NICE – When To Suspect Child Maltreatment

The question that needs to be asked here is, did the medics and hired experts use the up to date and best available evidence in concluding that a child suffered a non accidental injury. We suspect not. We believe that they are using old data to conclude NAI and they never bother to carry out exhaustive tests to form a differential diagnosis. 

4.1 Fractures

How can abusive fractures be differentiated from those resulting from conditions that lead to bone fragility and those resulting from accidents, particularly in relation to metaphyseal fractures?

Why this is important
The existing evidence base does not fully account for the features that differentiate fractures from different causes in infants and pre-school age children. A prospective comparative study of fractures in physical abuse, those resulting from conditions that lead to bone fragility and those resulting from accidental trauma would help address this question. Any such study should encompass a study of metaphyseal fractures.

Source: NICE – When To Suspect Child Maltreatment


Ultimately, researchers may have little power to prove or disprove by direct evidence whether child abuse is the cause of unexplained infantile fractures in a given case because of ethical and practical constraints. Medical practitioners do, however, have the technology to prove, by direct evidence and with a high degree of accuracy, whether a given infant with fractures has low bone density that may have predisposed the child to fractures during nonabusive handling. Mandating the use of this commonly available and relatively inexpensive technology would close a major evidentiary gap, which, ironically, allows room for both innocent caretakers to be convicted and guilty caretakers to be acquitted. Our
understanding of nonabusive conditions that can mimic child abuse has evolved to the point where it is simply no longer appropriate to presume child abuse based solely on the presence of unexplained fractures—even when those fractures are paired with intracranial
hemorrhaging. Since the technology to measure infant bone density exists and is relatively ubiquitous, its use should be mandated in cases where unexplained fractures will be used as evidence of abuse so that “beyond a reasonable doubt” will mean in practice what it says on paper in cases of alleged infant abuse.