• Child Abuse
• Evidence Based Medicine

Trust your hunches. They’re usually based on facts filed away just below the conscious level.

    James Joyce (1882–1941)

Child protection is one of the most challenging aspects of paediatric practice. The consequences of missing a case of serious abuse are self-evident, with one child dying every week as a result of deliberately inflicted injury, abuse or neglect; indeed recently released data identified this as the single largest category of childhood deaths with modifiable factors in England.1

Clinicians working in this field need the most sophisticated diagnostic, communication and team working skills and great personal resilience to deal with the emotional demands of the work. Despite this, the role has often been undervalued and poorly supported, with some viewing it as a ‘Cinderella specialty’. The stress on clinicians has also been exacerbated by high-profile media cases in which paediatricians have been vilified in the press, both for missing diagnoses and conversely for making positive diagnoses which have subsequently been overturned in court.

From a public perception, there is a view that medicine is based on a robust body of evidence, with little tolerance for error, or understanding of the fact that diagnosis is actually the art of making a best estimate based on probabilities. This is particularly the case for child protection, in which the evidence base has been slow to emerge and forms only part of the picture. Hence, diagnosis is dependent on the trigger of an initial index of suspicion, supported by a mix of corroborative detail, experience, triangulation, monitoring, review and above all the highest level of multiagency communication and cooperation.

Fortunately, there is a slow but steady change in status and perception of the specialty, in large part due to clearer guidance and better multiprofessional working. Alongside this, the gradual emergence of a more robust evidence …