Evidence base in child protection litigation

A recent BMJ article has pointed out some of the problems associated with the presentation of medical evidence of child abuse in the United Kingdom. It focuses on the omission from the Royal College of Paediatrics and Child Health's new handbook, Child Protection Companion, of research evidence gathered by two controversial paediatricians—David Southall and Sir Roy Meadow.

A well developed evidence base exists for child abuse medicine that is suitable for use in litigation for child protection. The published evidence on the abuse and neglect of children begins with a descriptive article by Tardieu (the father of  forensic medicine) in 1860. He pointed out how medical conditions that he had observed in 32 children defined the abusive nature of the events that had occurred. In 1962 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. The medical consequences of neglect have been noted since the 1960s, and the extensive medical assessment of sexual abuse cases began in the 1970s.

The American Board of Pediatrics has recently approved the definition of the new subspecialty of child abuse paediatrics. In describing this development, Block and Palusci, in the BMJ, note that the knowledge and evidence base on child abuse is similar to that of other accredited medical specialties. PubMed contains more than 16,000 citations for child abuse and a similar number for neglect. Like the medical definitions of breast cancer, AIDS, myocardial infarction, and many other disorders, those of medical conditions resulting from child abuse are based first on observations of patients—initially descriptions of individual cases that are then supplemented by defined case series.

The evidence base contains work that uses many scientific methods in addition to the observation of cases. Useful tools include confidential surveys of adults' childhood histories, surveys of adults' admitted violent and sexual behaviours with children, and confessions. Overt and covert video surveillance of adults' behaviour with children has recorded astonishing and incontrovertible abuse. Further evidence has come from medical knowledge about the healing of injuries of known causes and the medical documentation of damage that results from reliably observed injury events.

Research evidence on prevention and treatment is important but has prompted little attention from lawyers. It is the work that underpins the definitions of different kinds of abuse that has generated the political and personal attacks on responsible expert witnesses such as Southall and Meadow.

The identification of Munchausen syndrome by proxy, the suffocation of infants and young children, and the shaken baby syndrome have particularly sparked great controversy recently in the United Kingdom. Consensus statements and many reviews in the English language literature support the existence and general definitions of these conditions. Yet each case of suspected abuse is unique, and the applicability of the evidence base will always differ from case to case. This makes the testimony of doctors who specialise in the study of child abuse particularly valuable and important. Without such testimony from expert witnesses children may be unprotected from abuse.

In the United Kingdom, expert witness are now advised to follow the "3 Rs" of good practice: record (everything they do from the start of the case), retain (the records until the prosecution says they can be destroyed), and reveal (the records to the prosecution). In addition, peer review of expert testimony may help to regulate the quality of expert testimony.

The child abuse medical evidence base is robust and thriving, but, like the evidence base for AIDS or breast cancer, is a long way from perfect or complete. With reasonable public support, doctors practising child abuse medicine will continue to develop the evidence and to use it in court to protect children.

To do so, however, doctors everywhere require the sort of protections generally provided by the laws on child abuse reporting and witness immunity that prevail in the United States rather than those in the United Kingdom.

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NICE advises a more personalised approach to postnatal care

A low rate of breast feeding and inconsistent healthcare advice to new mothers are targeted by new clinical guidelines on postnatal care for England and Wales.  The guidance, issued by the National Institute for Health and Clinical Excellence (NICE) sets out a standard of care that women and their new babies can expect from labour through to eight weeks after birth.

It recommends personalised care for mothers—in which an individual care plan would be drawn up soon after birth—and a move away from the more common "tick box" approach. The guideline also says that all care providers, whether in hospitals or primary care, should implement an externally evaluated, structured programme that encourages breast feeding. The programme should use as a minimum standard the "baby friendly initiative," a worldwide programme run by Unicef and the World Health Organization.

The rate of breast feeding in England is among the lowest in Europe. The baby friendly initiative has been successful in increasing the rate of breast feeding through training and supporting health professionals. However, in England only 10% of babies are born in a unit that is accredited by the baby friendly initiative. London, in common with several other areas, has no accredited unit as yet.

Carmel Duffy, deputy programme director of the UK baby friendly initiative, said: "We can now really go out and promote the initiative, because NICE is saying this has been proven to work."

NICE has also produced an easy to use "quick reference guide" for healthcare professionals that presents the guideline in a straightforward format. For example, it details what the full examination of a newborn baby at 72 hours should consist of. It also deals with the signs and symptoms of potentially serious or life threatening conditions in the mother or baby.

David Elliman, a consultant in community child health at Great Ormond Street Hospital and Islington Primary Care Trust and a member of the guideline development group, said, "Quite often people are given inconsistent advice. What new parents don't need is to be told one thing by the GP, another by the midwife, and another by the health visitor."

The guideline also details the importance of educating parents in caring for themselves and their baby—for example, knowing what support networks exist in their area.

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