The evidence base in child protection litigationBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7560.160 (Published 20 July 2006) Cite this as: BMJ 2006;333:160
All rapid responses
Dr Chadwick. in reference to my Rapid Response, states " The note
by LC Blakemore-Brown (a psychologist) illustrates a serious but common
error about the Munchausen Syndrome by Proxy (MSBP). This is the idea that
the condition can be defined or excluded by psychological observations or
I am afraid it is Dr Chadwick who has made a serious but common
error, and one regularly found at the very outset in false allegations of
MSBP/SBS - he has made an early false assumption about my concerns and
then built his case on that.
Where in my response do I say what he has attributed to me?
However, I do state that I am a Psychologist and it would seem that
Dr Chadwick has therefore leapt to the conclusion he reached because of
In actual fact, I am in total agreement with Dr Chadwick about
psychological observations and criteria! I too do not consider that they
help us to establish whether a parent has abused their child. Thinking
that there is a psychological or psychiatric profile is simply not
I differ from Dr Chadwick in that he thinks that covert video
surveillance can lead to conclusive diagnoses. To my certain knowledge
great errors have been made in the interpretation of such videos and to my
certain knowledge women have had children removed despite no evidence at
all following covert surveillance, only to have them returned by a Court.
Furthermore, by knowing, as I said in my response, that some women
have harmed their children, this should not lead us to assume (assumption
again) that many have. This means that because some people have genuinely
been seen to cause harm to children under covert surveillance, for
instance, cannot possibly allow us to make assumptions about the vast
majority who have been accused when they have been nowhere near a camera.
The fact that Professor Southall may have been able to capture some
cases of disturbed women harming their children and that this may have
also happened in some cases around the world, does not permit us to make
assumptions about the vast majority who fall foul of this allegation
without ever being filmed doing anything. The theorising and methodology
is palpably not robust.
To make it clear, my fundamental concern as a Psychologist is, in
agreement with Dr Chadwick, that we are assuming psychological profiles
can be used to accuse parents and this is simply wrong. Furthermore and
clearly not in agreement with Dr Chadwick who has made the same sort of
errors and shown the same sort of thinking in his response, we are using
assumption and rumour and processes of suggestibility to guide and train
thousands of medically unqualified staff to go on to accuse parents of
causing real illnesses and disorders.
It is my opinion that many of those illnesses and disorders could
very well have been caused by iatrogenic processes.
I want to see iatrogenic abuse becoming a routine part of the
differential diagnosis in child abuse cases.
I want to know why it NEVER is.
Expert in Autim and related conditions often misdiagnosed as child abuse
Competing interests: No competing interests
To the Editor, BMJ Rapid Responses
August 13, 2006
Seven Rapid Responses have now appeared in response to my editorial
on the state of the evidence base in child protection litigation. They
include far more words and more specificity than was allowed in the
original (800-word) contribution. I will attempt to answer each as
briefly as possible.
Michael Innis proposes two theories to explain the findings in Shaken
Baby Syndrome. The one that attempts to connect subclinical Vitamin C
deficiency is novel and so weakly supported as to constitute “unique
causal theory”  . The other, the need to look for coagulopathies and
to explain them in cases of suspected inflicted head injury is well-
Elizabeth Marsh raises many interesting questions, and the most
relevant to the editorial is the question of the need to provide
protection for persons who are required or expected to report child abuse
when they perceive it. The writers of these reporting laws recognized
that without such protections the laws would not be observed because to
observe them would be too dangerous. This appears to be the case in the
U.K. Further, without witness protection laws that cover court testimony
there would be no witness testimony at all. Ms. Marsh’s comments about
the prevention and the preventability of child abuse go beyond the scope
of the editorial, but there is a robust and developing literature on this
topic also. However, this issue is rarely the subject of litigation
except in the occasional case in which a failure to report is followed by
a catastrophic second injury.
I appreciate Oliver Dearlove’s comment that I should have been more
emphatic that: “that it is not and never was, the function of the General
Medical Council to do in child protection.” I also agree that all is not
entirely rosy in the land of the free. We still observe much
irresponsible expert testimony [1, 3]. Some medical societies in the U.S.
are doing their best to deal with this issue. The American Association of
Neurological Surgeons took the lead a few years ago . In the case of
the neurosurgeons (who pay $100,000/yr for malpractice insurance) the
resources to provide competent peer review of expert testimony may be
available. The Florida State Medical Society experiment is unique in the
U.S. and it’s too soon to evaluate it fairly. However, few, if any, of
our state licensing boards (the U.S. equivalent of the GMC) have the
resources to provide competent review of expert testimony and none have
tried it on their own.
Joyce Adams has already responded to the note by Felicity Goodyear-
Smith about gonorrhea and Nancy Kellogg may soon do so also. I will leave
this interesting discussion to these experts.
The note by L.C. Blakemore-Brown (a psychologist) illustrates a
serious but common error about the Munchausen Syndrome by Proxy (MSBP).
This is the idea that the condition can be defined or excluded by
psychological observations or criteria. It cannot be. In fact, it is
defined as a form of child abuse in which a caretaker fakes illness in a
child with resulting harm to the child. It can be conclusively diagnosed
by covert video surveillance in a hospital and this has now been done in
hundreds of cases in a number of countries. The condition is uncommon but
not rare and the documentation of these behaviors is beyond dispute.
Southall’s pioneer work on this issue  may be the principal cause of
his current difficulties with the GMC. MSBP can also be diagnosed by the
“separation test” . Although this is less conclusive it is often
certain enough to support a life-saving protective intervention. MSBP may
be excluded by the firm diagnosis of a well-described medical condition in
the child that provides a “natural” explanation for all signs and
symptoms. The fact that not all suspected cases can be clearly placed in
one category or another  does not diminish the validity of the basic
concept and definition or the need to intervene when a child’s life or
health is threatened by it.
I have saved the comment by Kemp, Sibert and Maguire for last because
these writers themselves are major contributors to the growing literature
that can be referenced in child protection litigation. Their
contributions are admirable.
I agree with a number of the specific points in their note. We
cannot read the age of bruises with our eyes as we might like to although
everyone knows that they evolve. There is a “clock” in bruise resolution,
and we still need to learn to read it.
I differ with their views on the radiological dating of certain
fractures. For example, it is clearly correct to say that a rib or long-
bone fracture in an infant or young child that demonstrates subperiosteal
new bone formation is more than 5 days old . Often this fact is
sufficient to invalidate a history provided with an injured child. To
argue otherwise is simply nihilistic. An enormous clinical experience
backs up this finding. The fact that the chief reference for this position
is given in a book chapter does not invalidate it. Much that is true can
be found in book chapters and much that is not can be found in peer-
reviewed journal articles.
The torn labial frenulum example is something of a straw man. In
young infants is may certainly be an indicator of abuse, but what it
really indicates is blunt facial or oral trauma that often occurs
unintentionally in toddlers and preschool children.
The comparison of the child abuse medical literature to that
pertaining to cancer or AIDS is (of course) unfair. With 10% of the
recent research funding for cancer and AIDS, child abuse researchers might
be much more advanced than they are. It is no longer possible to argue
that cancer is a more important medical problem than child abuse .
Kemp appears to agree that the subject is important.
I am only surprised by Kemp’s surprise at my use of the term “robust”
since their contributions to the literature have contributed so much. I
stick with it. “Complete” is something else, of course.
David L. Chadwick
1. Brent, R.L., The irresponsible expert witness: a failure of
biomedical graduate education and professional accountability. Pediatrics,
1982. 70(5): p. 754-62.
2. Hymel, K.P., et al., Coagulopathy in pediatric abusive head trauma.
Pediatrics, 1997. 99(3): p. 371-5.
3. Chadwick, D.L. and H.F. Krous, Irresponsible expert testimony by
medical experts in cases involving the physical abuse and neglect of
children. Child Maltreatment, 1997. 2: p. 315-321.
4. AANS, Professional association's disciplinary action upheld. Austin v.
American Association of Neurological Surgeons. Hosp Law Newsl, 2002.
19(6): p. 4-7.
5. Southall, D.P., et al., Covert video recordings of life-threatening
child abuse: lessons for child protection [see comments]. Pediatrics,
1997. 100(5): p. 735-60.
6. Rosenberg, D.A., Munchausen syndrome by proxy: currency in counterfeit
illness, in The Battered Child, M.E. Helfer, R.S. Kempe, and R.D. Krugman,
Editors. 1997, University of Chicago Press: Chicago. p. 413-430.
7. Rosenberg, D.A., Munchausen Syndrome by Proxy: medical diagnostic
criteria. Child Abuse Negl, 2003. 27(4): p. 421-30.
8. O'Connor, J.F. and J. Cohen, Dating Fractures, in Diagnostic Imaging of
Child Abuse, P.K. Kleinman, Editor. 1998, Mosby: St. Louis. p. 168-177.
9. Felitti, V.J., et al., Relationship of childhood abuse and household
dysfunction to many of the leading causes of death in adults. The Adverse
Childhood Experiences (ACE) Study [see comments]. Am J Prev Med, 1998.
14(4): p. 245-58.
Competing interests: No competing interests
I agree with Dr. Goodyear-Smith’s last paragraph. However, she has
not established that contemporary publications demonstrate “DENIAL
(emphasis added) of the possibility that children may be infected non-
sexually,” nor has she acknowledged that in most situations post-natal non
-sexual acquisition of gonorrhea is uncommon. A more careful perusal of
the American Academy of Pediatrics clinical report that was cited (1) will
reveal that in Table 2, a positive test for gonorrhea should elicit a high
level of concern about sexual abuse “if nonsexual transmission is unlikely
or excluded.” “Think common, remember rare” is a lesson from residency
It is also instructional to look critically at the references
provided in Dr. Goodyear-Smith’s response; many are more than 50, and some
are more than 100, years old. Many are textbook references or case
reports, not case control studies. In these older studies, we do not know
if Neisseria gonorrhoeae was appropriately diagnosed; even now, in some
regions, laboratories fail to conduct the appropriate confirmatory tests
to determine the correct Neisseria species. We do know that child abuse
was not even fully acknowledged as a possibility until the 1960's
(excepting Mary Ellen) and it is safe to say that sexual abuse of children
was acknowledged later than physical abuse. It is possible that sexual
transmission may not have been considered in many of these earlier
Prospective case-control studies are one of the best ways to address
the question of transmission modes. Dr. Gardner did a prospective study
comparing gonorrhea culture results in 209 sexually abused girls to 108
girls with no history or indicators of sexual abuse. No gonorrhea was
found among the latter group (2). In an earlier retrospective study(3)
that included children between 1 and 14 who were infected with gonorrhea,
sexual contact was confirmed in 126, and 32 were said to be infected via
“casual acquaintances” which was not further clarified. Of interesting
note, one child with GC between 5 and 9 years of age was determined to
have been infected through “boyfriend-girlfriend relationship”; this also
was not further elucidated. Another retrospective chart review (4)
describes 15 children with gonorrhea, 3 of whom had a history of sexual
abuse and 5 of whom had unknown mechanisms of infection. The remaining 7
all co-slept with their parents and either one or both parents were noted
to have GC. The gender of the infected parent was not given, but it is
interesting that in the 5 of 7 cases where the child and one parent had
GC, the other parent who was in the same bed did not have GC. Could it be
that there was closer or more frequent "contact" between the child and the
infected parent than between the infected and non-infected parent? More
studies, as always, would be instructive. Currently, a confirmed
gonorrhea infection in a child that is determined not to be infected
through vertical transmission at birth deserves a referral for an
investigation. While some of these children (few in my experience) will
not initially have a history of sexual contact, many do disclose sexual
abuse during the process of the investigation.
Practitioners should, and many do, consider all possibilities in
evaluating suspected child abuse. The key is not only to become familiar
with – to quote Dr. Chadwick – the “well developed evidence base” - but
also to read such studies with a careful, critical and discerning eye.
Nancy D. Kellogg, M.D.
1. Kellogg ND, American Academy of Pediatrics Committee on Child
Abuse. The evaluation of sexual abuse in children. Pediatrics 2005; 116:
2. Gardner JJ. Comparison of the vaginal flora in sexually abused
and nonabused girls. J Pediatrics 1992; 120: 872-7.
3. Branch GB and Paxton R. A study of gonococcal infections among
infants and children. Public Health Reports 1965; 80: 347-352.
4. Shore WB and Winkelstein JA. Nonvenereal transmission of
gonococcal infections to children. J Peds 1971; 79: 661-663.
Competing interests: No competing interests
Kemp, Sibert and Maguire write: "Expert witnesses appearing in court
require a thorough understanding of the quality of the available
scientific evidence and must be able to convey this to the Court in an
understandable manner. Courts and clinicians need to appreciate that child
abuse evidence base is a long way from being robust or complete..."
I very much welcome the fact that these particular workers have done
the research and come to the conclusion which I reached back in 1996 after
being an Expert Witness in a court case in which Munchausen Syndrome by
proxy was being alleged.
My published article in The Psychologist (1) states: " I cannot
estabish a robust scientific base .... I am of the opinion that we need to
clarify the nature of MSBP with some urgency. That some disturbed women
are known to have seriously harmed their children should not lead to
distortions of thinking in which many are assumed to have done so. One
swallow does not make a summer."
Tragically, as John Stone writes, such assumptions based on such
theories without robust research to back them up, have now coursed their
way through the entire system.
Training and guidance based on such theories - as Patricia Hamilton,
President of the RCPCH confirms on bmj.com - has been and continues to be
handed down to multiple thousands of workers with no qualifications in
medicine/psychology or psychiatry. So the errors which have happened in
Court are now spread far and wide through the system and have the
potential to negatively affect untold numbers of children and families
whose cases may never reach Court.
The potential for a social disaster that I wrote about all those
years ago has become a reality.
1. Blakemore-Brown LC Munchausen Syndrome by Proxy. Letters The
Psychologist September 1997
Expert in Autism and related disorders frequently misinterpreted as child abuse
Competing interests: No competing interests
Regarding Goodyear-Smith's response to the article by Chadwick, I
would like to submit a correction to one of the citations. The article I
published in The APSAC (American Professional Society on the Abuse of
Children)Advisor (1) contained a table: "Approach to Interpreting Physical
and Laboratory Findings in Suspected Child Sexual Abuse: 2005 Revision".
This table was developed through a process of consensus development and
endorsed by group of physician experts in child sexual abuse medical
evaluation. The wording our group agreed upon for interpreting the
significance of infections caused by gonorrhea, syphilis, Trichomonas
vaginalis, Chlamydia trachomitis and HIV, when perinatal transmission is
ruled out, was: "Presence of Infection Confirms Mucosal Contact with
Infected and Infective Bodily Secretions, Contact Most Likely to Have Been
Sexual in Nature". If there is an explanation for how fresh infected
secretions from an individual with gonococcal vaginitis, urethritis or
conjuctivitis came to be directly deposited on the eye or genitals of a
child in a non-sexual manner, then it may not be necessary to suspect
sexual abuse. With common good hygiene practices, this should not happen,
but in areas where people don't wash their hands between touching their
own infected genitalia or eyes before touching a child's genitalia or
eyes, then such non-sexual transmission probably does occur. The table in
the Advisor article does note that for gonorrhea, syphilis, Chlamydia and
HIV, the most recent guidelines from the American Academy of Pediatrics
Committee on Child Abuse and Neglect (in the Clinical Report authored by
Nancy Kellogg, MD)(2)consider these infections to be diagnostic of sexual
transmission if neonatal transmission is ruled out, however the group of
experts who reviewed the listing of findings did not want to use
"diagnostic" or "clear evidence" terminology.
Alternative modes of transmission, in cases where a child is too young to
give a history of sexual abuse, or who denies such contact, should always
(1) Adams JA. Approach to the interpretation of medical and
laboratory findings in suspected child sexual abuse: A 2005 revision. The
APSAC 2005;17 (3):7-13.
(2) American Academy of Pediatrics, Committee on Child Abuse and
Neglect, & Kellogg NK.(2005). Clinical Report: The evaluation of
sexual abuse of children. Pediatrics, 116 (2):506-512.
Competing interests: No competing interests
Chadwick writes that there is a robust evidence base in child
protection litigation.1 Unfortunately large bodies of evidence may not be
easily accessible to potential medical experts. For example, while it has
always been recognised that Neisseria gonorrhoea is a sexually transmitted
infection,9 there is loss of appreciation that pre-pubertal girls, beyond
the perinatal period, are also susceptible to non-sexual transmission of
American Academy of Paediatrics guidelines state ‘Physicians should
assume that children with gonorrhoea have acquired it by sexual contact
and that most such contacts are sexually abusive’.2 Kellogg claims a
positive culture for N gonorrhoeae makes ‘the diagnosis of sexual abuse a
near medical certainty’ and is diagnostic of sexual abuse ‘if not
perinatally acquired and rare nonsexual vertical transmission is
excluded’.3 Guidelines citing a working party of the Royal College of
Physicians as an evidence source state ‘The bulk of evidence strongly
suggests that gonorrhoea in young people over one year is sexually
transmitted and the isolation of a gonococcal infection is highly
suggestive of sexual abuse’.4 5 Child abuse authorities Sgroi and Adams
write ‘Except in the neonate, gonorrhoea in a child signifies sexual
abuse’’6 and ‘Positive confirmed culture for gonorrhea (from genital area,
anus, throat) in a child outside the neonatal period’ is diagnostic of
sexual contact.7 These various documents either provide no supportive
primary data or refer to a 1985 paper cklaiming to have summarised ‘all
studies of gonococcal infections in children since 1965’8 and concluding
that ‘the bulk of evidence strongly suggests that gonorrhoea in children,
as in adults, is sexually transmitted.’ However a literature search
reveals that this review does not include all studies between 1965 to
1985. Furthermore there are numerous studies of non-sexual transmission
both prior and subsequent to their review.
Prior to the advent of antibiotics, N gonorrhoeae was endemic.
Epidemics of vaginal gonococcal infection was a serious problem in
children’s wards and orphanages, usually through some failure in nursing
care.9 10 The source of infection for an index case might have been sexual
transmission. However once an infected child was admitted, the infection
spread rapidly among other girls within the institution. The literature
records over 40 epidemics involving about 2000 children in Europe and the
United States.9 11-21 Communal baths, towels, bedding and other cloth,
rectal thermometers, enema nozzles, and caregivers’ hands22-2728 were all
identified as agents of transmission. Prior to the advent of penicillin
there was no adequate treatment. While generally causing vulvovaginitis,
to which young girls are particularly susceptible, there were cases of
conjunctivitis and more serious complications including arthritis,
peritonitis and fatality. Epidemics often would continue until strategies
to isolate infected children and identify the transmission source (nurses’
hands or fomites) were implemented. The pattern of spread was clearly due
to contamination not sexual abuse of children within the institutions.
Modern-day epidemics of non-sexually transmitted conjunctival N
gonorrhoeae occur in parts of Africa and Australia where adequate
facilities for diagnosis, treatment and epidemiological surveillance are
lacking.29 In Ethiopia over 9,000 cases of gonococcal conjunctivitis,
particularly affecting children under five years of age, were reported
during eight months in one district.30 Epidemical, surveillance and
clinical data showed no concurrent genital gonorrhoea outbreak - genital
transmission could not explain the community-wide epidemic. Similar
outbreaks occur in Aboriginal communities in rural Australia under
conditions of substandard, overcrowded housing with insufficient water
supply, poor sanitation and sewerage disposal and inadequate food
hygiene.31-35 Children with unwashed faces and/or hands are more likely to
be infected.36 Flies are possible vectors.30 32 37
Many other studies link clusters of family members and associates
having conjunctival or vulvovaginal gonococcal infection with non-sexual
transmission.38-47 48-52 Children may acquire gonococcal infections
through contact with infected towels or bedding.29 48 53-56 Accidental
transmission through freshly contaminated hands of mothers or other
contacts is another mode of infection.49 46 57-59 In some cases it cannot
be established whether transmission was sexual or non-sexual.
Unusual accidental modes of infection include sharing a bed urinal
bottle with an infected fellow-patient,8 ingestion of chocolate agar from
a culture plate,60 being struck in the eye with an infected face mask
strap,61 spraying the eyes with infected fluid62 or bathing them in
contaminated urine.63 Infected toilet seats are an unlikely source of
indirect transmission,64 although contact with contaminated toilet paper
has greater potential to cause infection. 65
While N gonorrhoea is killed by drying or heating, it can survive for
hours if kept warm and damp on towels, bedding and other objects27 39 66-
68 69-71 24 and has .been cultivated from infected bathwater after 24
The prepubertal girl develops vulvovaginitis rather than cervicitis.
She is susceptible to this for many reasons: the vulva lack the protection
of adult labial fat pads and pubic hair and the labia minora tend to open
when the child squats; the vulval skin is thin, delicate and sensitive,
susceptible to irritation, infection, drying, chapping and blistering; the
vagina is an excellent bacterial culture medium being warm, moist and of
neutral pH with an atrophic anoestrogenic mucosa; antibodies that may be
present in adolescents and adults are lacking and children may have poor
With the advent of antibiotics, gonorrhoea is no longer endemic.
Epidemics in institutions are an event of the past. Gonorrhoea in children
is relatively rare. Knowledge of nonsexual transmission has largely been
lost to modern literature. Medical experts rely on ‘guidelines’ from
leading medical institutions3-5 9 78 rather than referring to primary
sources. Unfortunately these documents are opinion not evidence-based. For
example, Kelly assumes all paediatric cases of gonorrhoea due to sexual
abuse ('the consensus in the Western literature is that genital gonorrhoea
in a child, out of the neonatal period, is a sexually transmitted
disease') with the child requiring urgent placement 'in a safe
household'.79 While some cases may result from sexual abuse, non-sexual
transmission is not considered a possibility. Babies and young children
are taken in to custody and adults prosecuted solely on the finding of
paediatric gonorrhoea. Expert witnesses testify that sexual abuse is a
medical certainty, citing the leading authorities listed above.
Clearly it is important to identify cases of sexual abuse and keep
children safe. Paediatric gonorrhoea is a strong indicator that must be
taken seriously. However denial of the possibility that children may be
infected non-sexually has grave medicolegal implications and may result in
harm and injustice.
1. Chadwick D. The evidence base in child protection litigation. BMJ
2. American Academy of Pediatrics. Committee on early childhood aadc.
Gonorrhea in prepubertal children. Pediatrics 1983;71(4):553.
3. Kellogg N, Committee on Child Abuse and Neglect. Clinical Report: the
evaluation of sexual abuse in children. Pediatrics 2005;116(2):506-512.
4. Thomas A, Forster G, Robinson A, Rogstad K, Clinical Effectiveness
Group Association of Genitourinary M, Medical Society for the Study of
Venereal D. National guideline for the management of suspected sexually
transmitted infections in children and young people. Archives of Disease
in Childhood 2003;88(4):303-11.
5. Thomas A, Forster G, Robinson A, Rogstad K, Clinical Effectiveness G.
National guideline for the management of suspected sexually transmitted
infections in children and young people. Sexually Transmitted Infections
6. Sgroi SM. Pediatric gonorrhea and child sexual abuse: the venereal
disease connection. Sexually Transmitted Diseases 1982;9(3):154-6.
7. Adams J. Approach to the Interpretation of Medical and Laboratory
Findings in Suspected Child Sexual Abuse: a 2005 Revision. The APSAC
8. Neinstein LS, Goldenring J, Carpenter S. Nonsexual transmission of
sexually transmitted diseases: an infrequent occurrence. Pediatrics
9. Hamilton A. Gonorrheal vulvovaginitis in children with special
reference to an epidemic occurring in scarlet fever wards. Journal of
Infectious Diseases 1908;5:133-157.
10. King A, Nicol C. Veneral diseases. 3rd ed. London: Bailliere Tindall,
11. Gittings C, Mitchell G. Review of the literature of the past five
years on gonovoccus vulvovaginitis in childhood. American Journal of
Diseases in Children 1917;13:438-456.
12. Abt I. Gonorrhea in children. Journal of American Medical Association
13. Morse J. Five cases of gonorrhoeae in little girls. Achives of
Pediatrics 1894;11: 596-598.
14. Sheffield H. Contribution to the study of infectious vulvo-vaginitis
in children, with remarks upon purulent ophthalmia, and a report of sixty-
five cases. American Medico-Surgical Bulletin 1896;9(30 May):726-731.
15. Cotton A. An epidemic of vulvovaginitis among children. Archives of
Pediatrics & Adolescent Medicine 1905;22(Feb):352-335.
16. Baer J. Epidemic gonorrheal vulvo-vaginitis in young girls. Journal of
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18. Seippel C. Venereal diseases in children. Illinois Medical Journal
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20. Altchek A. Pediatric vulvovaginitis. Pediatric Clinics of North
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22. Catterall R. A short textbook of venereology. 2nd ed. London: English
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29. Osoba A, Alausa K. Vulvovaginitis in Nigerian children. Nigerian
Journal of Paediatrics 1974;1:26-32.
30. Mikru FS, Molla T, Ersumo M, Henriksen TH, Klungseyr P, Hudson PJ, et
al. Community-wide outbreak of Neisseria gonorrhoeae conjunctivitis in
Konso district, North Omo administrative region. Ethiopian Medical Journal
31. Matters R. Non-sexually transmitted gonococcal conjunctivitis in
Central Australia. Communicable Diseases Intelligence 1981;13:3.
32. Brennan R, Patel M, Hope A. Gonococcal conjunctivitis in Central
Australia. Medical Journal of Australia 1989;150(1):48-9.
33. van Buynder P, Bailey S, Adams J, Talbot J, Sullivan H, Waddingham A,
et al. A cluster of non-sexually transmitted gonococcal conjunctivitis in
the Pilbara, Western Australia. Western Australian Notifiable Diseases
34. Matters R, Wong I, Mak D. An outbreak of non-sexually transmitted
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Communicable Diseases Intelligence 1998;22(4):52-6; discussion 57-8.
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vector of Neisseria gonorrhoeae conjunctivitis. Medical Journal of
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preadolescent children: an inquiry into source of infection and mode of
transmission. Pediatrics 1977;60(2):153-6.
39. Cohn A, Steer A, Adler E. Gonococcal vaginitis: a preliminary report
on one year’s work. Vener Dis Inform 21:208–20 1940;21:208-220.
40. Burry VF, Thurn AN. Gonococcal infections in prepubertal children.
Missouri Medicine 1971;68(9):691-2.
41. Ingram DL, Everett VD, Flick LA, Russell TA, White-Sims ST. Vaginal
gonococcal cultures in sexual abuse evaluations: evaluation of selective
criteria for preteenaged girls. Pediatrics 1997;99(6):E8.
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Competing interests: No competing interests
The editorial entitled “The evidence base in child protection
litigation” BMJ July 22 2006: places a welcome emphasis on the importance
of scientific evidence and specialisation that is required in the clinical
field of child protection. We have undertaken a series of systematic
reviews of the evidence base that underpins the diagnosis of physical
abuse and were surprised, however, that the author describes the evidence
behind child abuse as robust. This broad statement is made on the basis of
16,000 citations for child abuse and historical reference to the formative
work of Tardieu 1860 and Kempe 1962. We feel that this perception is
misleading and fails to assess the quality of the published evidence base.
When a standard systematic approach to the critical appraisal of this
literature is adopted, the findings are very different and there are
significant scientific limitations to many of the published studies.
Child abuse is a generic term and includes physical, sexual, neglect
and emotional abuse. Within each category there are a huge variety of
types of abuse and clinical presentations that result. The
multidisciplinary nature of child protection means that each agency
involved comes with a different agenda and different questions that it
requires the literature to resolve.
As one of the few systematic review teams in this field we have
interrogated the scientific literature around several key questions around
the diagnosis of physical child abuse (www.core-info.cf.ac.uk) . In
general, there was a paucity of literature. Most studies are performed in
the United States and while these studies are invaluable, the difference
in health systems, demographics, definitions and types of abuse and legal
systems mean that the study findings are not necessarily directly
transferable to UK. Studies are compromised by the differences in
definition of abuse used in different countries over the 50 year time
period of this research and the variation in diagnostic techniques. The
security of diagnosis of abuse and reverse causality introduce significant
bias. Case numbers included in studies are small and highly selective and
most observational studies are of a case series design, inherently
compromised by selection bias and lacking any comparative data.
There are areas where the quality of evidence is good, examples
include rib fractures in young children that have a high specificity for
abuse and the profile of non accidental scalds where the literature
defines clear differences between intentional and non intentional scalds.
Our work demonstrates other areas that refute widely established dogma. A
review of 50 years of international literature identified three studies
that give good evidence that the age of bruises cannot be accurately
judged on a visual interpretation of bruise colour . When we evaluated
the evidence surrounding the dating of fractures we identified only three
studies that addressed the topic . These studies included 56 children
under the age of five. They evaluated fracture dating at different
anatomical sites and used different radiological signs to inform their
decision. Each came up with different time frames for these signs of
healing. Radiologists use guidelines drawn together from an individual
expert and published in a textbook: these have yet to be scientifically
validated on a large scale. The overriding feeling is that fractures can
only be aged in the broadest sense.
A torn labial frenum has long been held as a strong indicator of
physical abuse. The entire published evidence around this topic amounts to
28 case reports of torn frenum in abuse. Most cases are of severely abused
children under the age of five. Although accidental torn frena are
mentioned in the literature, there are no published comparative studies.
The probability that a torn frenum is abusive is impossible to calculate
from the literature and a prospective comparative study is called for.
This same profound lack of published evidence applies to the recognition
of adult bites and cigarette burns.
These are a few examples of the strengths and weaknesses in the
scientific literature which lead us to question the term “robust” in
relation to the evidence base.
Towards the end of the article the author reassuringly admits that
there are shortcomings and that the evidence base is a long way from
perfect or complete. He likens the situation to the evidence base for AIDS
or Breast Cancer. There are however profound scientific differences
between these three areas. Both of the latter topics are the subjects of
systematic reviews with meta-analyses that evaluate the strength of
evidence displayed in Randomised Control Trials. Research into the
diagnosis of child abuse cannot avail itself of these trials for obvious
reasons. Studies must rely upon good quality comparative observational
studies. This field of research must be prioritised if we are to promote
the interests of the abused child in the UK in the current climate of
mistrust where clinicians are increasingly reluctant to participate in the
This field of research is challenged in several areas. It is
difficult to perform standard diagnostic studies in the absence of a gold
standard test for abuse that is independent of the presenting injuries or
symptoms of neglect. Consent issues for the inclusion of abused children
and the relative rarity of abuse make it difficult to undertake cohort
studies not to mention the challenges of defining ideal control cases.
David Chadwick is correct that we must be creative in our study design and
use several sources and study types to inform the evidence base that we
draw upon in decision-making.
The overriding priority must be to encourage optimal research in this
field. There are many paediatricians and allied professionals who have
worked in the child protection field for many years and continue to do so.
Many have experience that could be translated into scientific published
evidence if they were able to publish their data from often meticulously
kept retrospective case series or better still use their experience to set
hypothesise and under take well designed prospective comparative studies.
This work urgently needs the support of research funding bodies.
Expert witnesses appearing in court require a thorough understanding
of the quality of the available scientific evidence and must be able to
convey this to the Court in an understandable manner. Courts and
clinicians need to appreciate that child abuse evidence base is a long way
from being robust or complete and that “absence of evidence is not
necessarily evidence of no effect or no association”. Where opinion is
drawn from personal practice, this must be explicit. As Baroness Kennedy
stated ‘A doctor can be convinced, based on his or her experience, that a
defendant is guilty - but unless there is compelling evidence supported
scientifically, he or she should not express that view in criminal
proceedings’ , which sets the standard for an expert opinion in the
Although the clinical field of child protection is going through a
difficult period in the UK, the current situation has the capacity to
stimulate good quality scientific research. This is greatly needed to
build the discipline up to the standards of evidence based clinical
practice that is required throughout clinical practice.
1 Maguire S, Mann M, Sibert J, Kemp A. Can you age bruises accurately
in children? A systematic review. Arch Dis Ch. 2005.90 182-6
2 I.Prosser, S. Maguire, S.K. Harrison, M. Mann, J.R. Sibert, A.M.
Kemp.How old is this fracture? Radiological dating of fractures in
children: A systematic review. AJR; 2005: 184(4)
3 Kennedy H. Sudden Unexpected Death in Infancy. 2004 The Royal
College of Pathologists and The Royal College of Paediatrics and Child
Competing interests: No competing interests
Dr Chadwick states that: "Medical expert witnesses need legal
protection too, to use the evidence effectively".
I would like to ask why do medical expert witnesses need legal
protection? If they are testifying in a court of law why would legal
protection be required? Does this mindset not leave itself open to
criticism or ridicule if using evidence effectively is a criteria for
conviction? Isn't one's responsibility to use medical evidence honestly,
rather than effectively?
An almost unassailable mountain of advice and contradiction, claim
and counter-claim has arisen over the past decade or so, none moreso in
the medical environment than in the area of child abuse and child
protection. Too many involved in a professional response are caught up
and swept along by what is topical, rather than having the ability or
freedom to be able to think for themselves, in order to challenge that
which may not be right - thereby causing an imbalance of the facts -
significantly weighted against the individual; be they the victim of
abuse, or the perpetrator.
But what is child abuse? Is there a specific definition that people
can identify with? As recently as a generation ago, most of what is now
perceived as child-abuse would have been viewed as discipline. But
successive liberal policies adopted predominantly by the incumbent
government have eroded family values, undermining all that was once viewed
a necessary part of growing up as to now be frowned upon. Parents have
been emascualted of many of their former parental rights and in its place
we have ASBOs !
Yet an army of child protection officanado have sprung up to pre-empt
child abuse occurring, without realising or understanding that child abuse
often cannot be prevented. This is the one fundamental difference between
all the health professionals/social workers and the general public. The
layman understands that child abuse happens as surely as night follows day
- even knowing that sometimes it may be excessive. How can a parent
discipline a child if doing so now potentially elicits a lablel of child
abuse? Where is balance - and reason? A much greater wrong is done when
innocent children die and those who set themselves up as experts fail to
prevent it. Or when experts use their knowledge effectively, instead of
honestly, which may lead to wrongful convictions of innocent people.
Child abuse happens. It often cannot be prevented. To try to do so
is like trying to pre-empt the direction of the wind. Understanding the
direction of the wind is possible, preventing it is not.
Competing interests: No competing interests
Chadwick conludes, “….doctors require the sort of protections
generally provided by the laws on child abuse reporting and witness
immunity that prevail in the US.” I think someone had better tell us what
these protections available to doctors actually, are. I include an
annotation from The New York Times 2004 which appeared in a paediatric
journal, which clearly does not paint such a wonderful picture in the land
of the free.
Incidentally in England, libel proceedings are not possible on sworn
evidence as such evidence is privileged, so what follows in the article
below could not happen in England. If evidence is wrong, then perjury
could be alleged. Indeed it is notable that untrue oral evidence had been
a basis for a finding of serious professional misconduct at the GMC (1,2)
I think the point Chadwick should be making loudly, is that it is not
and never was, the function of the General Medical Council to do in child
protection. No wonder it is getting reformed, it needs it. (BMJ this issue
DOCTOR’S TESTIMONY LEADS TO A COMPLEX LEGAL FIGHT
“A San Francisco internist and an occasional expert witness in
medical malpractice suits opened a letter from the Florida Medical
Association not long ago. Inside, was a complaint from 3 doctors about
expert testimony he had given for the patient in a malpractice case
against them in Tampa last year. The doctors had won, and now they wanted
the medical association to punish [the expert] for what they said were his
‘erroneous opinions.’ [The expert] filed his own lawsuit last month in
Tallahassee, saying the doctors and the association had libelled him.
Legal experts say the suit is the first to use a libel claim to challenge
charges made in a medical disciplinary proceeding concerning expert
testimony. The duelling disputes have a question in common: should medical
groups have the power to discipline doctors for their expert testimony?
Medical groups say they can help weed out incompetent and dishonest
experts. Plaintiffs’ lawyers say the groups’ real goal is to silence
doctors who testify for plaintiffs. And legal experts say the case in
Florida shows that the entire malpractice system has gone off the rails.
Several medical societies have created tribunals to consider complaints
that expert testimony by their members was substandard.”
Liptak A. New York Times. June 20, 2004
Noted by JFL, MD
Submitted by Oliver R Dearlove
References for the text,
1.Daily Telegraph. Surgeon lied under oath 2 December 2000
2.R v General medical Council ex parte Kypros Nicolaides Lloyds Law
Reports Medical (2000) 525-529
Like many of his colleagues, the author steers well away from child protection work - an easy task as he is an anaesthetist
Competing interests: No competing interests
Dr Chadwick suggests, “A well developed evidence base exists for
child abuse medicine that is suitable for use in litigation for child
protection …. Kempe and colleagues reiterated that doctors could and
should infer abuse on the basis of certain medical findings of injury. The
"battered child syndrome" that they defined is still a valid concept based
on observational research.”
In essence this so-called “evidence base” is characterized by acute
encephalopathy with subdural and retinal haemorrhages, occurring in a
context of inappropriate or inconsistent history and commonly accompanied
by other apparently inflicted injuries(1). These other apparently
inflicted injuries being bruises, and fractures often of various ages.
What the proponents of this “evidence base” are forgetting, ignoring
or are unaware of, is deficiencies of Vitamin C and/or K can and do
produce identical signs and symptoms in vulnerable infants. Deficiencies
of Vitamin D can result in fractures.
Professor Alan Clemetson and Dr A. Kalokerinos have drawn the
attention of the profession to the origin and consequences of Vitamin C
deficiencies in Western Societies (2,3). Others have suggested the need to
supplement the diet of children with Vitamin D
Less well known are the origins and consequences of Vitamin K
deficiency. Apart from Haemorrhagic Disease of the Newborn little or no
thought has been given to the fact that it is a cofactor for the
carboxylation of osteocalcin and is essential for the mineralization of
bone(4). When reduced or absent fractures may occur.
It is a lack of knowledge of the causation of these nutritional
deficiencies and their effects, coupled with the injunction to “think
dirty” that is responsible for the misdiagnoses of “child abuse” so
common in the Western World.
Unless Paediatricians take more care with the investigation of these
children by becoming familiar with newer Laboratory tests such as PIVKA-
II, Undercarboxylated Osteocalcin and Blood Histamine levels innocent
people are bound to suffer.
Michael Innis FRCPA;FRCPath
1. Harding B, Risdon RA, Krous HF Shaken baby syndrome
BMJ, Mar 2004; 328: 720 - 721
2.Clemetson CAB Is it “Shaken Baby,”or Barlow’s Disease Variant. A A
P S 2004;Vol 9 No 3:
3. Kalokerinos A. Every Second Child. 1981 pp 3 –165 Thomas Nelson
4. Conway SP, Wolfe SP , Brownlee KG, White H, et al; Vitamin K
Status Among Children With Cystic Fibrosis and Its Relationship to Bone
Mineral Density and Bone Turnover PEDIATRICS Vol. 115 No. 5 May 2005, pp.
As previously declared
Competing interests: No competing interests