Can Systematic Reviews of Child Protection contribute to

knowledge transfer?

Dr Sabine MaguireSenior Lecturer Child Health

Cardiff University

Do we need SR in Child Protection?

• ‘Baby P doctor under investigation Lawyers claim paediatrician failed to spot broken back and ribs during examination of boy two days before his death’ guardian.co.uk, November 2008

• ‘Sir Roy Meadow struck off by GMC’ www.bbc.co.uk 2005

• ‘Sally Clark doctor wins GMC case’ www.bbc.co.uk 2006

Legal aspects of Child Protection

• Family Courts ‘Balance of probability’ • Criminal courts ‘Beyond reasonable doubt’

• Kennedy report ‘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’

Challenges of SR in physical abuse

Varying definition of abuse (time/ country/ culture)

Quality and paucity of evidence Lack of case control data Mixed fatal/non-fatal cases Reverse causality

Can you age bruises accurately with the naked eye?

• Ageing of bruises directly influences investigation of child abuse

• Numerous publications ‘timetable’ of colour change in bruises to enable clear dating of injury

Clinicians confident in ageing bruises – welcomed by police / courts

Inclusion and Exclusion Criteria

Included

• All languages • 1950- 2010• Ageing of bruises of

any origin in children between 0-17 years

• Observational studies ( including case series)

Excluded

• Review articles• Expert opinion• No details on

confirmation of age of bruise

• Methodologically flawed

Ageing of Bruises SR: Methodology

• Panel of 15 reviewers ( paediatric, child protection expertise)

• Trained in Critical Appraisal, customised CAF based on NHS CRD standards

2 independent reviews all studies, 3rd review to resolve differences

Narrative summary

Included 3

ASSIA 1987-2010Caredata 1980-2010Child Data 1958-2010CINAHL 1982-2010Embase 1980-2010ISI Proceedings 1990-2007Medline 1950-2010Ovid MEDLINE In-Process & Other Non-Indexed Citations May 2010Science Citation Index 1981-2010SIGLE 1980-2010Social Science CitationIndex 1981-2010TRIP database1997-2010

Hand search of text books

Hand search of all articles identified from other sources

Scanning total titles & abstract for duplicates and relevancy

8102

Total articles reviewed 187

Translated14

3rd Review80

Published evidence in relation to ageing of bruises

• Stephenson T, Bialas Y. ADC 1996 - photos of 23 children, 36 bruises - observer estimate of age correct 24/44, Blue, brown, grey and purple -1-14 days, Yellow - only after 1 day, 10/42 > 1 day

• Carpenter RF. ADC 1999 - 32 bruises in 22 children. Yellow only seen in bruises over 48 hours

• Bariciak ED, Plint AC, et al Pediatrics 2003 -.Red/blue, purple commoner <48hrs, also seen in 30% >7days. Yellow/brown/green most often >7days, but seen in <48 hrs. Accuracy < 50%

Can You Age Bruises Accurately in Children? (with the naked eye)

No!

Ageing – Important Pitfalls

• Different colours present in the same bruise at one time,

• Different areas, different colours • Deep injury – delayed appearance• Individual perception of colour is different

(Munang et al, 2003)• Ability to perceive yellow varies with age

(Hughes et al, 2004)

Ageing of bruises: knowledge transfer

• SR published in ADC in 2005• Review findings initially rejected by

practitioners• Incorporated UK national guidance• Citations (google scholar/ Harzing’s publish or

perish 2012) 71• Stimulated 11 publications aiming to identify

a more scientific method of ageing of bruises

What radiological investigations should be performed to identify

fractures in suspected child abuse?

• 34 studies included in original SR 2004• Key conclusion – single investigation ( skeletal

survey or radionuclide bone scan) will miss occult fractures

• Results published 2006 – RCR/RCPCH National standards for Radiological Investigation Suspected Abuse – March 2008

What radiological investigations should be performed to identify

fractures in suspected child abuse?

• Original SR – 2004 (34 included studies)• Updates 2004-2010 – 13 further studies• Citations:39 studies ( to 2012) • Current accepted practice – single

investigation is inadequate• Current research focusing on what is the

optimal strategy for further Investigations•

CAN SYSTEMATIC REVIEWS OF CHILD PROTECTION CONTRIBUTE TO KNOWLEDGE TRANSFER?

Systematic Reviews of Child Abuse

Challenging to achieve internationally accepted ‘Quality Standards’ for SR

Results may not endorse well established practiceDrives a higher quality research agenda

Establishes state of current evidence for Medical practitioners, Investigating agencies and Legal practitioners

Core InfoCardiff Child PrOtection Systematic REviews

Please visit our newly-launched site:

www.core-info.cardiff.ac.uk