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Trefan L, Harris C, Evans S, Nuttall D, Maguire S, Kemp AM. A comparison of four different imaging modalities - Conventional, cross polarized, infra-red and ultra-violet in the assessment of childhood bruising. J Forensic Leg Med 2018; 59:30-35. [PMID: 30096460 PMCID: PMC6125673 DOI: 10.1016/j.jflm.2018.07.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 07/23/2018] [Accepted: 07/31/2018] [Indexed: 01/24/2023]
Abstract
Background It is standard practice to image concerning bruises in children. We aim to compare the clarity and measurements of bruises using cross polarized, infra-red (IR) and ultra-violet (UV) images to conventional images. Methods Children aged <11 years with incidental bruising were recruited. Demographics, skin and bruise details were recorded. Bruises were imaged by standard protocols in conventional, cross-polarized, IR and UV lights. Bruises were assessed in vivo for contrast, uniformity and diffuseness, and these characteristics were then compared across image modalities. Color images (conventional, cross polarized) were segmented and measured by ImageJ. Bruises of grey scale images (IR, UV) were measured by a ‘plug in’ of ImageJ. The maximum and minimum Feret's diameter, area and aspect ratio, were determined. Comparison of measurements across imaging modalities was conducted using Wilcoxon rank sum tests and modified Bland-Altman graphs. Significance was set at p < 0.05. Results Twenty five children had 39 bruises. Bruises that were of low contrast, i.e. difficult to distinguish from surrounding skin, were also more diffuse, and less uniformity in vivo. Low contrast bruises were best seen on conventional and cross-polarized images and less distinctive on IR and UV images. Of the 19 bruises visible in all modalities, the only significant difference was maximum and minimum Feret's diameters and area were smaller on IR compared to conventional images. Aspect ratios were not affected by the modality. Conclusions Conventional and cross-polarized imaging provides the most consistent bruise measurement, particularly in bruises that are not easily distinguished from surrounding skin visually. Diffuse bruises may be measured on conventional & cross polarized imaging. Infrared or ultraviolet imaging may not show bruises which are difficult to see in vivo. Measurements of bruises using infrared imaging may be smaller than other modalities.
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Affiliation(s)
- L Trefan
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - C Harris
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - S Evans
- Chief Clinical Photographer, Dental Photography, School of Dentistry, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff, CF14 4XY, UK.
| | - D Nuttall
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - S Maguire
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
| | - A M Kemp
- Division of Population Medicine, School of Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS, UK.
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Harris C, Alcock A, Trefan L, Nuttall D, Evans ST, Maguire S, Kemp AM. Optimising the measurement of bruises in children across conventional and cross polarized images using segmentation analysis techniques in Image J, Photoshop and circle diameter measurements. J Forensic Leg Med 2018; 54:114-120. [PMID: 29413952 DOI: 10.1016/j.jflm.2017.12.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 08/25/2017] [Accepted: 12/31/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bruising is a common abusive injury in children, and it is standard practice to image and measure them, yet there is no current standard for measuring bruise size consistently. We aim to identify the optimal method of measuring photographic images of bruises, including computerised measurement techniques. METHODS 24 children aged <11 years (mean age of 6.9, range 2.5-10 years) with a bruise were recruited from the community. Demographics and bruise details were recorded. Each bruise was measured in vivo using a paper measuring tape. Standardised conventional and cross polarized digital images were obtained. The diameter of bruise images were measured by three computer aided measurement techniques: Image J (segmentation with Simple Interactive Object Extraction (maximum Feret diameter), 'Circular Selection Tool' (Circle diameter), & the Photoshop 'ruler' software (Photoshop diameter)). Inter and intra-observer effects were determined by two individuals repeating 11 electronic measurements, and relevant Intraclass Correlation Coefficient's (ICC's) were used to establish reliability. Spearman's rank correlation was used to compare in vivo with computerised measurements; a comparison of measurement techniques across imaging modalities was conducted using Kolmogorov-Smirnov tests. Significance was set at p < 0.05 for all tests. RESULTS Images were available for 38 bruises in vivo, with 48 bruises visible on cross polarized imaging and 46 on conventional imaging (some bruises interpreted as being single in vivo appeared to be multiple in digital images). Correlation coefficients were >0.5 for all techniques, with maximum Feret diameter and maximum Photoshop diameter on conventional images having the strongest correlation with in vivo measurements. There were significant differences between in vivo and computer-aided measurements, but none between different computer-aided measurement techniques. Overall, computer aided measurements appeared larger than in vivo. Inter- and intra-observer agreement was high for all maximum diameter measurements (ICC's > 0.7). CONCLUSIONS Whilst there are minimal differences between measurements of images obtained, the most consistent results were obtained when conventional images, segmented by Image J Software, were measured with a Feret diameter. This is therefore proposed as a standard for future research, and forensic practice, with the proviso that all computer aided measurements appear larger than in vivo.
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Affiliation(s)
- C Harris
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Edgbaston, Birmingham, UK.
| | - A Alcock
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Newport, UK.
| | - L Trefan
- School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Heath Park, Cardiff, UK.
| | - D Nuttall
- School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Heath Park, Cardiff, UK.
| | - S T Evans
- Dental Photography, School of Dentistry, College of Biomedical & Life Sciences, Cardiff University, Heath Park, Cardiff, UK.
| | - S Maguire
- School of Medicine, College of Biomedical & Life Sciences, Cardiff University, Heath Park, Cardiff, UK; Division of Population Medicine, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff CF14 4YS, UK.
| | - A M Kemp
- Division of Population Medicine, College of Biomedical and Life Sciences, Cardiff University, Heath Park, Cardiff CF14 4YS, UK.
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Naughton AM, Cowley LE, Tempest V, Maguire SA, Mann MK, Kemp AM. Ask Me! self-reported features of adolescents experiencing neglect or emotional maltreatment: a rapid systematic review. Child Care Health Dev 2017; 43:348-360. [PMID: 28238208 DOI: 10.1111/cch.12440] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 11/24/2016] [Accepted: 11/27/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Neglect is often overlooked in adolescence, due in part to assumptions about autonomy and misinterpretation of behaviors being part of normal adolescent development. Emotional maltreatment (abuse or neglect) has a damaging effect throughout the lifespan, but is rarely recognized amongst adolescents. Our review aims to identify features that adolescents experiencing neglect and/ or emotional maltreatment report. METHOD A rapid review methodology searched 8 databases (1990-2014), supplemented by hand searching journals, and references, identifying 2,568 abstracts. Two independent reviews were undertaken of 279 articles, by trained reviewers, using standardised critical appraisal. Eligible studies: primary studies of children aged 13-17 years, with substantiated neglect and/ or emotional maltreatment, containing self-reported features. RESULTS 19 publications from 13 studies were included, demonstrating associations between both neglect and emotional maltreatment with internalising features (9 studies) including depression, post traumatic symptomatology and anxiety; emotional maltreatment was associated with suicidal ideation, while neglect was not (1 study); neglect was associated with alcohol related problems (3 studies), substance misuse (2 studies), delinquency for boys (1 study), teenage pregnancy (1 study), and general victimization for girls (1 study), while emotionally maltreated girls reported more externalising symptoms (1 study). Dating violence victimization was associated with neglect and emotional maltreatment (2 studies), while emotional abuse of boys, but not neglect, was associated with dating violence perpetration (1 study), and neither neglect nor emotional maltreatment had an association with low self-esteem (2 studies). Neither neglect nor emotional maltreatment had an effect on school performance (1 study), but neglected boys showed greater school engagement than neglected girls (1 study). CONCLUSIONS If asked, neglected or emotionally maltreated adolescents describe significant difficulties with their mental health, social relationships, and alcohol or substance misuse. Practitioners working with youths who exhibit these features should recognize the detrimental impact of maltreatment at this developmental stage, and identify whether maltreatment is a contributory factor that should be addressed.
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Affiliation(s)
- A M Naughton
- Designated Doctor Safeguarding Children, National Safeguarding Team, Public Health Wales NHS Trust, UK
| | - L E Cowley
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK
| | - V Tempest
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK
| | - S A Maguire
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK
| | - M K Mann
- Support Unit for Research Evidence, Cardiff University, Cardiff, UK
| | - A M Kemp
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK
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Burrows P, Trefan L, Houston R, Hughes J, Pearson G, Edwards RJ, Hyde P, Maconochie I, Parslow RC, Kemp AM. Head injury from falls in children younger than 6 years of age. Arch Dis Child 2015; 100:1032-7. [PMID: 26297697 PMCID: PMC4680174 DOI: 10.1136/archdischild-2014-307119] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 04/13/2015] [Indexed: 01/12/2023]
Abstract
UNLABELLED The risk of serious head injury (HI) from a fall in a young child is ill defined. The relationship between the object fallen from and prevalence of intracranial injury (ICI) or skull fracture is described. METHOD Cross-sectional study of HIs from falls in children (<6 years) admitted to UK hospitals, analysed according to the object fallen from and associated Glasgow Coma Score (GCS) or alert, voice, pain, unresponsive (AVPU) and CT scan results. RESULTS Of 1775 cases ascertained (median age 18 months, 54.7% boys), 87% (1552) had a GCS=15/AVPU=alert. 19.3% (342) had a CT scan: 32% (110/342) were abnormal; equivalent to 5.9% of the overall population, 16.9% (58) had isolated skull fractures and 13.7% (47) had ICI (49% (23/47) had an associated skull fracture). The prevalence of ICI increased with neurological compromise; however, 12% of children with a GCS=15/AVPU=alert had ICI. When compared to falls from standing, falls from a person's arms (233 children (mean age 1 year)) had a significant relative OR for a skull fracture/ICI of 6.94 (95% CI 3.54 to 13.6), falls from a building (eg, window or attic) (mean age 3 years) OR 6.84 (95% CI 2.65 to 17.6) and from an infant or child product (mean age 21 months) OR 2.75 (95% CI 1.36 to 5.65). CONCLUSIONS Most HIs from a fall in these children admitted to hospital were minor. Infants, dropped from a carer's arms, those who fell from infant products, a window, wall or from an attic had the greatest chance of ICI or skull fracture. These data inform prevention and the assessment of the likelihood of serious injury when the object fallen from is known.
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Affiliation(s)
- P Burrows
- Institute of Primary Care and Public Health, Cardiff School of Medicine, Cardiff, Wales, UK
| | - L Trefan
- Institute of Primary Care and Public Health, Cardiff School of Medicine, Cardiff, Wales, UK
| | - R Houston
- Placements Manager at Kids Company, London, UK
| | - J Hughes
- Institute of Primary Care and Public Health, Cardiff School of Medicine, Cardiff, Wales, UK
| | - G Pearson
- Department of Anaesthesia and Intensive Care, University of Birmingham
| | - R J Edwards
- Department of Neurosurgery, Bristol Hospital for Children, Bristol, UK
| | - P Hyde
- Paediatric Intensive Care Unit, Southampton Childrens Hospital, Southampton, UK
| | - I Maconochie
- National Institute for Health Research (NIHR) Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London
| | - R C Parslow
- Division of Epidemiology and Biostatistics, Leeds Institute of Genetics, Health and Therapeutics (LIGHT), University of Leeds, Leeds, UK
| | - A M Kemp
- Institute of Primary Care and Public Health, Cardiff School of Medicine, Cardiff, Wales, UK
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Maguire SA, Williams B, Naughton AM, Cowley LE, Tempest V, Mann MK, Teague M, Kemp AM. A systematic review of the emotional, behavioural and cognitive features exhibited by school-aged children experiencing neglect or emotional abuse. Child Care Health Dev 2015; 41:641-53. [PMID: 25733080 DOI: 10.1111/cch.12227] [Citation(s) in RCA: 111] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2014] [Indexed: 01/14/2023]
Abstract
BACKGROUND Interventions to minimize the long-term consequences of neglect or emotional abuse rely on prompt identification of these children. This systematic review of world literature (1947-2012) identifies features that children aged 5-14 years experiencing neglect or emotional abuse, as opposed to physical or sexual abuse, may exhibit. METHODS Searching 18 databases, utilizing over 100 keywords, supplemented by hand searching, 13,210 articles were identified and 111 underwent full critical appraisal by two independent trained reviewers. RESULTS The 30 included studies highlighted behavioural features (15 studies), externalizing features being the most prominent (8/9 studies) and internalizing features noted in 4/6 studies. Four studies identified attention deficit hyperactivity disorder (ADHD) associated features: impulsivity, inattention or hyperactivity. Child difficulties in initiating or developing friendships were noted in seven studies. Of 13 studies addressing emotional well-being, three highlighted low self-esteem, with a perception of external control (1), or depression (6) including suicidality (1). A negative internal working model of the mother increased the likelihood of depression (1). In assessing cognition or academic performance, lower general intelligence (3/4) and reduced literacy and numeracy (2) were reported, but no observable effect on memory (3). CONCLUSIONS School-aged children presenting with poor academic performance, ADHD symptomatology or abnormal behaviours warrant assessment of neglect or emotional abuse as a potential underlying cause.
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Affiliation(s)
- S A Maguire
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK
| | - B Williams
- ST6 Community Child Health, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff, UK
| | - A M Naughton
- Safeguarding Children Service, Public Health Wales NHS Trust, Cardiff, UK
| | - L E Cowley
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK
| | - V Tempest
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK
| | - M K Mann
- Support Unit for Research Evidence, Cardiff University, Cardiff, UK
| | - M Teague
- Masters in Education Programme, Cardiff University, Cardiff, UK
| | - A M Kemp
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, UK
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Abstract
OBJECTIVE To describe the characteristics of childhood burns and scalds, mechanisms and agents to inform prevention. METHODS Prospective multicentred cross-sectional study of children (<16 years) with unintentional burns/scalds from five Emergency Departments (ED), a burns assessment unit and three regional children's Burns Units. DATA COLLECTED site, severity, distribution of the burn/scald, age, motor development of the child, agent and mechanism of the injury. Comparative analysis for children <5 and 5-16 years. RESULTS Of 1215 children, 58% (709) had scalds, 32% (390) contact burns and 116 burns from other causes, 17.6% (214/1215) were admitted to hospital and the remaining treated in ED or burns assessment centre. 72% (878) were <5 years, peak prevalence in 1-year-olds. Commonest scald agent (<5 years) was a cup/mug of hot beverage 55% (305/554), and commonest mechanism was a pull-down injury 48% (66/554). In 5-16-year-olds, scalds were from hot water 50% (78/155) and spill injuries 76% (118/155). Scalds affected the front of the body in 96% (680/709): predominantly to the face, arms and upper trunk in <5-year-olds, older children had scalds to the lower trunk, legs and hands. Contact burns (<5 years) were from touching 81% (224/277) hot items in the home, predominant agents: hair straighteners or irons 42% (117/277), oven hobs 27% (76/277), 5-16-year-olds sustained more outdoor injuries 46% (52/113). 67% (262/390) of all contact burns affected the hands. CONCLUSIONS Scalds to infants and toddlers who pull hot beverages over themselves or sustain burns from touching irons, hair straighteners or oven hobs are a high priority for targeted prevention.
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Affiliation(s)
- A M Kemp
- Early Years Research Programme, Institute of Primary Care and Public Health, Cardiff University, , Heath Park, Cardiff, UK
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Maguire SA, Upadhyaya M, Evans A, Mann MK, Haroon MM, Tempest V, Lumb RC, Kemp AM. A systematic review of abusive visceral injuries in childhood--their range and recognition. Child Abuse Negl 2013; 37:430-445. [PMID: 23306146 DOI: 10.1016/j.chiabu.2012.10.009] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2012] [Revised: 10/28/2012] [Accepted: 10/31/2012] [Indexed: 06/01/2023]
Abstract
OBJECTIVES To define what abusive visceral injuries occur, including their clinical features and the value of screening tests for abdominal injury among abused children. METHODS We searched 12 databases, with snowballing techniques, for the period 1950-2011, with all identified studies undergoing two independent reviews by trained reviewers, drawn from pediatrics, radiology, pediatric surgery and pathology. Of 5802 studies identified, 188 were reviewed. We included studies of children aged 0-18, with confirmed abusive etiology, whose injury was defined by computed tomography, contrast studies or at surgery/post mortem. We excluded injuries due to sexual abuse, or those exclusively addressing management or outcome. RESULTS Of 88 included studies (64 addressing abdominal injuries), only five were comparative. Every organ in the body has been injured, intra-thoracic injuries were commoner in those aged less than five years. Children with abusive abdominal injuries were younger (2.5-3.7 years vs. 7.6-10.3 years) than accidentally injured children. Duodenal injuries were commonly recorded in abused children, particularly involving the third or fourth part, and were not reported in accidentally injured children less than four years old. Liver and pancreatic injuries were frequently recorded, with potential pancreatic pseudocyst formation. Abdominal bruising was absent in up to 80% of those with abdominal injuries, and co-existent injuries included fractures, burns and head injury. Post mortem studies revealed that a number of the children had sustained previous, unrecognized, abdominal injuries. The mortality from abusive abdominal injuries was significantly higher than accidental injuries (53% vs. 21%). Only three studies addressed screening for abdominal injury among abused children, and were unsuitable for meta-analysis due to lack of standardized investigations, in particular those with 'negative' screening tests were not consistently investigated. CONCLUSIONS Visceral injuries may affect any organ of the body, predominantly abdominal viscera. A non-motor vehicle related duodenal trauma in a child aged<five years warrants consideration of abuse as an etiology. In the absence of clear evidence for a screening strategy, clinical vigilance is warranted in any young child with suspected abuse for the presence of abdominal injury, where the absence of abdominal bruising or specific symptoms does not preclude significant injury.
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Affiliation(s)
- S A Maguire
- Child Health Department, School of Medicine, Cardiff University, University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK
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Kemp AM, Jaspan T, Griffiths J, Stoodley N, Mann MK, Tempest V, Maguire SA. Neuroimaging: what neuroradiological features distinguish abusive from non-abusive head trauma? A systematic review. Arch Dis Child 2011; 96:1103-12. [PMID: 21965812 DOI: 10.1136/archdischild-2011-300630] [Citation(s) in RCA: 155] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To identify the evidence base behind the neuroradiological features that differentiate abusive head trauma (AHT) from non-abusive head trauma (nAHT). DESIGN Systematic review. SETTING Literature search of 14 databases, websites, textbooks, conference abstracts and references (1970-February 2010). Studies had two independent reviews (three if disputed) and critical appraisal. PATIENTS Primary comparative studies of children <11 years old hospitalised with AHT and nAHT diagnosed on CT or MRI. MAIN OUTCOME MEASURES Neuroradiological features that differentiated AHT from nAHT. RESULTS 21 studies of children predominantly <3 years old were analysed. Subdural haemorrhages (SDH) were significantly associated with AHT (OR 8.2, 95% CI 6.1 to 11). Subarachnoid haemorrhages were seen equally in AHT and nAHT and extradural haemorrhages (EDH) were significantly associated with nAHT (OR for AHT 0.1, 95% CI 0.07 to 0.18). Multiple (OR 6, 95% CI 2.5 to 14.4), interhemispheric (OR 7.9, 95% CI 4.7 to 13), convexity (OR 4.9, 95% CI 1.3 to 19.4) and posterior fossa haemorrhages (OR 2.5, 95% CI 1 to 6) were associated with AHT. Hypoxic-ischaemic injury (HII) (OR 3.7, 95% CI 1.4 to 10) and cerebral oedema (OR 2.2, 95% CI 1.0 to 4.5) were significantly associated with AHT, while focal parenchymal injury was not a discriminatory feature. SDH of low attenuation were more common in AHT than in nAHT. CONCLUSION Multiple SDH over the convexity, interhemispheric haemorrhages, posterior fossa SDH, HII and cerebral oedema are significantly associated with AHT and should be considered together with clinical features when identifying the condition.
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Affiliation(s)
- A M Kemp
- School of Medicine, Cardiff University, UHW, Heath Park, Cardiff CF14 4XN, UK.
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Kemp AM, Joshi AH, Mann M, Tempest V, Liu A, Holden S, Maguire S. What are the clinical and radiological characteristics of spinal injuries from physical abuse: a systematic review. Arch Dis Child 2010; 95:355-60. [PMID: 19946011 DOI: 10.1136/adc.2009.169110] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM Systematic review of 'What are the clinical and radiological characteristics of inflicted spinal injury?' METHODS Literature search of 20 electronic databases, websites, references and bibliographies (1950-2009) using selected keywords. Critical appraisal: by two trained reviewers, (a third review, if discrepant). INCLUSION CRITERIA primary studies of inflicted spinal injury in children <18 years, alive at presentation, with a high surety of diagnosis of abuse and sufficient detail to analyse. RESULTS 19 studies of 25 children were included. Twelve children (median age 5 months) had cervical injury. In seven cases, the clinical signs of spinal injury were masked by respiratory symptoms and impaired levels of consciousness; six of these children had coexistent inflicted head trauma. Twelve children had thoraco-lumbar injury (median age 13.5 months), 10/12 had lesions at T11-L2, and 9/12 had fracture dislocations. All children had focal signs: 10/12 had lumbar kyphosis or thoraco-lumbar swelling, and two had focal neurology. One child had cervical, thoracic and sacral injuries. CONCLUSIONS Spinal injury is a potentially devastating inflicted injury in infants and young children. The published evidence base is limited. However, this case series leads us to recommend that any clinical or radiological indication of spinal injury warrants an MRI. In children undergoing brain MRI for abusive head trauma, consideration should be given to including an MRI of the spine. All skeletal surveys in children with suspected abuse should include lateral views of the cervical and thoraco-lumbar spine. Further prospective comparative studies would define the discriminating features of inflicted spinal injuries.
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Affiliation(s)
- A M Kemp
- Department of Child Health, School of Medicine, Cardiff University, Cardiff, Wales, UK.
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Maguire S, Pickerd N, Farewell D, Mann M, Tempest V, Kemp AM. Which clinical features distinguish inflicted from non-inflicted brain injury? A systematic review. Arch Dis Child 2009; 94:860-7. [PMID: 19531526 DOI: 10.1136/adc.2008.150110] [Citation(s) in RCA: 150] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIM A systematic review of the scientific literature to define clinical indicators distinguishing inflicted (iBI) from non-inflicted brain injury (niBI). METHODS An all language literature search of 20 electronic databases, websites, references and bibliographies from 1970-2008 was carried out. Relevant studies were independently reviewed by two trained reviewers, with a third review where required. Inclusion criteria included primary comparative studies of iBI and niBI in children aged <18 years, with high surety of diagnosis describing key clinical features. Multilevel logistic regression analysis was conducted, determining the positive predictive value (PPV) and odds ratios (OR) with p values for retinal haemorrhage, rib/long bone/skull fractures, apnoea, seizures and bruising to head/neck. RESULTS 8151 studies were identified, 320 were reviewed and 14 included, representing 1655 children, 779 with iBI. Gender was not a discriminatory feature. In a child with intracranial injury, apnoea (PPV 93%, OR 17.06, p<0.001) and retinal haemorrhage (PPV 71%, OR 3.504, p = 0.03) were the features most predictive of iBI. Rib fractures (PPV 73%, OR 3.03, p = 0.13) had a similar PPV to retinal haemorrhages, but there were less data for analysis. Seizures and long bone fractures were not discriminatory, and skull fracture and head/neck bruising were more associated with niBI, although not significantly so. CONCLUSIONS This systematic review shows that apnoea and retinal haemorrhage have a high odds ratio for association with iBI. This review identifies key features that should be recorded in the assessment of children where iBI is suspected and may help clinicians to define the likelihood of iBI.
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Affiliation(s)
- S Maguire
- Child Health, School of Medicine, Cardiff University, Heath Park, Cardiff CF14 4XN, UK.
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Kemp AM, Rajaram S, Mann M, Tempest V, Farewell D, Gawne-Cain ML, Jaspan T, Maguire S. What neuroimaging should be performed in children in whom inflicted brain injury (iBI) is suspected? A systematic review. Clin Radiol 2009; 64:473-83. [PMID: 19348842 DOI: 10.1016/j.crad.2008.11.011] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2008] [Revised: 10/31/2008] [Accepted: 11/11/2008] [Indexed: 10/21/2022]
Abstract
AIMS To investigate the optimal neuroradiological investigation strategy to identify inflicted brain injury (iBI). MATERIALS AND METHODS A systematic review of studies published between 1970-2008 in any language was conducted, searching 20 databases and four websites, using over 100 keywords/phrases, supplemented by hand-searching of references. All studies underwent two independent reviews (with disagreements adjudicated by a third reviewer) by trained reviewers from paediatrics, paediatric neuroradiology and related disciplines, using standardized critical appraisal tools, and strict inclusion/exclusion criteria. We included primary studies that evaluated the diagnostic yield of magnetic resonance imaging (MRI), in addition to initial computed tomography (CT), or follow-up CT or ultrasound in children with suspected iBI. RESULTS Of the 320 studies reviewed, 18 met the inclusion criteria, reflecting data on 367 children with iBI and 12 were published since 1998. When an MRI was conducted in addition to an abnormal early CT examination, additional information was found in 25% (95% CI: 18.3-33.16%) of children. The additional findings included further subdural haematoma, subarachnoid haemorrhage, shearing injury, ischaemia, and infarction; it also contributed to dating of injuries. Diffusion-weighted imaging (DWI) further enhanced the delineation of ischaemic changes, and assisted in prognosis. Repeat CT studies varied in timing and quality, and none were compared to the addition of an early MRI/DWI. CONCLUSIONS In an acutely ill child, the optimal imaging strategy involves initial CT, followed by early MRI and DWI if early CT examination is abnormal, or there are ongoing clinical concerns. The role of repeat CT imaging, if early MRI is performed, is unclear, as is the place for MRI/DWI if initial CT examination is normal in an otherwise well child.
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Affiliation(s)
- A M Kemp
- Department of Child Health, Wales School of Medicine, Cardiff University, Cardiff, UK
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Kemp AM, Butler A, Morris S, Mann M, Kemp KW, Rolfe K, Sibert JR, Maguire S. Which radiological investigations should be performed to identify fractures in suspected child abuse? Clin Radiol 2006; 61:723-36. [PMID: 16905379 DOI: 10.1016/j.crad.2006.03.017] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2005] [Revised: 03/22/2006] [Accepted: 03/28/2006] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- A M Kemp
- Welsh Child Protection Systematic Review Group, Department of Child Health, Cardiff University, UK.
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Abstract
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.
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Affiliation(s)
- B A Ellaway
- Department of Child Health and Epidemiology, Cardiff University, Wales College of Medicine, Academic Centre, Llandough Hospital, Wales, UK
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14
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Abstract
AIMS (1) To identify whether infants and young children admitted to hospital with subdural haematomas (SDH) secondary to non-accidental head injury (NAHI), suffer from apnoea leading to radiological evidence of hypoxic ischaemic brain damage, and whether this is related to a poor prognosis; and (2) to determine what degree of trauma is associated with NAHI. METHODS Retrospective case series (1992-98) with case control analysis of 65 children under 2 years old, with an SDH secondary to NAHI. Outcome measures were presenting symptoms, associated injuries and apnoea at presentation, brain swelling or hypoxic ischaemic changes on neuroimaging, and clinical outcome (KOSCHI). RESULTS Twenty two children had a history of apnoea at presentation to hospital. Apnoea was significantly associated with hypoxic ischaemic brain damage. Severe symptoms at presentation, apnoea, and diffuse brain swelling/hypoxic ischaemic damage were significantly associated with a poor prognosis. Eighty five per cent of cases had associated injuries consistent with a diagnosis of non-accidental injury. CONCLUSIONS Coma at presentation, apnoea, and diffuse brain swelling or hypoxic ischaemia all predict a poor outcome in an infant who has suffered from SDH after NAHI. There is evidence of associated violence in the majority of infants with NAHI. At this point in time we do not know the minimum forces necessary to cause NAHI. It is clear however that it is never acceptable to shake a baby.
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Affiliation(s)
- A M Kemp
- Department of Child Health, University of Wales College of Medicine, Cardiff, UK.
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Abstract
AIMS To determine whether abused and non-abused children differ in the extent and pattern of bruising, and whether any differences which exist are sufficiently great to develop a score to assist in the diagnosis of abuse. METHODS Total length of bruising in 12 areas of the body was determined in 133 physically abused and 189 control children aged 1-14 years. RESULTS Our method of recording bruises by site, maximum dimension, and shape was easy to use. There were clear differences between cases and controls in the total length of bruises. These differences were at their greatest in the head and neck and were less notable in the limbs. A scoring system was developed using logistic regression analysis using total lengths of bruising in five regions of the body. Good discrimination between the two sets of children was achieved using this score; by including a variable that indicates whether a bruise had a recognisable shape the discrimination could be made even better. Given a prior probability of abuse the score can be used to give posterior odds of abuse, given a particular bruising pattern. CONCLUSIONS The scoring system provides a measure that discriminates between abused and non-abused children, which should be straightforward to implement, though the results must be interpreted carefully. We do not see this score as replacing the complex qualitative analysis of the diagnosis of abuse. This clearly includes history as well as examination, but rather as the beginning of the development of an important aid in this process.
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Affiliation(s)
- F D Dunstan
- Department of Child Health, University of Wales College of Medicine, Academic Centre, Llandough Hospital, Penarth, Wales CF64 2XX, UK
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Sibert JR, Payne EH, Kemp AM, Barber M, Rolfe K, Morgan RJH, Lyons RA, Butler I. The incidence of severe physical child abuse in Wales. Child Abuse Negl 2002; 26:267-276. [PMID: 12013058 DOI: 10.1016/s0145-2134(01)00324-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
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.
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Affiliation(s)
- J R Sibert
- Cardiff Family Studies Research Centre, Department of Child Health, University of Wales College of Medicine, Llandough Hospital, Penarth, UK
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18
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Abstract
When an infant or young child presents with subdural haemorrhage, the diagnostic priority is to exclude physical child abuse. A team approach should be adopted for the clinical child protection investigation. The diagnostic process is inevitably one of detective work; appropriate radiological, ophthalmological, haematological, biochemical, and postmortem investigations are discussed.
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Affiliation(s)
- A M Kemp
- A M Kemp, University of Wales College of Medicine, Academic Centre, Llandough Hospital, Cardiff CF64 2XX, UK.
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Jayawant S, Rawlinson A, Gibbon F, Price J, Schulte J, Sharples P, Sibert JR, Kemp AM. Subdural haemorrhages in infants: population based study. BMJ 1998; 317:1558-61. [PMID: 9836654 PMCID: PMC28734 DOI: 10.1136/bmj.317.7172.1558] [Citation(s) in RCA: 219] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To identify the incidence, clinical outcome, and associated factors of subdural haemorrhage in children under 2 years of age, and to determine how such cases were investigated and how many were due to child abuse. DESIGN Population based case series. SETTING South Wales and south west England. SUBJECTS Children under 2 years of age who had a subdural haemorrhage. We excluded neonates who developed subdural haemorrhage during their stay on a neonatal unit and infants who developed a subdural haemorrhage after infection or neurosurgical intervention. MAIN OUTCOME MEASURES Incidence and clinical outcome of subdural haemorrhage in infants, the number of cases caused by child abuse, the investigations such children received, and associated risk factors. RESULTS Thirty three children (23 boys and 10 girls) were haemorrhage. The incidence was 12.8/100 000 children/year (95% confidence interval 5.4 to 20.2). Twenty eight cases (85%) were under 1 year of age. The incidence of subdural haemorrhage in children under 1 year of age was 21.0/100 000 children/year and was therefore higher than in the older children. The clinical outcome was poor: nine infants died and 15 had profound disability. Only 22 infants had the basic investigations of a full blood count, coagulation screen, computed tomography or magnetic resonance imaging, skeletal survey or bone scan, and ophthalmological examination. In retrospect, 27 cases (82%) were highly suggestive of abuse. CONCLUSION Subdural haemorrhage is common in infancy and carries a poor prognosis; three quarters of such infants die or have profound disability. Most cases are due to child abuse, but in a few the cause is unknown. Some children with subdural haemorrhage do not undergo appropriate investigations. We believe the clinical investigation of such children should include a full multidisciplinary social assessment, an ophthalmic examination, a skeletal survey supplemented with a bone scan or a skeletal survey repeated at around 10 days, a coagulation screen, and computed tomography or magentic resonance imaging. Previous physical abuse in an infant is a significant risk factor for subdural haemorrhage and must be taken seriously by child protection agencies.
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Affiliation(s)
- S Jayawant
- Department of Child Health, University of Wales College of Medicine, Academic Centre, Llandough Hospital, Penarth, Vale of Glamorgan CF64 2XX
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Kemp AM, Sibert J. The shaken infant syndrome. Deal with minor episodes of abuse to prevent more serious injuries. BMJ 1995; 310:1600; author reply 1600-1. [PMID: 7787659 PMCID: PMC2549955 DOI: 10.1136/bmj.310.6994.1600a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Abstract
The causes, classification, and prevention of mechanical asphyxial death in children were examined. The Office of Population Censuses and Surveys (OPCS) identified children, under 15 years of age, who had died as a result of choking, suffocation, or strangulation in England and Wales during the years 1990 and 1991. Cases in the International Classification of Diseases (ICD) codes of E911-3, E953, E963, and E983 were selected and case details from HM coroners' records and the death certificates were extracted. The OPCS identified 136 children (99 boys, 37 girls) in the two year period, 65% were under 3 years of age. The children were classified as dying from choking (21 cases), aspirating gastric contents (39 cases), suffocation (29 cases), strangulation (11 cases), and hanging (36 cases). The strangulation cases could be further subdivided into a group of 12 younger children who were suspended from ligatures around the home and a group of 21 boys (8-14 years) who died of self initiated hanging. Overall, 11 children were deliberately killed and 31 children died in beds or cots. Children whose deaths are classified as being due to aspiration of vomit appear to be cases of the sudden infant death syndrome or background medical conditions. This study suggests the need for advice on maintaining a safe sleeping environment. Only one child choked on a toy and European Standards for Toy Safety appear to have been successful. The prevention of hanging in the group of older boys needs further exploration.
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Affiliation(s)
- J W Nixon
- Department of Child Health, University of Wales College of Medicine, Llandough Special Children Centre, Penarth, South Glamorgan
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22
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Abstract
Non-accidental bath drowning is an infrequently reported form of child abuse. Details of 44 children who suffered from drowning or near drowning in the bath were analysed from a two year (1988-9) UK study to investigate factors that might point to abuse. Cases of near drowning were notified through the British Paediatric Surveillance Unit inquiry system and drowning cases from the Office of Population Censuses and Surveys, the Scottish Government Record Office, and the Northern Ireland Office. In 28 cases the story was of accidental submersion with a baby of modal age 9 months being left unsupervised in a bath. Two other neonates briefly slipped from the parents arms while having a bath. Four bathtub drownings were related to epilepsy. In contrast 10 cases (six drowning and four near drowning) had stories very suggestive of abuse with inconsistent histories, previous history of abuse, and late presentation for medical care. A diagnosis of abuse should be considered in the differential diagnosis of atypical bathtub immersions in the absence of epilepsy and developmental delay.
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Affiliation(s)
- A M Kemp
- Department of Child Health, University of Wales College of Medicine, Lansdowne Hospital, Cardiff
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Kemp AM, Sibert JR. Childhood drowning. Ir Med J 1994; 87:35-6. [PMID: 8194946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Abstract
To clarify the risks of drowning for children with epilepsy we have studied the records of the 306 children who drowned or nearly drowned in the UK in 1988 and 1989. Ten children with incidents related to epilepsy presented over the study period, four of whom drowned. Children with epilepsy had a higher incidence of submersion accidents but no child participating in supervised swimming drowned. Two children died in the bath. Five children had special needs. We conclude that children with epilepsy can enjoy swimming with a friend in a lifeguard supervised swimming pool. They should be encouraged to shower in a non-glass cubicle rather than have a bath. The bathroom should remain unlocked. Children with poorly controlled epilepsy or associated learning difficulties are at a higher risk from all accident trauma. They need a very high level of supervision while swimming and advice should be given on an individual basis according to what is considered realistic for that child.
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Affiliation(s)
- A M Kemp
- Department of Child Health, University of Wales College of Medicine, Cardiff
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Abstract
OBJECTIVE To determine the outcome in nearly drowned children in the British Isles and identify factors that might predict a poor prognosis. DESIGN Study of drowned and of nearly drowned children aged less than or equal to 14. Information on nearly drowned children admitted to hospital obtained from consultant paediatricians returning monthly notification cards through the British Paediatric Surveillance Unit. Information on drowned children obtained from Office of Population Censuses and Surveys and other national epidemiological offices. SETTING British Isles, 1988 and 1989. SUBJECTS 330 children who had confirmed submersion incidents. 142 died before admission to hospital and 188 children were admitted after nearly drowning. MAIN OUTCOME MEASURES Death, full recovery, or degree of handicap after near drowning and signs on admission to hospital. RESULTS All of the children who were conscious on admission fully recovered. Of the 64 children unconscious on admission, 31 had normally reactive pupils and all but three (all of whom had severe preexisting neurological disease) recovered fully. Of the 33 children with fixed dilated pupils on admission, 10 fully recovered, 13 died, and 10 had severe neurological deficit. Spontaneous respiratory effect on admission was associated with normal survival. Pupils that remained dilated six hours after admission and fits continuing 24 hours after admission predicted a poor outcome. CONCLUSION Children can survive normally after near drowning in the British Isles, particularly if they have been hypothermic. Resuscitation should not be abandoned in nearly drowned children until they have been rewarmed.
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Affiliation(s)
- A M Kemp
- Department of Child Health, University of Wales College of Medicine, Llandough Hospital, South Glamorgan
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Nickelsen C, Weber T, Parnell C, Nim J, Kemp AM, Junge I. [Cardiotocographic monitoring of deliveries. A prospective comparative study of 2 types of electrodes]. Ugeskr Laeger 1989; 151:440-2. [PMID: 2919468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
The number of electrodes employed, the frequency of reapplication, the technical quality of monitoring and the complications of use of spiral electrodes and Copeland electrodes for cardiotocographic monitoring of deliveries are assessed in a prospective randomized investigation. The number of electrodes employed and the frequency of reapplications were significantly lower employing Copeland electrodes. Similarly, the electrode signal was significantly better as assessed by the percentage of the duration of monitoring in which the cardiotocogram did not register during the second stage of labour on account of poor electrode signals. No differences were found in the frequencies of complications or subjective discomfort in the mother on employing the two types of electrodes.
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Abstract
A 14 year old boy presented with a painful hip, initially attributed to Perthes' disease although it is uncommon in teenagers. Subsequent investigation showed that the underlying pathology was non-Hodgkin's lymphoma.
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Affiliation(s)
- S Renowden
- Department of Radiology, University Hospital of Wales, Health Park, Cardiff, UK
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