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The evidence base in child protection litigation

BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7560.160 (Published 20 July 2006) Cite this as: BMJ 2006;333:160

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Re: Goodyear-Smith's response to the evidence base in child abuse

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
days.

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
reports.

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:
506-512.
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:
None

Competing interests: No competing interests

12 August 2006
Nancy D. Kellogg
Professor of Pediatrics
University of Texas Health Science Center at San Antonio; 7703 Floyd Curl Drive San Antonio Texas 78