Paediatric Clinical Guideline by N1di70N

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									Paediatric Clinical Guideline
Emergency 1.6 Child Protection


Contents
What to do if you are concerned that a child may have been abused?

The Medical Assessment
   History
   Examination

Assessment of different types of injury
    Bruises
    Bites
    Fractures
    Non-accidental Head Injury
    Intra-abdominal Injury
    Thermal Injury
    Other Non-accidental Injuries

Examination of Siblings

Discharge and Follow-up

Documentation and Recording
   Photographs
   Growth Charts
   Developmental Assessment
   Collection of Forensic Specimens
   Formulating your Opinion
   Telephone Calls
   Report Writing
   Statements to the Police

Directory of Important Contacts

Appendix 1 – The child protection examination pack

Appendix 2 – Consent form

Appendix 3 – Proforma for dictated reports to social services




Damian Wood                                 Page 1 of 45             May 2007
Paediatric Clinical Guideline
Emergency 1.6 Child Protection

What to do if you are concerned that a child may have been
abused?
Paediatricians may become concerned that a child is being abused or neglected because:
   child discloses abuse
   parent alleges/discloses abuse
   as part of the differential diagnosis of a medical problem (e.g. unexplained injury or
      faltering growth)
   children’s social care or the police request assessment of a child when concerns have
      been raised by others
   other professionals e.g. health visitor has concerns about a child

The golden rules
   consult widely
   gather information (HV, School Nurse, GP, emergency department)
   check the child protection register
   a referral should be made by telephone to children’s social care with a written referral
     within 48hours
   record all concerns and discussions, including telephone conversations
   if you feel that your concerns have not been addressed contact the named professionals

Remember
   the interests of the child are paramount (Children Act 1989)
   do not accuse anybody of harming the child (a concern does not mean a diagnosis has
    been made, but it does require further assessment and investigation)
   discuss your concerns with the parents (and the child/young person if developmentally
    appropriate)
   explain to the parents that you are making a referral to children’s social care (except in
    suspected cases of fabricated or induced illness or sexual abuse)

Make an immediate referral to:
   Police
          o Allegations of recent rape or sexual assault
          o Dead or severely injured children where abuse is thought likely
          o Threatened removal from hospital where the child is thought to be in danger
   Children’s Social Care and/or police
          o Suspected abuse/neglect where siblings may be unprotected
          o Serious abuse that has been witnessed e.g. shaking of infant or smothering of
              child


The Police have extra powers of protection that may be required in serious circumstances

Most abused and neglected children do not require admission to hospital but consider admission
for:
    Injured children requiring treatment
    Any infant or child requiring in-patient investigation e.g. neuroimaging
    Where the family or social situation indicates an immediate need for a temporary safe and
     supportive space whilst investigations take place




Damian Wood                               Page 2 of 45                                May 2007
Paediatric Clinical Guideline
Emergency 1.6 Child Protection

The Medical Assessment
“The central medical task in child protection is a comprehensive paediatric assessment. It should
 be conducted with the same thoroughness and attention to detail as you would any potentially
               life-threatening medical condition” (Victoria Climbie Inquiry 2003)

The assessment should be carried out by an experienced paediatrician (consultant, associate
specialist, staff grade, or specialist registrar working under consultant supervision)

The degree of urgency depends on the nature of the concerns:
   Physical injury should be seen if at all possible on the same day
   Acute sexual assault – examination to collect forensic specimens should occur as soon as
      possible but evidence may still be gathered up to 7 days later. Examinations should be
      performed by a trained examiner (separate rota for Community Paediatrician on-call for
      Child Sexual Abuse – contactable via switchboard 24 hrs a day)


Before you begin
       Introduce yourself to the child and family and Social Worker.
       Ensure the child has an appropriate understanding of the examination
       Ask the Social Worker whether she/he wishes to speak to you alone first.
       Establish consent for examination – link to consent form
       Remember to make clear notes at the time of the consultation.
       Use the Child Protection Examination Pack.
       Medical notes including all diagrams must be dated, timed and signed
       Ensure that patient identifiers are clear on each page
       Avoid examining the child alone (even if a carer is present). Always ensure you have a
        chaperone.
       Avoid asking leading questions
       Record verbatim any comments made by the child/young person




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Emergency 1.6 Child Protection
History and Circumstances of the Injury
Circumstances of the injury
 Time and place
 Witnesses
 Precise details of events
 Actions afterwards
 Child and parent response
 Consider:
           Is the injury reasonably explained by the history?
           Any unreasonable delay in seeking medical help?
           Is there one or several versions of the history for the injury?
           Have there been any changes in the history?
           Do you clearly understand what is being said?
           Bearing in mind the child’s development is it possible for him to have done what is
              suggested?
           Is there a history of inappropriate child response (e.g. didn’t cry, felt no pain)
           Have there been any previous injuries, accidents or admissions to hospital?
              Recurring injuries in child or sibling
           Are there any injuries that could not have occurred simultaneously?

History of Child: (record from whom you obtained this information)
 Age, medical and developmental history
 Significant life events
 Previous injuries/hospital admissions
 General health, recent symptoms or illness, medicines, drugs - In teenagers use the
    HEADSSS psychosocial profile
 Factors which may put child at increased risk of harm:
         Prematurity
         Difficulty with feeding
         Disability (including learning difficulties)
         Chronic illness
         Children looked after
 Is the child and family known to Children’s Social Care?
         Are they on the child protection register?
         Have there been previous concerns about child care for this or any other child?
         Have there been other Register enquiries about the child?

History of Family
 Place in family tree
 Composition of household
 Family medical conditions
 Family accommodation and supports
 School circumstances
 Other professionals involved with the children
 Risk factors in the family:
        o Drug and alcohol abuse
        o Domestic violence
        o Mental health problems
        o Learning difficulties
        o Disability and chronic illness
        o Homelessness



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Emergency 1.6 Child Protection
        o     Young, unsupported parents
        o     Parents with poor role models of their own

Examination

Check that you have consent from parent/child as appropriate – see appendix for information on
consent in cases where there are safeguarding concerns
    Examination of the whole child – explain to child and parent that you will do a top to toe
       examination. Older children may refuse to have a genital inspection and this must be
       respected
    General appearance, cleanliness, state of clothes
    Length/height and weight plotted on percentile charts with previous measurements if
       known
    Head circumference in younger children
    Note the interactions with parents and staff
    General emotional state and comment on development

In particular, examine
     Scalp and hair, where injuries may be hidden (a fractured skull need not be bruised)
     Fontanelle
     Behind ears, ear canals and drums
     Eyes, for conjunctival haemorrhage and ophthalmoscopic search for retinal haemorrhage
     Mouth, particularly for gum or tooth damage, torn frenulum
     Face and neck for fine bruises from strangulation
     Ribs for bruising, swelling, tenderness or fractures
     Arms and legs for grip marks, ligature marks
     Palms and soles
     Abdomen for bruises or internal damage
     Genitalia – inspection of penis, scrotum, anus, vulva, uretha and hymen where
         appropriate




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Paediatric Clinical Guideline
Emergency 1.6 Child Protection

Bruises
Several recent studies have increased our knowledge about the age, frequency, site and
association with developmental stage in relation to accidental infant bruising. This guideline is
based on these studies and looks at different factors useful in the assessment of non-accidental
injury in infants found to have bruising presenting to the paediatric emergency department (QMC)
or to the non-accidental injury clinic (CHN).
     Bruising in young infants is uncommon. “Those who don’t cruise rarely bruise”
     Patterns and sites of bruising in children that are suggestive of abuse have been well
                     1-3
        documented .

Age of the child
There is good evidence that babies less than 9 months of age rarely have bruises related to
accidental injury.
    In two large studies only 1.2% and 1.5% of babies under nine months had bruising.
                         4,5

    Those over nine months had bruising much more commonly (12-40%).
    One study showed that this increase in bruising with age was independent of mobility .
                                                                                          5

Based on this evidence there should be a high index of suspicion of non-accidental injury in
babies less than nine months of age who are found to have bruising. This is particularly true of
those less than 6 months of age.

Developmental stage
Several studies have shown that the numbers of bruises is directly related to mobility. Accidental
                                                            5
injuries occur rarely in those babies who are ‘pre-cruisers’ .
     One study showed that babies who were not yet cruising had bruises in only 2.2 % of
                  5

       cases.
     However, 18% of cruisers and 52% of walkers had at least one bruise.
     Another study showed that in babies from 6 to 12 months only 4% of ‘sitters’ had bruises
                       6

       compared to 17% of ‘crawlers’ and 38% of ‘walkers’.

       It is therefore essential to obtain information about gross motor development.

Site of the bruising
There is good evidence that site of bruising can be useful in helping to determine the risk of non-
accidental injury in infants.
    The most common sites of accidental injury in infants are the anterior tibia, knee and upper
      leg (especially in ‘walkers’) and the forehead.
    ‘Soft’ sites such as the face (not forehead) and trunk are very rare in accidental injury and
      suggest non-accidental injury in all age groups, especially infants.
    Common and important sites for non-accidental bruises are:
             o Buttocks and lower back
             o Slap marks on side of face scalp and ears
             o Bruises on external ear
             o Neck, eyes and mouth
             o Trunk including chest and abdomen
             o Lower jaw and mastoid
    No site itself is pathognomonic and a careful history is required

Number of bruises
The number of bruises found in accidental injury is related to age and mobility.
   One study showed that the mean number of bruises for a ‘pre-cruiser’ who had bruising
                5

      was 1.3 (1-4) as compared to 2.4 (1-11) per ‘walker’ with bruising.



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Emergency 1.6 Child Protection
    Other studies have shown that in mobile children of all ages about 20% will have >5
      injuries, 4% have 10 or more and <1% will have over 15. This is independent of age.
Therefore suspicion should be raised if an infant is found to have numerous bruises even if they
are mobile.

Ageing of bruises
The statements on ageing bruises in many review articles and textbooks are not based on any
scientific evidence. Do not attempt to age bruises. Provide a factual description and as opinion as
to whether the bruises are likely to be non-accidental in origin.

History of the injury
One study stated that injuries sustained after falling from a bed or sofa tend to be minor. Similarly
                                                                                            9
children falling down a flight of stairs will frequently injure themselves but not seriously .

                    It is important to document developmental stage clearly

Other important history
History should include
    A full history of family coagulation disorders is required including bleeding after surgery,
      delivery, dental care and immunization
    Drug history (aspirin , NSAIDs, warfarin)

Assessment
    Use the body maps to document the injuries
    Carefully describe each and every bruise
             Site
             Size (measure)
             Shape
             Colour
             Shape
             Pattern (e.g. fingertip, slap mark)
    Formal photography of bruises
    Bloods
             FBC and Film
             Coagulation screen (PT, APTT, Thrombin time, Fibrinogen)
             If there is a family or personal history of bleeding tendency or any of the above
                 are borderline or abnormal discuss with Dr Forman, Consultant Paediatric
                 Haematologist regarding further investigation
    If the child is <2 years of age consider a skeletal survey

Differential Diagnosis of Bruising
    Meningococcal disease (rarely)
    Coagulation disorder (haemophilia, Christmas disease, Factor VIII,/iX deficiency, Von
     Willebrand disease)
    Immune Thrombocytopenia purpura
    Henoch Schonlein Purpura
    Connective Tissue Disorders e.g. Ehlers-Danlos syndrome
    Drugs (aspirin, NSAIDs, Warfarin)
    Birth marks (Mongolian blue spots, haemagiomata)
    Cultural practices (coining or cupping)
    Photosensitive/contact dermatitis
    Artifact (dirt/dye/paint)



Damian Wood                                  Page 7 of 45                                   May 2007
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Emergency 1.6 Child Protection
    Self inflicted injuries – this should not be accepted as the explanation without careful
     assessment
    Striae




Damian Wood                                 Page 8 of 45                                    May 2007
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Emergency 1.6 Child Protection
Bites

   Bites are always inflicted injuries but may be animal, adult or child
   Bites are marks made by teeth either alone or with other parts of the mouth
   “Love bites” are suction marks and can appear as petechial haemorrhages

Animal or human bite?
   Domestic dogs have 4 very prominent canine teeth that are considerably longer than incisor
    teeth. Dog bites consist of pairs of triangular/rounded puncture wounds from the canine teeth.
   The upper and lower dental arches of dogs are v-shaped whilst human dental arches are U-
    shaped.
   Human canines are not prominent, thus human bites consist of canines and incisors together.
    The upper and lower 12 front teeth may produce curved arcades forming a circle or oval
    injury.
   Human bites are mostly paired crescent shaped arches of bruises.
   The skin may be broken in the most aggressive bites
   Individual teeth marks maybe seen
   The marks may be distorted by the contour of the area bitten

Adult or child?
   The differences between adult and child bites are subtle
   The intercanine distance is <3cm in young child with primary teeth but >3cm in an adult

Assessment of bite marks
 Measure and document bite mark
 Contact a Forensic Odontologist
       o Dr R L Evans (CRFP)
           22 Belton Drive
           West Bridgford
           Nottingham
           NG2 7SJ
           Tel: 01159864741
           Mobile: 07973519266
           Fax: 07092141208
           Email: leigh.evans@bigfoot.com
       o If you are unable to contact Mr Evans then the British Association of Forensic
           Odontologists Member’s secretary (Jane Reece 01634 822262) will provide details of
           other Forensic Odontologists
 Photographs of the bite should be discussed with the Forensic Odontologist as special
   oblique views may be required. Serial photographs may be required at 12-24hr intervals for
   evolving bites




Damian Wood                                Page 9 of 45                                   May 2007
Paediatric Clinical Guideline
Emergency 1.6 Child Protection

Fractures

 It takes considerable force to produce a fracture in an infant or child
 All fractures in children and young people require adequate explanation and this must be
  consistent with the child’s developmental age
 Abusive fractures are commonly occult (e.g. rib fractures)
 Assessment requires joint working between the emergency department, pediatric medical
  team, paediatric radiology and the paediatric orthopaedic team

Age of the child
The younger the child the greater the likelihood of non-accidental fracture.
   80% of children with non-accidental fractures are less than 18 months old
   85% of accidental fractures occur in the over 5 age group
   Infants under 4 months of age with fractures are more likely to have been abused

Suspicious Fractures
The following fractures are most commonly associated with non-accidental injury

Multiple fractures
Multiple fractures are significantly commoner in abused children

Ribs
    In the absence or underlying bone pathology or major trauma rib fractures in very young
     children are highly specific for abuse
    Posterior rib fractures are relatively common in physical abuse and must be looked for
     carefully as they can easily be missed
    Posterior rib fractures have never been described following resuscitation. Anterior or
     costochondral fractures have been described extremely rarely in resuscitated children
    If fractures are seen on an x-ray after resuscitation they must be investigated on the basis
     that they occurred before admission

Femur
   Femoral fractures in children who are not independently mobile are suspicious of abuse,
    regardless of type
   Transverse fractures can occur in accidental and non-accidental injury
   Spiral fractures can occur when a child falls whilst running but spiral fractures are more
    commonly a result of physical abuse

Spine
    Spinal fractures most commonly occur in the cervical or lower thoraco-lumbar vertebra.
    Spinal fractures are often accompanied by head injury
    Cervical spine fractures can occur if an infant is vigorously shaken
    Compression fractures or fractures with anterior dislocation of T12-L2 are seen with
             o Hyperflexion
             o A direct blow
             o Forcibly placing the child on their bottom or feet
    It is vital to consider spinal fractures early as the child may require urgent surgery

Metaphyseal fractures
   These fractures are relatively rare
   They are often overlooked
   In the neonatal period they can be related to:



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           o Birth injury
           o Physiotherapy
           o Casting of talipes
    Outside the neonatal period they may indicate abuse, especially femoral Metaphyseal
     fractures

Skull Fractures
   Skull fractures require considerable force
   It is vital to assess the height, force of the fall, and the exact surface the child lands on
   The commonest skull fracture (both accidental and non-accidental) is a linear parietal
      fracture
            o Other skull fractures require a greater degree of force.
   Upto 88% of abusive skull fractures occur in children < 1yr old but this is also the
      commonest age for accidental skull fractures
   Skull fractures of particular concern
            o Occipital
            o Depressed fractures
            o Growing fractures
            o Wide fracture (>3.0mm on on X-ray)
            o Complex fractures
            o Multiple fractures
            o Fractures crossing suture lines
            o Fracture with associated intracranial injury
            o A history of a fall of less than 3 feet

Differential Diagnosis
    Normal variants
    Accidental injury
    Birth injury – these usually heal within a few weeks and calcification will be evident within
      11-14 days.
    Bilateral physiological periosteal reaction
    Infection (e.g. syphilis)
    Malignancy
    Caffey’s disease
    Osteogenesis imperfecta
             o Type I is mild
             o Type II is lethal
             o Type III is severe with progressive bone deformity
             o Type IV is intermediate (white sclera)
             o Associated features
                      Ligamentous laxity
                      Blue sclerae
                      Wormian bones
                      Dentinogenesis
    Osteopenia
             o Prematurity
             o Chronic illness
             o Severe failure to thrive
    Nutritional
             o Copper deficiency, Vitamin A deficiency, Vitamin C deficiency are all rare
             o Vitamin D deficiency
    Iatrogenic – interosseous needle insertion with periosteal reaction




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Emergency 1.6 Child Protection
Investigation
    Skeletal survey for children < 2years of age
    Will need repeat CXR after 11-14 days
    Discuss the results of the skeletal survey with the paediatric radiologists to determine if
      follow-up films or other imaging (e.g. a bone scan) is required
    Consider
            o FBC
            o Bone profile (serum Ca, phosphate and alkaline phosphatase)
            o Serum Vitamin D and PTH
            o Serum copper and caeruloplasmin (especially in preterm babies who have been
                parenterally fed)
    If bone density is questioned check neonatal history and results of previous blood and
      other investigations to look for biochemical and radiological evidence of bone disease.
            o Non-accidental injury and bone disease can co-exist

Skeletal Survey
The purpose of the skeletal survey is to:
   Detect and date fractures
   Provide information on bone density and skeletal development
   To detect occult bony injury in infants <1 year

Indications for skeletal survey
    When there is concern that a fracture may be the result of non-accidental injury
    In all children under 1 year when there is suspected physical abuse - in children over 1
      year of age discuss with the consultant responsible and the paediatric radiologist (or the
      on-call senior radiology registrar)
    Sudden unexpected death in infancy
    Sibling or twin of infant with evidence of physical abuse

           All children undergoing skeletal survey should also have neuroimaging.

Requesting a skeletal survey
 The child should be in a stable condition prior to imaging
 Obtain informed consent from those with parental responsibility (this should be undertaken by
  the specialist registrar or consultant). Explain that the skeletal survey is to search for other
  injuries and bone disease
 Complete a radiology request and indicate on the request that non-accidental injury is being
  considered
         o Discuss the possible diagnosis with a paediatric radiologist
         o Book an appointment time with Mrs E Franklin or deputy on extension 62485.
             Skeletal survey is done in normal working hours
 Reporting of skeletal survey requires careful attention to a number of images. The report will
  usual be available within 24hrs.
 If a skeletal survey has been performed other than at Nottingham University Hospitals
  organize for them to be reviewed by a Paediatric Radiologist as soon as possible.
 A CXR will be repeated at 10-14 days




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Emergency 1.6 Child Protection

Non-accidental Head Injury
Introduction
   Head injury is the commonest cause of death in physical child abuse
   95% of severe head injury in the first year of life is inflicted
   Non-accidental head injury is most commonly seen in infants under 6 months of age
   The mortality from non-accidental head injury is 30%. Half of the survivors will have some
    degree of residual disability
   In Nottingham there are approximately 25 new cases of non-accidental head injury per year.

Presentation
Non-accidental head injury may present to hospital with a variety of clinical symptoms ranging
from:
     Poor feeding
     Lethargy
     Seizures
     Apnoea
     Increasing head size
     Reduced conscious level/Encephalopathy
     Focal neurological symptoms or signs
     Other signs of physical abuse
     A history of shaking in an infant under 2years of age
     A skull fracture
     Blood stained CSF which fails to clear in an infant with suspected meningitis
     Sudden Unexpected Death in Infancy

In some cases there will be no external signs of head injury or other injuries.

The diagnosis of non-accidental head injury must be considered in any infant or young child who
inexplicably collapses

Assessment
Resuscitation
Assess need for resuscitation/conscious level

History
It is important to take a careful history of:
      The timing of the onset of the child’s symptoms
      If there is a history of injury, no matter how minor, document
              o How did it occur?
              o When, where and who was present?
              o What effect did it appear to have on the child?
              o If a fall is alleged, from what height and onto what surface?
              o What did the parent carer do next?
      Any previous or recent injury
      Birth history
      Past medical history
      Developmental milestones
      Vitamin K status
      Social and family history (including full names and ages) of all members of the household
        and witnesses



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Examination
    Look for signs of external injury (including the mouth)
    Does the child look neglected?
    Is the child failing to thrive?
    Plot weight, length and OFC
    Check fontanelle
    Examine for signs of abdominal injury
    Examine the eyes and fundi

Imaging
Neuroimaging
This is the definitive diagnostic investigation and should be performed whenever there are
concerns about non-accidental head injury. This includes any child under 1 year of age who
requires a skeletal survey.

Cranial ultrasound is insensitive. MRI is a more sensitive method of detecting small intracranial
collections, especially in areas less well seen on CT scan. Cerebral oedema and ischaemic
changes are best demonstrated on diffusion weighted MRI.

       Ensure the child is stabilised prior to imaging
       Cranial CT scanning ASAP after admission
           o If CT scan is positive, cranial MRI within 24-48 hours of admission
           o If CT negative
                     If no neurological abnormality or ongoing clinical concern, no further
                        neuroimaging is necessary
                     If neurological state remains abnormal proceed to MRI
       Repeat CT after 3 and 7 days if first scan positive
       Repeat cranial MRI after 14 days if first scan positive

All neuroimaging requests for suspected non-accidental injury should be discussed with
Consultant Paediatric Neuroradiologist Dr Jaspen (ext 61951) or the on-call neuroradiologist.
Sedation or anaesthesia may be required and should be discussed with the paediatrician
responsible, the neuradiology team and the anaesthetic/PICU team

Skeletal Survey
This is essential in all cases of non-accidental head injury in children less than 1 year of age to
exclude skeletal injury. Other skeletal injuries will be present in around 50% of cases. Repeat
CXR will be performed after 10- 4 days.

All infants who require neuroimaging for suspected non-accidental injury will also require
                                   a skeletal survey.

Ophthalmology Examination
 Examine the eyes, pupillary responses and fundi yourself and document your findings.
 Contact Mr Gregson, Consultant Ophthalmologist, via sec 62679
         o If unavailable: Bleep the Specialist Registrar in Ophthalmology
 The child will need both pupils dilating with Cyclopentolate 1% 1 drop each eye 30 minutes
  prior to the examination.

If scans have been performed other than at the university hospital, organise for them to be
reviewed by the Nottingham Paediatric Neuroradiologist.




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Emergency 1.6 Child Protection
Laboratory Investigation
   FBC – this should be repeated after 24-48hrs to detect rapidly falling heamoglobin
   Clotting studies
   U&Es/LFTs
   Infection screen – where there is diagnostic uncertainty an infection screen including
     lumbar puncture may be required. Remember that subdural collections can be associated
     with meningitis. Discuss with the paediatric consultant.
   Urine for toxicology and inborn of metabolism screen

Differential Diagnosis
Birth injury
     Retinal haemorrhages are common after birth
              o Most disappear rapidly within the first few days of life
              o Occasional larger subhyaloid and intraretinal haemorrhages lasting upto 6 weeks
              o The consultant ophthalmologist will provide an opinion as to the most likely cause
                   of the retinal haemorrhages
     Subdural haemorrhage may occur in the perinatal period
              o They may be asymptomatic or present with severe symptoms
              o Asymptomatic subdural haemorrhages resolve within 4 weeks
Accidental injury
     Both retinal and subdural haemorrhages can occur in severe accidental head injury (e.g.
        road traffic accidents)
Bleeding disorders
     Haemophilia, haemorrhagic disease of the newborn (vitamin K deficiency)

Rare causes of subdural haemorrhage
   Cranial malformations
   Glutaric aciduria type I (nearly always accompanied by frontal lobe hypoplasia and there is
      often no accompanying skull fracture)
   Post-operative complication of open-heart or neurosurgery
   Hypernatraemic dehydration

Retinal haemorrhages are very unlikely to follow resuscitation or epileptic fits

Management
Discuss with senior staff as soon as possible after admission
    o Consultant Paediatrician on call
    o Consultant Paediatric Neurosurgeon (pager 01426 300249)
    o Consultant Paediatric Neuroradiologist

Paediatric registrar on call to complete the medical examination including:
   o Documentation of other injuries and consideration of other forms of abuse
   o Arranging the necessary investigations
   o Examination of the siblings
   o Arrange photographs of any external injuries

Check the child protection register
Referral to children’s social care and the police child protection unit.

It is helpful to nominate a senior member of the medical team to be responsible for continuing
liaison with the police and social services, to aid communication

Contact the Named Doctor for Child Protection for further advice if required or alternatively the
Designated Doctor for Child Protection.


Damian Wood                                   Page 15 of 45                                 May 2007
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Damian Wood                      Page 16 of 45   May 2007
Paediatric Clinical Guideline
Emergency 1.6 Child Protection

Intra-abdominal Injury

 Intra-abdominal injury is very uncommon in children
        o It typically occurs in children <3yrs of age
        o high mortality rate (especially if delayed presentation)
 Diagnosis can be difficult
        o Delay in presentation
        o Lack of clear history
 May present with
        o Unexplained collapse, severe abdominal pain or sepsis
        o Clinical signs may be absent especially if retroperitoneal structures are damaged
        o There may be no signs of external injury or development of bruising may be
            delayed. Upto 25% may have no bruises
        o Free gas may be found on abdominal x-ray

Examination
 Abdominal distension (serial girth measurements may be helpful)
 Signs of peritonitis (localized or generalized)
 Petechiae (suggesting raised intra-abdominal pressure)
 Palpable masses
 Ano-rectal rectal examination (blood or anterior tenderness)
 Pass an nasogastric tube and aspirate stomach contents

Investigation
 FBC
 Serum amylase
 LFTS – elevated liver enzymes in hepatic injury
 Urinalysis
 Radiology
        o AXR – plain X-rays may appear normal despite significant injury
        o CXR erect – to look for rib fracture, pneumothorax and pleural fluid
        o CT scan or abdominal USS

Management
 Resuscitate
       o NBM
       o NGT on free drainage
       o IV fluids
 Discuss further management with the Consultant Paediatric Surgeon on-call in conjunction
   with colleagues in paediatrics and radiology




Damian Wood                               Page 17 of 45                                May 2007
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Emergency 1.6 Child Protection

Thermal Injury
 Burns and scalds are common injuries in children
 The majority result from non-intentional injury. They may involve parental inattention or even
  neglect
 In a smaller number of cases thermal injury may be inflicted
 Estimates of the proportion of thermal injuries where abuse or neglect are contributing factors
  ranges from 1-20% depending on the case series.

Concerning features in the history of thermal injury:
   o The injury does not fit the history
   o A delay in seeking treatment
   o Surprising lack of pain described
   o History incompatible with the developmental stage of the child
   o Vague or changing histories, including a different version from the child
   o Speculative account of what happened
   o Denial that a lesion is a burn
   o Burn attributed to siblings

Differential Diagnosis
   Skin infection
    o Impetigo
    o Staphylococcal scalded skin syndrome
   Contact Dermatitis
   Healing varicella zoster (multiple cigarette burns)

Common patterns of abusive burns and scalds
o   Contact burns – there will be a clearly outlined mark from contact with a hot object, for
    example:
         o Clothes iron
         o Fire guard
         o Cooker hot plate
         o Hot fork, spoon or knife
o   Cigarette burns
         o Deep, cratered circular burns
         o Rolled edge
o   Immersion scalds from hot water (e.g. dipped into hot bath)
         o Glove and stocking circumferential burns
         o Limbs and buttocks
         o Clear waterlines
         o Lack of splash marks
o   Friction or carpet burns from being dragged across the carpet
o   Bilateral burns are more commonly non-accidental
o   Common sites of non-accidental thermal injury
         o Feet and hands (especially back of hands)
         o Legs and buttocks
         o Face

If there are any doubts as to whether a burn is accidental or intentional an opinion should
  be sought from a senior member of the burns team. This should be done in conjunction
                  with the paediatric consultant responsible for the child.




Damian Wood                                 Page 18 of 45                                  May 2007
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Assessment
    o   Examine the burn during a dressing change
    o   Detailed drawing of the burn
           o Site
           o Pattern
           o Surface area involved (Lund and Browder Chart)
           o Depth of burn
           o Any special areas involved
                     Face and mouth – risk of airway compromise
                     Hand – may cause functional loss
                     Perineum – prone to infection and difficult to dress

Superficial Burns                Partial Thickness Burns          Full Thickness
Skin is erythematous and dry     Pink and moist. Blistered and    White, red or charred and
without blistering               painful. Hair follicles and      feel parchment like.
                                 sweat glands intact              Destruction of all skin
                                                                  appendages and some
                                                                  subcutaneous tissue.
                                                                  Thrombosis of small blood
                                                                  vessels is apparent. Painless

    o   Which areas have been spared?
    o   Was the injured area clothed or unclothed?
    o   Photographs
             o Distant and close up views
    o   Assessment of development
    o   Genital and anal inspection – there is an association between abuse thermal injury and
        child sexual abuse
    o   If the injuries appear non-accidental or if there is doubt as to whether they were
        accidental or intentional further investigation may require a home visit by the police.

General Management of Burns
o   Resuscitation
        o Airway - early intubation to secure the airway if there burns to the face or signs of
            airway compromise
        o Breathing
        o Circulation – consider other injuries if signs of hypovolaemia develop within first 2
            hours after burn
        o Disability – consider head injury or CO poisoning as causes of reduced conscious
            level
o   Fluids
        o For burns less than 10% BSA this can be given as extra oral fluid (preferably oral
            rehydration solution) in addition to maintenance fluids
        o For burns >10% BSA fluids should be calculated using the Muir and Barclay formula
            and given in addition to maintenance fluids (see Emergency Department Guideline
            and APLS manual for further details)
o   Adequate analgesia – burns are very painful and children often need opiate analgesia for
    adequate pain control.
o   Antibiotics - All children less than five years of age should receive oral flucloxacillin for 5
    days to reduce the risk of Toxic Shock Syndrome
        o 1 month – 2years 125mg po qds
        o 2-5years 250mg po qds for 5 days




Damian Wood                                 Page 19 of 45                                   May 2007
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Emergency 1.6 Child Protection
o   Dressings – this will depend on the site and thickness of the burn and the age of the child.
    See the emergency department guideline on the management of burns in children. Discuss
    with senior ED Nursing staff or the Burns unit NCH x 56401if you need further advice.

Other Non-accidental Injuries
These include:
   Scratches and abrasions

     Incisions

     Oral injuries
            o Teeth – fractured, luxated, intruded or avulsed
            o Lacerations and bruises to lips and tongue
            o Torn labial frenum in infant or toddler
            o Palate/pharynx – burns from hot food, lacerations from cutlery/other objects
                 forced into the mouth
            o Poor dental hygiene as a sign of neglect

     Injuries to nails – avulsed or broken, subungual haematoma

     Injury to hair – traumatic alopecia

     Marks from tourniquets/ligatures – facial petechiae and external bruising to neck

     Injuries from insertion of needles and injection of material into skin – fabricated or induced
      illness

     Induction of hyperthermia or hypothermia

     Deliberate drowning




Damian Wood                                  Page 20 of 45                                   May 2007
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Documentation and Recording
Note-keeping
 Use the examination pack available in Paediatric ED, the Paediatric Wards and Outpatients or
  you can download a copy
 All notes must be written in black ink, timed, dated and signed
 Your name and job title should be clearly printed next to your signature
 Patient identifies must be clear on each page

For injuries record:
    o Length and width
    o Positions and relations to bony landmarks
    o Colour, shape, definition, character, age
    o Use diagrams where appropriate
    o Consider taking photographs (especially if marks are unusual, caused by an implement,
         or particularly obvious and significant) – ideally in audiovisual department (polaroid in ED
         and in the Doctor’s office on Papplewick Ward)

Photographs
Medical Staff are not recommended to take photographs themselves in normal hours, as
photographs must meet certain standards for use in Court. The Photographic Department at
QMC can be contacted during normal working hours on ext 64690 and at the City Hospital on ext
56493. The photographs then form a part of the clinical record and can be used in Court in the
same way that any part of the clinical record can be used. Ensure consent is obtained and
documented.

If the Police are involved and the case is likely to go to Court or the Police are asking for
photographs, then they should arrange them themselves. The photographs then belong to the
Police and fulfil their requirements for evidence

Growth Charts
    Plot measurements carefully and check accuracy of plotting by others
    Always plot weight, height and OFC
    Transpose weights, lengths and OFC from parent held child health record (red book) onto
     hospital growth chart

Developmental Assessment
    Describe the method of assessment e.g. parental report, Denver, Schedule of Growing
     Skills, Griffiths




Damian Wood                                  Page 21 of 45                                   May 2007
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Formulating your Opinion
State your opinion as to whether the injuries you have found are possible or probable non-
accidental injuries, and how they might have occurred.

Document this clearly in the notes
   o Consider differential diagnosis and your reasons for excluding them
   o Highlight results of relevant investigations and any results which are awaited
   o Document the results of the child protection register check
   o Document any:
           o further investigations which will be required (e.g. follow-up scans/X-rays)
           o treatment required (e.g. anticonvulsants)
           o follow-up with paediatrician (this should be arranged in all cases)
   o State clearly whether a multi-agency meeting and/or case conference is required

All child protection cases should be discussed with a Paediatric Consultant on-call to clarify the
opinion and management plan.

Explain your opinion and management plan to the family and the social worker.

Siblings
o   Siblings of the index child will routinely be examined at the Children’s Centre in the Child
    Protection Department between the hours of 9am – 5pm.
o   Siblings of any child who is an inpatient should be examined at the admitting hospital
    (urgently if the siblings are very young).

Discharge from hospital
o   Any child admitted to hospital for whom there are child protection concerns should have a
    medical assessment completed within 24 hours of admission
o   There should be a clearly documented plan for future care before discharge and this may
    require multidisciplinary and multiagency discussion and agreement.
o   A child about whom child protection concerns have been raised whilst in hospital must only
    be discharged on the decision of a consultant paediatrician
o   The discharge checklist must be completed and signed off before discharge. (See appendix)

If you are responsible for discharging children about whom there are child protection
concerns you should be familiar with section 4.80 of the Nottingham City and
Nottinghamshire SCB Child Protection Procedures.




Damian Wood                                 Page 22 of 45                                    May 2007
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Report Writing

    Reports and police statements should ideally be given on the day of the examination
    Clearly state your opinion
    Dictate an initial medical report for Social Services at the time of the examination
    A photocopy of hospital records is not adequate for this purpose and should not be sent
     to Social Services.
    Your report may be used in obtaining an Emergency Protection Order at a Child Protection
     Case Conference, and/or in subsequent Care Proceedings.


  Avoid giving opinions under pressure (take time to think/consult). If necessary indicate
                             that it is a provisional opinion.


Format of the Report to Social Services
    Begin with your qualifications and experience
    Use clear, non-medical words, as far as possible, (or explain medical terms in brackets).
    Mark as PRIVATE AND CONFIDENTIAL NOT TO BE DISTRIBUTED WITHOUT THE
     AUTHORS PERMISSION
    Use separate sections for
           o History
                 Include times and dates in the chronology
                 Use child’s own words where possible
                 Separate fact from opinion
                 Indicate the origin of any third party information
           Examination
           Investigations
                 Record results of investigations
                 Indicate if results of investigations are pending
           Management
                  Treatment required for injuries
                  Need for further investigation
                  Need for follow-up
                  Need to examine siblings
                  Request for case conference
           Summary
           Opinion
                 Consider differential diagnosis and your reasons for excluding them
           Copies to
               1. GP
               2. Community Child Health Service
               3. School Nurse or HV/Liaison HV if appropriate
               4. Social services if case conference planned
               5. Police if a criminal hearing is possible
               6. Copy for the notes




Damian Wood                                Page 23 of 45                                 May 2007
Paediatric Clinical Guideline
Emergency 1.6 Child Protection
Getting the Report Typed and sent to Social Services
    Reports for NUH patients are typed by the Child Protection Secretaries. Please ring both
       secretaries or email both of them to say there is a tape –
             Linda Statham ext 66275 - linda.statham@nuh.nhs.uk
             Denise Sears 65715 – denise.sears@nuh.nhs.uk
    Once typed check report and preferably discuss with a senior colleague before returning it
       promptly to the secretary to be sent on.
    Report to be sent to Social Worker within 1 week including any necessary follow-up
       arrangements. However there will be occasions when a report must be prepared within
       72 hours, e.g. for an Emergency Protection Order or if the examination is done on a Court
       Order. New referrals to Social Services should ideally be followed up in writing within 24
       hours.
    Reports should not generally be faxed. Arrangements should be made for them to be
       collected.


Statements to the Police
If the case goes to Court you may be asked to provide a statement. This has a standard format
which can be obtained from the Child Protection Office. Normally you can do it yourself and send
it to the Police rather than have the Police come to ‘take the statement’. It will differ from the
report you have written in that it will contain only factual comments and professional opinions
usually only relating to the current injury that you see the child for. For your first few statements
discuss with a senior colleague before you do it. Even after you have done several it is sensible
to get someone to read a statement before you send it off to see how someone else would
interpret what you say.




Damian Wood                                 Page 24 of 45                                   May 2007
Paediatric Clinical Guideline
Emergency 1.6 Child Protection

Directory
                                 Nottingham City                     Contact via the Child
Designated Doctors for           Dr Lizzie Didcock                   Protection Office at
   Child Protection              Nottinghamshire County              Children’s Centre
                                 Dr Yin Ng
                                 Dr Stephanie Smith (Consultant      0115 924 9924 x 62320 or
                                 Emergency Paediatrician, QMC )      bleep via switchboard

                                 Dr Andrew Dove                      QMC x 61152
  Named Doctors for              Consultant Emergency Physician
   Child Protection              Emergency Department, QMC

                                 Dr Joise Drew                       NCH x 34915
                                 Associate Specialist Paediatrics,
                                 Nottingham City Hospital
Named Nurse for Child            QMC & Nottingham City Hospital      QMC x 62921
      Protection                 Alyson Packham                      NCH x 56809
Liaison Health Visitors          Sue Threakall                       QMC x 63417
                                 Jan Cloake                          NCH x 54499
Child Protection Office          Brenda Forrester                    NCH x 56757
  Children’s Centre
    Antenatal Child              Sara Thomas                         QMC x 67453
 Protection Midwife
Consultant Paediatric            Dr Kate Forman                      QMC x 67251
    Haematologist
Consultant Paediatric            Mr. Richard Gregson                 QMC x62679
  Ophthalmologist                Mr. John Stokes                     QMC x 63033
Consultant Plastic and           Mr. Mark Henley                     NCH x 56706
    Burns Surgeon                                                    Burns Unit x 56401
Medical Photography                                                  QMC x 64690
                                                                     NCH x 56493
Forensic Odontologist            Dr R L Evans                        Tel: 01159864741
                                                                     Mobile: 07973519266
                                                                     Fax: 07092141208

 Consultant Paediatric           Dr Nigel Broderick                  QMC x61090
    Radiologists                 Dr Kath Halliday
                                 Dr John Sommer
                                 Dr Laura Fender
 Consultant Paediatric           Dr Timothy Jaspan                   QMC x 61951
   Neuroradiologist




Damian Wood                                     Page 25 of 45                           May 2007
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Emergency 1.6 Child Protection


Children’s Social Care
Nottinghamshire                  Ashfield                       Tel: 01623 405300
County                           Sutton Centre                  Fax: 01623 405366
                                 High Pavement
                                 Sutton-in-Ashfield
                                 Nottinghamshire
                                 NG17 1EE
                                 Bassetlaw                      Tel: 01777 716161
                                 Chancery Lane                  Fax: 01777 716171
                                 Retford
                                 Nottinghamshire
                                 DN22 6DG
                                 Broxtowe                       Tel: 0115 917 5800
                                 Prospect House                 Fax: 0115 917 5811
                                 Padge Road
                                 Beeston
                                 Nottingham
                                 NG9 2JR
                                 Gedling                        Tel: 0115 854 6000
                                 Sir John Robinson Way          Fax: 0115 854 6209
                                 Arnold
                                 Nottingham
                                 NG5 6DB
                                 Mansfield                      Tel: 01623 433433
                                 Meadow House                   Fax: 01623 433245
                                 Littleworth
                                 Mansfield
                                 Nottinghamshire
                                 NG18 2TB
                                 Newark and Sherwood            Tel: 01636 682700
                                 County Offices                 Fax: 01636 674731
                                 20 Balderton Gate
                                 Newark
                                 Nottinghamshire
                                 NG24 1UW
                                 Rushcliffe                     Tel: 0115 914 1500
                                 The Hall                       Fax: 0115 914 1510
                                 Bridgford Road
                                 West Bridgford
                                 Nottingham
                                 NG2 6AD
Nottinghamshire                  Out of hours                   0115 844 7333
County
Emergency Duty Team

Nottingham City                  Monday –Friday 9am-5pm         0115 915 5500
Nottingham City                  Out of hours                   0115 925 9299
Emergency Duty Team




Damian Wood                                     Page 26 of 45                        May 2007
Paediatric Clinical Guideline
Emergency 1.6 Child Protection


Appendix 1
The Child Protection Examination Proforma

Seen at…………………………………………………………

Date…………………………………… Day……………….                                   Time…………..

Hospital
No:……………………Name…………………………………………………………

Date of Birth:………………………… Age……………………Male/Female

Address………………………………………………………………………….
……………………………………………………………………………………

Post Code:……………………………


Consultant Paediatrician Responsible ………………………………………..

Examining Doctor …………………………………………… Grade……………..

Social Worker present…………………………… Base……………….

                                                         Tel No……………..

Senior Social Worker………………………………………… Base……………….

Police Officer present………………………………………                            Base………………

Senior/Investigating Officer…………………………………                        Base………………

General Practitioner……………………………………………………………………

School/Nursery…………………………………………………………………………
Who has parental
responsibility?……………………………………………………………

Verbal Consent obtained Y/N

Given by:                  Social Worker/Parent/Other Carer/Child/Verbal/Written



Damian Wood                              Page 27 of 45                         May 2007
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Damian Wood                      Page 28 of 45   May 2007
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Emergency 1.6 Child Protection

Events Leading to Examination/History of Injury
Child seen because:
1)     Brought by Social Worker for examination                

        Or

2)      Physical Abuse suspected due to observation of child   
        whilst in out-patients, ward or other clinical area


History of Events

Child’s History


Pregnancy                                 Immunisations


Birth                                     Development


Accidents/Fractures/Burns



Hospital admissions



School problems




General health




Recent illnesses




Damian Wood                         Page 29 of 45              May 2007
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Medicines




Family History

Family Tree




Who lives in the house?



Anyone on the Child Protection Register?



Known offences against children?




Family Problems?
Medical
Psychiatric
Behavioural
Social
Marital




Damian Wood                        Page 30 of 45   May 2007
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Emergency 1.6 Child Protection


History of the Injury/Incident




Damian Wood                      Page 31 of 45   May 2007
Paediatric Clinical Guideline
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Examination

Those present…………………………………………………………………………..

……………………………………………………………………………………………

……………………………………………………………………………………………

Height……………                      Centile………………

Weight…………..                     Centile………………

OFC.…………………                      Centile………………


General Appearance

Cleanliness



Clothing



Demeanour



Reaction to adults and situation



Skin……………Bruises/scars/burns……………..use map, describe injuries
fully


Development

Gross Motor
Fine Motor                                  Speech
Social                                      Hearing
Vision                                      Reading/writing




Damian Wood                           Page 32 of 45           May 2007
Paediatric Clinical Guideline
Emergency 1.6 Child Protection
Examination

                                        Normal                 Abnormal
                                                  (please detail on body map)

Scalp


Face/mouth


Neck


ENT


Eyes


Chest


CVS


Abdomen


Anus


Legs


Examine where appropriate only:

Puberty……………………………..                    Tanner Stage…………………………….
Genitalia…………………………….                   Use diagram
Anus………………………………..                      Use diagram




Damian Wood                       Page 33 of 45                         May 2007
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Investigations performed with Results

                                       Y         N

FBC and Clotting


X-rays


Swabs (please specify)
…………………………..

Photos


CT head


US head


Other……………………………




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Damian Wood                      Page 38 of 45   May 2007
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Summary and conclusions:




Immediate outcome:


Home………………………                        Y/N

New Address…………………………………………………………………………….

…………………………………………………………………………………………….

…………………………………………………………………………………………….

Other (continue on next page if required)
………………………………………………………..


Outcome

1)      Referred to Social Services              Y/N

(a)     Child Protection - Y/N or

(b)     Child in Need            - Y/N


2)      Child to stay in hospital                          Y/N

3)      Child to go home ………………………… ……                     Y/N

        who with …………………………………….



Paediatric Follow-Up:

GP………… School Doctor…………… Community Paediatrician…………………

Other……….. …………………………… None……………………...



Damian Wood                                Page 39 of 45   May 2007
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Damian Wood                      Page 40 of 45   May 2007
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Summary Continued




Damian Wood                      Page 41 of 45   May 2007
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Checklist:


Register check?                                                      Y/N

Report dictated to Social Services                                   Y/N

Referred to Social Services – followed up in writing                 Y/N

Paediatric Liaison Health Visitor form completed                     Y/N

Paediatric Consultant On-Call informed of actions                    Y/N

Paediatric Consultant On-Take informed (next day, if out of hours)   Y/N

Audit sheet completed                                                Y/N

Copies of report/referral to:

        GP                                                           Y/N

        Child Protection Department, Children’s Centre, NCH          Y/N

        Social Worker                                                Y/N

        School Nurse/Liaison Health Visitor                          Y/N

        Hospital notes                                               Y/N

        Child Protection Office at NCH/QMC                           Y/N




Damian Wood                          Page 42 of 45                   May 2007
Paediatric Clinical Guideline
Emergency 1.6 Child Protection

Appendix 3
                        GUIDELINE FOR REPORT TO SOCIAL SERVICES


                                   STRICTLY CONFIDENTIAL


Report at the request of……………………………………………………………………..

Child examined: Name & date of birth……………………………………………….

                          Address…………………………………………………………….

                                 ……………………………………………………………..

                                 ……………………………………………………………..

General Practitioner: ………………………………………………………………………

School/Nursery: ………………………………………………………………………….

Date of Examination: …………………………… Time: ……………………………..

Place: …………………………………………………………………………………….

Persons Present: ………………………………………………………………………….

                     …………………………………………………………………………

Background: (obtained from………………………………………………..)
(family circumstances, previous problems etc)



History of Injury/Incident/Current Concern (from………………………………………)
(may be separate history from Social Worker/Parents/Child)



EXAMINATION
(break down into sections with sub-headings if it is long and complicated. Add a copy of drawing
injuries if this will make things clearer)




CONCLUSION
(State clearly whether injury was caused accidentally or non-accidentally in your opinion, could be
either balance of probabilities or compatible/not compatible with history. Other relevant
comments e.g.: neglect, concern about relationships, relevant new medical findings. The
conclusion may be the bit that goes into the case conference minutes, so it might be useful to
think of it in these terms.)




Damian Wood                                Page 43 of 45                                   May 2007
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FOLLOW-UP
There may be none. You do not need to specify routine health visitor or general practitioner
follow-up. Specify what the follow up is for e.g.:

‘I will arrange follow-up with the local Community Paediatrician to monitor his growth and
development’

‘Hospital follow-up with Dr …………….. should continue, to review his failure to thrive’

‘I have referred to Child Psychiatry for help with the severe behaviour difficulties’

This is a report for Social Services and should not be used for Court purposes without
prior agreement of the author.




Dr……………………………………………………………………



cc’s    Social Worker
        General Practitioner
        Child Protection Office, Children’s Centre, City Hospital
        School Nurse/HV (if appropriate) or Liaison Health Visitor
        Hospital Notes




Damian Wood                                  Page 44 of 45                                   May 2007
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Emergency 1.6 Child Protection


References
DoH et al (2000) Framework for the assessment of Children in Need and their Families. DfES and
the Home Office. London: The Stationery Office

DoH et al (2003) What to do if you are worried that a child is being abused. London

HM Government (2006) Working together to Safeguard Children. DfES. Lo ndon

HMSO (1989) Children Act 1989

HMSO (2004) Children Act 2004

HMSO (2003) The Victoria Climbie Inquiry. Report of an Inquiry by Lord Laming. London. The
Stationery Office.

Nottingham LSCB (2007) Nottinghamshire and Nottingham City SCB Child Protection Policies
and Procedures. Nottingham

RCPCH (2004) Responsibilities of Doctors in Child Protection Cases with Regard to
Confidentiality. London. RCPCH.

RCPCH & AFP (2004) Guidance on Paediatric Forensic Examinations in relation to Possible
Child Sexual Abuse. RCPCH and AFP.

RCPCH (2006) Child Protection Companion. London. RCPCH.

Document Derivation

As well as incorporating updated national and local guidance. This guideline has been devised
from a number of pre-existing guidelines including:
        o Non-accidental head injury in children
        o Bruising
        o Child Protection Examination Pack
        o Non-accidental injury

It supersedes and replaces these guidelines.

Useful Websites
Association of Forensic Physicians www.afpweb.org.uk

British Association of Forensic Ondontology www.bafo.org.uk

British Society of Paediatric Radiology www.bspr.org.uk

Child Accident Prevention Trust www.capt.org.uk

Royal College of Paediatrics and Child Health www.rcpch.ac.uk

Welsh Child Protection Systematic Review www.core-info.cf.ac.uk




Damian Wood                                Page 45 of 45                                May 2007

								
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