ESPE Abstracts (2018) 89 P-P1-030

Bone Biochemistry in Children with Fractures Presenting with Suspected Non-accidental Injury

Owen Forbesa, Jane McNeillyb, Helen McDevittc, James Houstona, S. Faisal Ahmedc,d & Avril Masonc,d


aChild Protection Service, Royal Hospital for Chidren, Glasgow, UK; bBiochemistry Department, Royal Hospital for Children, Glasgow, UK; cRoyal Hospital for Children, Glasgow, UK; dDevelopmental Endocrinology Research Group University of Glasgow, Glasgow, UK


Introduction: Fractures have been recorded in up to one third of children who have suffered from physical abuse. The British Paediatric and Adolescent Bone Group (BPABG) position statement on vitamin D states that the level of 25 hydroxyvitamin D is not relevant to causation of fractures unless there is radiological or biochemical evidence of rickets. Clinicians are often asked in the court setting about the relevance of abnormal serum investigations in children who have fractures where there is a concern about non-accidental injury (NAI).

Aim: The primary aim of this study was to measure adherence to RCPCH recommendations: Children under two years, who have unexplained fractures raising suspicion of NAI, have the following investigations:- Vitamin D (VitD), Parathyroid hormone (PTH), Calcium (Ca), Phosphate (Ph) and Alkaline Phosphatase (Alkphos). In addition to analyse the pattern of these biochemical investigations in this population.

Method: A retrospective review of case notes, electronic results and radiology records over five years (2012–2016) at The Royal Hospital for Children, Glasgow. Children were included who were under two years and had undergone a skeletal survey as part of a child protection investigation and were found to have one or more fractures. Bone biochemical markers (Ca, Ph, Alk Phos, PTH and Vit D) were compared to age specific local reference ranges and classified as normal or abnormal.

Results: In 64 (59.8%) children the decision was made to request bone investigations, complete bone biochemistry was sent and reported in 57 (89%) of these. One child was found to be Vit D deficient, a further 19(33%) were found to be insufficient. 29/57 (50.8%) had one or more biochemical marker (Vit D, PTH, Ph, Ca, Alk Phos) outside reference range. In cases where NAI was confirmed either at case conference or by criminal conviction 12/27 (44.4%) had one or more biochemical marker outside reference range.

Conclusion: We have demonstrated that in children under going investigation of a fracture in suspected NAI vitamin D is often in the deficient or insufficient range in the absence of radiological or biochemical evidence of rickets. This review has also demonstrated that other bone biochemical markers are frequently outside the normal reference ranges in this population.

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