Elephants in the room…

We’re all familiar with this generic metaphorical idiom, referring to a problem of which everyone is cognisant, but about which no one wants to speak. While investigating the origins of the term, I learnt that it is thought to have first been used in Krylov (1769–1844) in his book, ‘The Inquisitive Man’. In the course of the novel, the protagonist, despite picking up on many small details, fails to see (or, more correctly acknowledge) the obvious one, the elephant. The reasons for such elephants largely stem from sensitivities: the potential to cause embarrassment or encroachment on subjects that are taboo. All elephants involve a degree of repression, and all ultimately are better off unfettered. I think this issue has unmanacled a fair number.

Trust

Paul Ward’s absorbing editorial ( see page 718 ) on the equally thought provoking paper by Lefevre et al ( see page 740 ) is a great place to start. The paper examines reasons for the low uptake of HPV vaccination (a mainstay of cervical cancer prevention) in French adolescents with less than 14% completing the course. Intriguingly, it presents the findings of a series of interviews with physicians with contact with adolescents and their attitude to the vaccination. The overriding theme was that the doctors’ attitudes to the vaccine reflected that of society, that implicit in discussing vaccination is a discussion of sexuality and that their own medical training left them unequipped to engage in these consultations. The editorial expands this theme and the way in which a doctor in a position of authority can no longer command trust simply by dint of her/his position. And though trust is an adhesive which defines much human behaviour, it requires a leap of faith by at least one party.

Non accidental injury: new, old clues

We might believe we are sensitive to child abuse in its protean manifestations, but three papers cast new light (shade perhaps) on less well acknowledged areas. In the large US wide analysis of children assessed for abuse (ExTRA), Dorfman et al ( see page 747 ) undertook 2890 consultations. Of these 3.3% had oral injury. Skeletal surveys were obtained in 84% and 25% of these identified occult fractures. Seventy-five per cent had neuroimaging and 38% identified injuries. Of those undergoing funduscopy, 24% of exams had retinal haemorrhages. Harris’ leading article ( see page 722 ) expands this theme examining dental caries as a marker of low grade, chronic neglect, the early warning sentinel oral injury before the watershed abusive event. That oral injury in a non-mobile child is highly unlikely to be accidental, their recommendation that a dental examination being part of any assessment of alleged abuse is a powerful one.

Animal abuse: child abuse?

In a related area, Finlay reviews ( see page 801 ) the literature (surprisingly extensive) on abuse of animals. Such behaviour is regarded as exploratory in young children, but, should raise concerns (for the child) if perpetrated by those of school age. Examples include odds ratios of animal abuse as a marker for mistreatment of the index child of 2.93 (95% CI 1.94—4.44) at the age of 5 years to 4.79 (95% CI 2.23—10.26) at 12 years. The strength of association is greater in girls (whom are less likely to abuse animals) and the rates of personal or witnessed domestic (spousal or partner) abuse very high in all older animal abusers.

Survivors of near drowning

Despite some progress with preventative measures (legislative and educational) drowning still ranks high (behind road traffic accidents) as a cause of accidental death globally. It is, therefore, easy to forget after an apparently successful resuscitation that survival does not rule out future problems. Manglick and colleagues ( see page 784 ) followed survivors of (mainly warm water) drowning in New South Wales and showed a 22% cumulative prevalence of executive, emotional, behavioural or cognitive dysfunction, twice that of unexposed counterparts. Each area is theoretically amenable to intervention so shouldn’t all such children be followed up their intensive care discharge?

Getting measures right

Be honest: how often do you accept ballpark figures for weight in outpatients or during a ward admission in children with complex neurodisabilty? Is the most recent weight a clothed weight estimated on adult scales after subtraction for the parental weight really good enough on which to base both nutritional assessment and drug dosing? Is it really that hard to do well? Hardy et al ( see page 757 ) debunk this myth in their validation of anthropometric measurements in 53 children with learning disability. Technical errors of measurement (TEM) between trained observers were low in all anthropometric measures except waist circumference though (unsurprisingly) less good in the non-standing children. The findings are important and illustrate that there is no excuse for not undertaking basic anthropometry even in a stretched clinic.

Just a few examples of the elephants in this issue and I’d like to think Krylov would appreciate the sentiment. Maybe he would have likened them more to his ‘Belling the Cat’ fable, but I think that’s (literally) another tale.