The short- and long-term effects on the visual system of children following exposure to maternal substance misuse in pregnancy.

PURPOSE: To document the prevalence of ophthalmic morbidities in babies born to mothers who misused substances in pregnancy and to assess whether it changes over 5 years. DESIGN: Retrospective comparative case series. METHODS: The series included: (1) a retrospective review of 301 children born between 2000 and 2004 to mothers misusing substances during pregnancy; (2) assessment at 5-year follow-up of this cohort; and (3) comparison with 7887 age-matched controls drawn from the preschool screening cohort in the north of Scotland in the same time period. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Following data collection in both patient and control groups, the following were calculated: (1) rate of referral to the ophthalmology department; (2) prevalence of nystagmus and strabismus at presentation in the study group and at 5 years of age in both patient and control group; (3) prevalence of reduced visual acuity and lack of stereopsis. RESULTS: Ophthalmology referrals, strabismus, and nystagmus were found to be statistically significantly higher in the study group compared with the control group. In the study group, at baseline referral, 46 of 301 (15.3%) had strabismus (2.8% in control group) and 11 of 301 (3.7%) nystagmus (0.004% in control group). At 5-year follow-up, the prevalence of strabismus was 14.0% (OR 5.70, 95% CI: 4.01-8.12) and that of nystagmus was 3.3% (OR 90.34, 95% CI 24.73-330.02). A total of 42.4% of these children at age 5 had no demonstrable binocular vision and 28.2% had visual acuity of 0.3 (logMAR) or worse in 1 or both eyes. Clinic attendance at last follow-up was poor (61.9%). CONCLUSIONS: Exposure to maternal drug misuse in utero is associated with a statistically significantly higher prevalence of strabismus and nystagmus. These abnormalities tend to persist at 5 years of age and are associated with long-term visual morbidity, such as lack of binocularity and poor visual acuity. Our study highlights the need for ophthalmologic surveillance of this population and supports attendance, as nonattendance may be linked to more problems with substance misuse in parents and greater pathology in the child.

Fractures in children younger than age 1 year: importance of collaboration with child protection services.

The medical records of all children less than 1 year of age presenting to the Accident and Emergency Department over a 5-year period (1995-1999) with a fracture were retrospectively reviewed for possible abuse. Seventy-four children presented with fractures during the study period, with a mean age at presentation of 5 months (range 2 weeks to 1 year). Of these children, 46 had skull fractures and 28 had long bone fractures. Children were classified into one of seven categories: definite abuse, likely abuse, suspicious, likely accident, definite accident, neglect, or unknown cause. A three-tier system of grading for possible abuse was then used to analyze variance. The first tier consisted of the initial assessment by staff clinicians, the second retrospectively by an orthopaedic registrar, and the third retrospectively by a designated doctor in child protection (consultant pediatrician), all using the same information from the case notes. The use of the three-tier system of grading demonstrated a variance in the diagnosis of nonaccidental injury. The possibility of abuse was underestimated at the time of the original injury in over a quarter of cases (28.4%) when compared with the assessment by the consultant pediatrician. In 34 children (46%), there was no written documentation that nonaccidental injury was ever considered. While management depends on local guidelines and arrangements, the authors would advise that all children under 1 year of age with a fracture should be admitted to the hospital and referred to a pediatrician for child protection assessment.