Clinical care of childhood sexual abuse: a systematic review and critical appraisal of guidelines from European countries.

Background: The clinical management of Child sexual abuse (CSA) demands specialised skills from healthcare professionals due to its sensitivity, legal implications, and serious physical health and mental health effects. Standardised, comprehensive clinical practice guidelines (CPGs) may be pivotal. In this systematic review, we examined existing CSA national CPGs (NCPGs) from European countries to assess their quality and reporting. Methods: We systematically searched six international databases and multiple grey literature sources, reporting by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) standards. Eligible guidelines were CSA guidance from national health agencies or societies in 34 COST Action 19106 Network Countries (CANC), published between January 2012 and November 2022. Two independent researchers searched, screened, reviewed, and extracted data. NCPGs were compared for completeness with reference WHO 2017 and 2019 guidelines. We used the Appraisal of Guidelines for Research and Evaluation (AGREE II) to appraise quality and reporting. PROSPERO: CRD42022320747. Findings: Of 2919 records identified by database searches, none met inclusion criteria. Of 4714 records identified by other methods, 24 NCPGs from 17 (50%) of CANC countries were included. In 17 (50%) of eligible countries, no NCPGs were found. Content varied significantly within and between countries. NCPGs lacked many components in state-of-the art clinical practice compared to WHO reference standards, particularly in safety and risk assessment, interactions with caregivers, and mental health interventions. Appraisal by AGREE II revealed shortcomings in NCPG development, regarding scientific rigour, stakeholder involvement, implementation and evaluation. Interpretation: A notable number of European countries lack an NCPG; existing NCPGs often fall short. The healthcare response to CSA in Europe requires a coordinated approach to develop and implement high-quality CPGs. We advocate for a multidisciplinary team to develop a pan-European CSA guideline to ensure quality care for survivors. Funding: Funding was provided by the International Centre for Missing and Exploited Children.

International Consensus Statement on the Radiological Screening of Contact Children in the Context of Suspected Child Physical Abuse.

Importance: Physical abuse is a common but preventable cause of long-term childhood morbidity and mortality. Despite the strong association between abuse in an index child and abuse in contact children, there is no guidance outlining how to screen the latter, significantly more vulnerable group, for abusive injuries. Consequently, the radiological assessment of contact children is often omitted, or variably performed, allowing occult injuries to go undetected and increasing the risk of further abuse. Objective: To report an evidence-based and consensus-derived set of best practices for the radiological screening of contact children in the context of suspected child physical abuse. Evidence Review: This consensus statement is supported by a systematic review of the literature and the clinical opinion of an internationally recognized group of 26 experts. The modified Delphi consensus process comprised 3 meetings of the International Consensus Group on Contact Screening in Suspected Child Physical Abuse held between February and June 2021. Findings: Contacts are defined as the asymptomatic siblings, cohabiting children, or children under the same care as an index child with suspected child physical abuse. All contact children should undergo a thorough physical examination and a history elicited prior to imaging. Contact children younger than 12 months should have neuroimaging, the preferred modality for which is magnetic resonance imaging, and skeletal survey. Contact children aged 12 to 24 months should undergo skeletal survey. No routine imaging is indicated in asymptomatic children older than 24 months. Follow-up skeletal survey with limited views should be performed if abnormal or equivocal at presentation. Contacts with positive findings should be investigated as an index child. Conclusions and Relevance: This Special Communication reports consensus recommendations for the radiological screening of contact children in the context of suspected child physical abuse, establishing a recognized baseline for the stringent evaluation of these at-risk children and providing clinicians with a more resilient platform from which to advocate for them.

Methodological standards for the development and evaluation of clinical prediction rules: a review of the literature.

Clinical prediction rules (CPRs) that predict the absolute risk of a clinical condition or future outcome for individual patients are abundant in the medical literature; however, systematic reviews have demonstrated shortcomings in the methodological quality and reporting of prediction studies. To maximise the potential and clinical usefulness of CPRs, they must be rigorously developed and validated, and their impact on clinical practice and patient outcomes must be evaluated. This review aims to present a comprehensive overview of the stages involved in the development, validation and evaluation of CPRs, and to describe in detail the methodological standards required at each stage, illustrated with examples where appropriate. Important features of the study design, statistical analysis, modelling strategy, data collection, performance assessment, CPR presentation and reporting are discussed, in addition to other, often overlooked aspects such as the acceptability, cost-effectiveness and longer-term implementation of CPRs, and their comparison with clinical judgement. Although the development and evaluation of a robust, clinically useful CPR is anything but straightforward, adherence to the plethora of methodological standards, recommendations and frameworks at each stage will assist in the development of a rigorous CPR that has the potential to contribute usefully to clinical practice and decision-making and have a positive impact on patient care.

First aid for children's burns in the US and UK: An urgent call to establish and promote international standards.

INTRODUCTION: Appropriate first aid can reduce the morbidity of burns, however, there are considerable variations between international first aid recommendations. We aim to identify, and compare first aid practices in children who present to Emergency Departments (ED) with a burn. METHODS: A prospective cross-sectional study of 500 children (0-16 completed years) presenting with a burn to a paediatric ED in the UK (Cardiff) and the USA (Denver, Colorado), during 2015-2017. The proportion of children who had received some form of first aid and the quality of first aid were compared between cities. RESULTS: Children attending hospital with a burn in Cardiff were 1.47 times more likely (RR 1.47; CI 1.36, 1.58), to have had some form of first aid than those in Denver. Denver patients were 4.7 time more likely to use a dressing and twice as likely to apply ointment/gel/aloe vera than the Cardiff cohort. First aid consistent with local recommendations was only administered to 26% (128/500) of children in Cardiff and 6% (31/500) in Denver. Potentially harmful first aid e.g. application of food, oil, toothpaste, shampoo or ice was applied to 5% of children in Cardiff and 10% in Denver. CONCLUSION: A low number of children received optimal burns first aid, with potentially harmful methods applied in a considerable proportion of cases. There is an urgent need for internationally agreed, evidence-based burn first aid recommendations.

To what extent are GCS and AVPU equivalent to each other when assessing the level of consciousness of children with head injury? A cross-sectional study of UK hospital admissions.

OBJECTIVE: To evaluate utility and equivalence of Glasgow Coma Scale (GCS) and the Alert, Voice, Pain, Unresponsive (AVPU) scale in children with head injury. DESIGN: Cross sectional study. SETTING: UK hospital admissions: September 2009-February 2010. PATIENTS: <15 years with head injury. INTERVENTIONS: GCS and/or AVPU at injury scene and in emergency departments (ED). MAIN OUTCOME: Measures used, the equivalence of AVPU to GCS, GCS at the scene predicting GCS in ED, CT results by age, hospital type. RESULTS: Level of consciousness was recorded in 91% (5168/5700) in ED (43%: GCS/30.5%: GCS+AVPU/17.3%: AVPU) and 66.1% (1190/1801) prehospital (33%: GCS/26%GCS+AVPU/7%: AVPU). Failure to record level of consciousness and the use of AVPU were greatest for infants. Correlation between AVPU and median GCS in 1147 children <5 years: A=15, V=14, P=8, U=3, for 1163 children ≥5 years: A=15, V=13, P=11, U=3. There was no significant difference in the proportion of infants who had a CT whether AVPU=V/P/U or GCS<15. However diagnostic yield of intracranial injury or depressed fracture was significantly greater for V/P/U than GCS<15 :7/7: 100% (95% CI 64.6% to 100%) versus 5/17: 29.4% (95% CI 13.3% to 53.1%). For children >1 year significantly more had a CT scan when GCS<14 was recorded than 'V/P/U only' and the diagnostic yield was greater. Prehospital GCS and GCS in the ED were the same for 77.4% (705/911). CONCLUSION: There was a clear correlation between Alert and GCS=15 and between Unresponsive and GCS=3 but a wider range of GCS scores for responsive to Pain or Voice that varied with age. AVPU was valuable at initial assessment of infants and did not adversely affect the proportion of infants who had head CT or the diagnostic yield.

Potential impact of the validated Predicting Abusive Head Trauma (PredAHT) clinical prediction tool: A clinical vignette study.

BACKGROUND: The validated Predicting Abusive Head Trauma (PredAHT) tool estimates the probability of abusive head trauma (AHT) in children <3 years old with intracranial injury. OBJECTIVE: To explore the impact of PredAHT on clinicians' AHT probability estimates and child protection (CP) actions, and assess inter-rater agreement between their estimates and between their CP actions, before and after PredAHT. PARTICIPANTS AND SETTING: Twenty-nine clinicians from different specialties, at teaching and community hospitals. METHODS: Clinicians estimated the probability of AHT and indicated their CP actions in six clinical vignettes. One vignette described a child with AHT, another described a child with non-AHT, and four represented "gray" cases, where the diagnosis was uncertain. Clinicians calculated the PredAHT score, and reported whether this altered their estimate/actions. The 'think-aloud' method was used to capture the reasoning behind their responses. Analysis included linear modelling, linear mixed-effects modelling, chi-square tests, Fisher's exact tests, intraclass correlation, Gwet's AC1 coefficient and thematic analysis. RESULTS: Overall, PredAHT significantly influenced clinicians' probability estimates in all vignettes (p < 0.001), although the impact on individual clinicians varied. However, the influence of PredAHT on clinicians' CP actions was limited; after using PredAHT, 9/29 clinicians changed their CP actions in only 11/174 instances. Clinicians' AHT probability estimates and CP actions varied somewhat both before and after PredAHT. Qualitative data suggested that PredAHT may increase clinicians' confidence in their decisions when considered alongside other associated clinical, historical and social factors. CONCLUSIONS: PredAHT significantly influenced clinicians' AHT probability estimates, but had minimal impact on their CP actions.

Qualitative analysis of clinician experience in utilising the BuRN Tool (Burns Risk assessment for Neglect or abuse Tool) in clinical practice.

INTRODUCTION: The BuRN-Tool (Burns Risk assessment for Neglect or abuse Tool) is a clinical prediction tool (CPT) aiding the identification of child maltreatment in children with burn injuries. The tool has been derived from systematic reviews and epidemiological studies, validated and is under-going an implementation evaluation. Clinician opinion on the use of this CPT is a key part of its evaluation. OBJECTIVES: To explore the experience of emergency clinicians use of the BuRN-Tool in an emergency department (ED). METHODS: Three focus groups were conducted over a six-week period by the research team in the ED in the University Hospital of Wales; 25 emergency clinicians attended. A semi-structured approach was taken with pre-determined open-ended questions asked followed by a series of case vignettes to which the CPT was applied. The focus groups were recorded and transcribed verbatim. Thematic analysis was conducted for identification of pre-set and emergent themes. All data were double-coded. RESULTS: All participants said that it was acceptable to use the BuRN-Tool to aid in the decision-making process surrounding child maltreatment. All participants said that the BuRN-Tool was helpful and straight forward to use. All participants said that the tool was clinically beneficial, particularly for junior staff and those who do not always work in a paediatric environment. The clinical vignettes identified subjectivity in interpretation questions around adequate supervision, previous social care involvement and full thickness burns. This resulted in some variation in scoring. CONCLUSIONS: This study confirms that the BuRN-Tool is acceptable in an ED setting. The focus groups demonstrated a homogenous and positive attitude regarding the layout, benefits and use of the BuRN-Tool. The subjective interpretation of some variables accounts for the non-uniformity in the scores generated. Clarification of questions will be made.

Factors influencing child protection professionals' decision-making and multidisciplinary collaboration in suspected abusive head trauma cases: A qualitative study.

Clinicians face unique challenges when assessing suspected child abuse cases. The majority of the literature exploring diagnostic decision-making in this field is anecdotal or survey-based and there is a lack of studies exploring decision-making around suspected abusive head trauma (AHT). We aimed to determine factors influencing decision-making and multidisciplinary collaboration in suspected AHT cases, amongst 56 child protection professionals. Semi-structured interviews were conducted with clinicians (25), child protection social workers (10), legal practitioners (9, including 4 judges), police officers (8), and pathologists (4), purposively sampled across southwest United Kingdom. Interviews were recorded, transcribed and imported into NVivo for thematic analysis (38% double-coded). We identified six themes influencing decision-making: 'professional', 'medical', 'circumstantial', 'family', 'psychological' and 'legal' factors. Participants diagnose AHT based on clinical features, the history, and the social history, after excluding potential differential diagnoses. Participants find these cases emotionally challenging but are aware of potential biases in their evaluations and strive to overcome these. Barriers to decision-making include lack of experience, uncertainty, the impact on the family, the pressure of making the correct diagnosis, and disagreements between professionals. Legal barriers include alternative theories of causation proposed in court. Facilitators include support from colleagues and knowledge of the evidence-base. Participants' experiences with multidisciplinary collaboration are generally positive, however child protection social workers and police officers are heavily reliant on clinicians to guide their decision-making, suggesting the need for training on the medical aspects of physical abuse for these professionals and multidisciplinary training that provides knowledge about the roles of each agency.

Acceptability of the Predicting Abusive Head Trauma (PredAHT) clinical prediction tool: A qualitative study with child protection professionals.

The validated Predicting Abusive Head Trauma (PredAHT) tool estimates the probability of abusive head trauma (AHT) based on combinations of six clinical features: head/neck bruising; apnea; seizures; rib/long-bone fractures; retinal hemorrhages. We aimed to determine the acceptability of PredAHT to child protection professionals. We conducted qualitative semi-structured interviews with 56 participants: clinicians (25), child protection social workers (10), legal practitioners (9, including 4 judges), police officers (8), and pathologists (4), purposively sampled across southwest United Kingdom. Interviews were recorded, transcribed and imported into NVivo for thematic analysis (38% double-coded). We explored participants' evaluations of PredAHT, their opinions about the optimal way to present the calculated probabilities, and their interpretation of probabilities in the context of suspected AHT. Clinicians, child protection social workers and police thought PredAHT would be beneficial as an objective adjunct to their professional judgment, to give them greater confidence in their decisions. Lawyers and pathologists appreciated its value for prompting multidisciplinary investigations, but were uncertain of its usefulness in court. Perceived disadvantages included: possible over-reliance and false reassurance from a low score. Interpretations regarding which percentages equate to 'low', 'medium' or 'high' likelihood of AHT varied; participants preferred a precise % probability over these general terms. Participants would use PredAHT with provisos: if they received multi-agency training to define accepted risk thresholds for consistent interpretation; with knowledge of its development; if it was accepted by colleagues. PredAHT may therefore increase professionals' confidence in their decision-making when investigating suspected AHT, but may be of less value in court.

Raising suspicion of maltreatment from burns: Derivation and validation of the BuRN-Tool.

BACKGROUND: 10-25% of childhood burns arise from maltreatment. AIM: To derive and validate a clinical prediction tool to assist the recognition of suspected maltreatment. METHODS: Prospectively collected data from 1327 children with burns were analyzed using logistic regression. Regression coefficients for variables associated with 'referral for child maltreatment investigation' (112 cases) in multivariable analyses were converted to integers to derive the BuRN-Tool, scoring each child on a continuous scale. A cut-off score for referral was established from receiver operating curve analysis and optimal sensitivity and specificity values. We validated the BuRN-Tool on 787 prospectively collected novel cases. RESULTS: Variables associated with referral were: age <5years, known to social care, concerning explanation, full thickness burn, uncommon body location, bilateral pattern and supervision concern. We established 3 as cut-off score, resulting in a sensitivity and specificity for scalds of 87.5% (95% CI:61.7-98.4) and 81.5% (95% CI:77.1-85.4) respectively and for non-scalds sensitivity was 82.4% (95%CI:65.5-93.2) and specificity 78.7% (95% CI:73.9-82.9) when applied to validation data. Area under the curve was 0.87 (95% CI:0.83-0.90) for scalds and 0.85 (95% CI:0.81-0.88) for non-scalds. CONCLUSION: The BuRN-Tool is a potential adjunct to clinical decision-making, predicting which children warrant investigation for child maltreatment. The score is simple and easy to complete in an emergency department setting.

Patterns of bruising in preschool children with inherited bleeding disorders: a longitudinal study.

OBJECTIVE: The extent that inherited bleeding disorders affect; number, size and location of bruises in young children <6 years. DESIGN: Prospective, longitudinal, observational study. SETTING: Community. PATIENTS: 105 children with bleeding disorders, were compared with 328 without a bleeding disorder and classified by mobility: premobile (non-rolling/rolling over/sitting), early mobile (crawling/cruising) and walking and by disease severity: severe bleeding disorder factor VIII/IX/XI <1 IU/dL or type 3 von Willebrand disease. INTERVENTIONS: Number, size and location of bruises recorded in each child weekly for up to 12 weeks. OUTCOMES: The interventions were compared between children with severe and mild/moderate bleeding disorders and those without bleeding disorders. Multiple collections for individual children were analysed by multilevel modelling. RESULTS: Children with bleeding disorders had more and larger bruises, especially when premobile. Compared with premobile children without a bleeding disorder; the modelled ratio of means (95% CI) for number of bruises/collection was 31.82 (8.39 to 65.42) for severe bleeding disorders and 5.15 (1.23 to 11.17) for mild/moderate, and was 1.81 (1.13 to 2.23) for size of bruises. Children with bleeding disorders rarely had bruises on the ears, neck, cheeks, eyes or genitalia. CONCLUSIONS: Children with bleeding disorder have more and larger bruises at all developmental stages. The differences were greatest in premobile children. In this age group for children with unexplained bruising, it is essential that coagulation studies are done early to avoid the erroneous diagnosis of physical abuse when the child actually has a serious bleeding disorder, however a blood test compatible with a mild/moderate bleeding disorder cannot be assumed to be the cause of bruising.

Development of a computational biomechanical infant model for the investigation of infant head injury by shaking.

The inertial loading thresholds for infant head injury are of profound medico-legal and safety-engineering significance. Injurious experimentation with infants is impossible, and physical and computational biomechanical modelling has been frustrated by a paucity of paediatric biomechanical data. This study describes the development of a computational infant model (MD Adams®) by combining radiological, kinematic, mechanical modelling and literature-based data. Previous studies have suggested the neck as critical in determining inertial head loading. The biomechanical effects of varying neck stiffness parameters during simulated shakes were investigated, measuring peak translational and rotational accelerations and rotational velocities at the vertex. A neck quasi-static stiffness of 0.6 Nm/deg and lowest rate-dependent stiffness predisposed the model infant head to the highest accelerations. Plotted against scaled infant injury tolerance curves, simulations produced head accelerations commensurate with those produced during simulated physical model shaking reported in the literature. The model provides a computational platform for the exploitation of improvements in head biofidelity for investigating a wider range of injurious scenarios.

Patterns of bruising in preschool children--a longitudinal study.

INTRODUCTION: This study aims to identify the prevalence and pattern of bruises in preschool children over time, and explore influential variables METHODS: Prospective longitudinal study of children (<6 years) where bruises were recorded on a body chart, weekly for up to 12 weeks. The number and location of bruises were analysed according to development. Longitudinal analysis was performed using multilevel modelling. RESULTS: 3523 bruises recorded from 2570 data collections from 328 children (mean age 19 months); 6.7% of 1010 collections from premobile children had at least one bruise (2.2% of babies who could not roll over and 9.8% in those who could), compared with 45.6% of 478 early mobile and 78.8% of 1082 walking child collections. The most common site affected in all groups was below the knees, followed by 'facial T' and head in premobile and early mobile. The ears, neck, buttocks, genitalia and hands were rarely bruised (<1% of all collections). None of gender, season or the level of social deprivation significantly influenced bruising patterns, although having a sibling increased the mean number of bruises. There was considerable variation in the number of bruises recorded between different children which increased with developmental stage and was greater than the variation between numbers of bruises in collections from the same child over time. CONCLUSIONS: These data should help clinicians understand the patterns of 'everyday bruising' and recognise children who have an unusual numbers or distribution of bruises who may need assessment for physical abuse or bleeding disorders.

Defining background DNA levels found on the skin of children aged 0-5 years.

There are currently no data available regarding the normal levels of DNA found on the skin of children engaging in routine day to day activities to assist with the forensic interpretation of DNA profiles generated from skin surface swabs. To address this deficit, skin surface swab samples were collected from 12 face/neck sites and 20 body sites on 50 children less than 5 years old. After exclusion of spoilt samples, 60 sets of swabs from 47 children (30 face/neck, 30 body) comprising of 944 individual samples were analysed. The number of alleles observed which could have originated from the child and the number which must have come from another source (non-child) were analysed. The following variables were evaluated: age, kissing, feeding and washing practices, number of contacts and application of cream. Overall, extremely small amounts of non-child DNA were retrieved from skin swabs. Child only (46.3%) or no DNA at all (18.6%) was observed for 64.9% of all swabbed samples. Low levels of non-child DNA (1-5 alleles) were observed on 31.6% of all swabs tested with only 3.4% of swabs showing six or more alleles. A great deal of variation between children and between sites in the levels of both child DNA and non-child DNA was observed. A multilevel model, taking account of clustering within children, showed that there was a strong direct association between the amounts of child and non-child DNA observed. There was no relationship between the amount of DNA recovered and the demographic and biographic variables analysed. These background data have the potential to assist the analysis of DNA from the skin of children during criminal investigation.

Characteristics of child dental neglect: a systematic review.

OBJECTIVE: Neglect of a child's oral health can lead to pain, poor growth and impaired quality of life. In populations where there is a high prevalence of dental caries, the determination of which children are experiencing dental neglect is challenging. This systematic review aims to identify the features of oral neglect in children. METHODS: Fifteen databases spanning 1947-2012 were searched; these were supplemented by hand searching of 4 specialist journals, 5 websites and references of full texts. Included: studies of children 0-18 years with confirmed oral neglect undergoing a standardised dental examination; excluded: physical/sexual abuse. All relevant studies underwent two independent reviews (+/- 3rd review) using standardised critical appraisal. RESULTS: Of 3863 potential studies screened, 83 studies were reviewed and 9 included (representing 1595 children). Features included: failure or delay in seeking dental treatment; failure to comply with/complete treatment; failure to provide basic oral care; co-existent adverse impact on the child e.g. pain and swelling. Two studies developed and implemented 'dental neglect' screening tools with success. The importance of Quality of Life tools to identify impact of neglected dental care are also highlighted. CONCLUSIONS: A small body of literature addresses this topic, using varying definitions of neglect, and standards of oral examination. While failure/delay in seeking care with adverse dental consequences were highlighted, differentiating dental caries from dental neglect is difficult, and there is a paucity of data on precise clinical features to aid in this distinction. CLINICAL SIGNIFICANCE: Diagnosing dental neglect can be challenging, influencing a reluctance to report cases. Published evidence does exist to support these referrals when conditions as above are described, although further quality case control studies defining distinguishing patterns of dental caries would be welcome.

Does a more "physiological" infant manikin design effect chest compression quality and create a potential for thoracic over-compression during simulated infant CPR?

Poor survivability following infant cardiac arrest has been attributed to poor quality chest compressions. Current infant CPR manikins, used to teach and revise chest compression technique, appear to limit maximum compression depths (CDmax) to 40 mm. This study evaluates the effect of a more "physiological" CDmax on chest compression quality and assesses whether proposed injury risk thresholds are exceeded by thoracic over-compression. A commercially available infant CPR manikin was instrumented to record chest compressions and modified to enable compression depths of 40 mm (original; CDmax40) and 56 mm (the internal thoracic depth of a three-month-old male infant; CDmax56). Forty certified European Paediatric Life Support instructors performed two-thumb (TT) and two-finger (TF) chest compressions at both CDmax settings in a randomised crossover sequence. Chest compression performance was compared to recommended targets and compression depths were compared to a proposed thoracic over-compression threshold. Compressions achieved greater depths across both techniques using the CDmax56, with 44% of TT and 34% of TF chest compressions achieving the recommended targets. Compressions achieved depths that exceeded the proposed intra-thoracic injury threshold. The modified manikin (CDmax56) improved duty cycle compliance; however, the chest compression rate was consistently too high. Overall, the quality of chest compressions remained poor in comparison with internationally recommended guidelines. This data indicates that the use of a modified manikin (CDmax56) as a training aid may encourage resuscitators to habitually perform deeper chest compressions, whilst avoiding thoracic over-compression and thereby improving current CPR quality. Future work will evaluate resuscitator performance within a more realistic, simulated CPR environment.

A timetable for the radiologic features of fracture healing in young children.

OBJECTIVE: Fracture dating significantly shapes decisions in child protection. With a dearth of primary evidence underpinning fracture dating in children, we examined the key radiologic features of fracture healing and their timelines. MATERIALS AND METHODS: Digital radiographs of children younger than 72 months old with accidental long bone fractures of known timing were reviewed independently by three pediatric radiologists blinded to the age of the fractures. Six radiologic features of fracture healing were evaluated: soft-tissue swelling, periosteal reaction, soft callus, hard callus, bridging, and remodeling. Interobserver agreement was assessed using kappa analysis. RESULTS: Two hundred twenty-eight films of 82 fractures in 63 children (mean age, 4.8 years) were assessed. Soft-tissue swelling was identified by two or more radiologists in 59% of the radiographs at days 1-2 after fractures, and prevalence sharply declined thereafter. Periosteal reaction was first seen at day 5 and was present in 62% of the films obtained between 15 and 35 days after the fracture. Soft callus was first seen at day 12 and was prevalent in 41% between 22 and 35 days. Hard callus and bridging began at day 19, increasing to 60% prevalence from 36 days onward. Remodeling was observed only in fractures 45 days old or more. Kappa scores were between 0.55 and 0.80 overall, with greater agreement when there was no plaster cast. CONCLUSION: The results of this study show that fractures in young children may be dated as acute (< 1 week), recent (8-35 days), or old (≥ 36 days) on the basis of the presence of six key radiologic features in combination. Furthermore, good interobserver agreement suggests these results are reproducible.

Abusive head trauma: recognition and the essential investigation.

Abusive head trauma (AHT) affects one in 4000-5000 infants every year and is one of the most serious forms of physical child abuse that has a high associated mortality and morbidity. Differentiating this form of abuse from another potential cause of brain injury is of utmost importance to the welfare of the child concerned and it is essential that the condition is correctly diagnosed. This article describes the evidence base behind the associated historical, clinical and neuroradiological features of AHT and spinal injury in physical abuse and sets out an algorithm of essential investigations that should be performed in any infant or young child where AHT is suspected.

Which is the preferred image modality for paediatricians when assessing photographs of bruises in children?

Images of bruises serve as a clinical record and may facilitate forensic analysis in the assessment of suspected physical child abuse. Currently, only conventional imaging techniques are employed; however, alternative imaging modalities using visible and non-visible light may provide additional information. We sought to determine the image modality preferences of paediatricians and the between-observer agreement therein. Nine paediatricians who work in child protection independently compared five image modalities (conventional colour, conventional grey-scale, cross-Polarised, ultraviolet, and infrared) of four bruises, with a compliance rate of 95%. All images were taken using a standardised set of protocols with Nikon D90 cameras and 105-mm macro-lenses. The paediatricians almost unanimously chose cross-Polarised as their preferred modality for all four bruises when assessing boundary, shape, colour, size, and absence of light reflectance. Conventional colour and grey-scale imaging were typically ranked second and third. Ultraviolet and infrared were consistently ranked in the least two favourable positions. Between-observer agreement on ranking order was high, with coefficients of concordance ranging from 0.76 to 0.96. Combinations of imaging modalities chosen to give the most complete picture of the bruise predominantly consisted of cross-Polarised and conventional (colour and grey-scale). This pilot study demonstrated that clinicians collectively favoured cross-Polarised in addition to conventional imaging. Further studies are required to determine the value of ultraviolet and infrared imaging in the assessment of childhood bruises.