnaires to responding paediatricians.

SETTING

The UK and Republic of Ireland, September 1992 to August 1994.

SUBJECTS

Children under 14 years diagnosed with the above.

MAIN OUTCOME MEASURES

Placement and child protection measures for victims and siblings; morbidity and reabuse rates for victims; abuse of siblings; prosecution of perpetrators.

RESULTS

Outcome data for 119 with median follow up of 24 months (range 12 to 44 months). No previously diagnosed factitious disease was found to have been caused by genuine disease. Forty six children were allowed home without conditions at follow up. Children who had suffered from suffocation, non-accidental poisoning, direct harm, and those under 5 years were less likely to go home. Twenty seven (24%) children still had symptoms or signs as a result of the abuse at follow up; 108/120 were originally on a child protection register and 35/111 at follow up. Twenty nine per cent (34/118) of the perpetrators had been prosecuted and most convicted; 17% of the milder cases of Munchausen syndrome by proxy allowed home were reabused. Evidence in siblings suggests that in 50% of families with a suffocated child and 40% with non-accidental poisoning there would be further abuse, some fatal.

CONCLUSIONS

This type of abuse is severe with high mortality, morbidity, family disruption, reabuse, and harm to siblings. A very cautious approach for child protection with reintroduction to home only if circumstances are especially favourable is advised. Paediatric follow up by an expert in child protection should also occur.

Safety of surfaces and equipment for children in playgrounds

BACKGROUND

The safety of playgrounds is important to protect children from injury, but studies are mostly done mainly under laboratory conditions without epidemiological data. We investigated the safety of different playground surfaces, and types and heights of equipment in public playgrounds in the City of Cardiff, UK.

METHODS

We did a correlational study of 330 children aged between 0 and 14 years. All children were hurt when playing in playgrounds in Cardiff and presented to the Accident and Emergency Department in Cardiff Royal Infirmary during summer (April to September) 1992 and 1993, and the whole of 1994. We studied the children's hospital records to establish the type of injury and interviewed their parents to find out the playground and type of equipment involved. The main outcome measures were the number of children injured whilst playing, and injury rates per observed number of children on different surfaces, types, and heights of equipment.

FINDINGS

Children sustained significantly more injuries in playgrounds with concrete surfaces than in those with bark or rubberised surfaces (p < 0.001). Playgrounds with rubber surfaces had the lowest rate of injury, with a risk half that of bark and a fifth of that of concrete. Bark surfaces were not significantly more protective against arm fractures than concrete. Most injuries were equipment related. Injury risk due to falls from monkey bars (suspended parallel bars or rings between which children swing) was twice that for climbing-frames and seven times that for swings or slides. The height of the equipment correlated significantly with the number of fractures (p = 0.005) from falls.

INTERPRETATION

Rubber or bark surfacing is associated with a low rate of injuries and we support their use in all public playgrounds. Bark alone is insufficient, however, to prevent all injuries, particularly arm fractures. Rubberised impact-absorbing surfaces are safer than bark. We believe that playing on monkeys bars increases the risk of injury in playgrounds and that they should generally not be installed. Safety standards should be based on physical and epidemiological data. Our data suggest that the proposed raising of the maximum fall height from 2.5 m to 3.0 m in Europe is worrying.

Patterns of injuries to children on public playgrounds

The incidence and pattern of injuries to children in public playgrounds presenting to the accident and emergency department were reviewed over two six month summer periods in Cardiff. A total of 178 children (mean age 7.5 years) attended with a playground injury representing 1.1% of all the children attending. One hundred and five children fell from equipment, of which the commonest was the climbing frame; 125 children had playground surface related injuries, 86 on bark and 30 on concrete. The pattern of injuries on the playground surfaces was different: fractures and sprains were more common on bark surfaces and lacerations and abrasions on concrete surfaces. Comparison of total injury rates showed there were fewer injuries on modernised playgrounds than expected but these differences were not significant. Modernised playgrounds are more popular, have new exciting equipment, and offer good play opportunities for children. However, the high fracture rate on modernised bark playgrounds is concerning and requires further research.