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I haven't got any more clear now. I haven't got any more clear the before before I. Ok. Yeah. So who's going right now? My leg it 400 a year. It's a, to be honest. Yeah, bye bye. Ok. And I think you've got this. Hm uh we will just wait a few more minutes. It is just about five o'clock. So I think we a few people are still expected to join, so we will just wait for another at least 334 minutes. Oh, uh, Daniel, you can start sharing your screen so long. Ok, right now. Ok. I, I wanna look for it to be done. I I Mhm. I, I, no. Mhm. Yeah. Oh, ok. Ok. Hard. Uh um time, right. I think Daniel. Uh you can start now. Um because anyway, the meeting is being recorded so those who join late, uh I can always give them the link uh for the meeting. Uh Just see what is being written in the chat. Uh ok, that's fine. Ok, so good afternoon. Uh everybody uh let's hope that power shedding uh does not affect our meeting uh today. Um We welcome registers and trainees from outside Eastern Cape as well. Doctor Daniel Ivi, our medical officer is going to talk about child abuse or non accidental injuries. Ok, Danielle, you can go ahead. Thank you pro um this afternoon, I'm going to speak a bit about non accidental injuries um in the context of pediatric surgery. So with the content that we will be discussing, um we will look at the definition, the incidence recognition, the presentation, radiology, as well as the management by us and a take home message and then also look at it at the references. So with the definition, there's a a big difference between Western and African um definition for non accidental injuries or child abuse in the Western population. According to the wh o it's any physical or emotional ill treatment, sexual or neglect or negligent treatments or commercial or other exploitation that can cause actual or potential harm towards the child's health, survival, developmental or dignity. All of this is placed in the context of a relationship of responsibility, trust or power with us in Africa. And the definition differs a bit because of our, all our different cultures that we have. So um they define um give a definition of abuse to an extent that is not acceptable in the particular culture. So if we can give you an example, some of the cultures accept male as well as female circumcision. While in the Western communities, it might be um seen as abuse towards the female child, if you look broadly at it, both of them agree still that it's maltreatment of Children. It can be um, of their peers as well, but it's normally in someone that has a power over them or a responsibility over them that abuses them. So if you look a bit at the incidence in Africa, um, Africa has the highest rate of homicide, um, for Children under five years for the boys, it's 17 per 0.9 per 100,000 and the girls is twe 12.7 per 100,000. This incidence is six times more than in western countries. The magnitude is even obscured by um different legal and cultural definitions of abuse, poor reporting, as well as poor recording of them. So why is Children mostly involved? The reason is that Children is normally weak and vulnerable. They are very easy targets for abuse, the smaller the child, the greater the danger of abuse and they also have a higher fatality risk. The highest risk that we've seen is with firstborn um Children, pre babies, stepchildren and any type of disabled child with the incidence. Um As you can see there, if you look at the right side, the average age for the the abuse normally um happens at seven years. But the average age for the um fatality cases is normally at three years, the physical abuse. Um you can see they're at the top for the physical abuse. A third of them are for less than six months, a third of them, six months to three years and a third of them. Um Children over three years abuse is also a common cause of childhood death. Um in the age group of less than six months, it is second um to, to sudden infant death syndrome. So when we look at different types of Children abuse, there's um a few different types. The most commonly known is the physical as well as sexual. But there's also other types with the physical. That is when there's injuries inflicted physically by the care. Um The caretaker, there's also a thing that they call the shielding phenomenon. So that is when a child, let's say a child gets an adult gets attacked um from another person with a knife and the the adult uses the child then as a shield to protect themselves. We normally see those mostly with knife injuries with sexual abuse. The it's very, the term is broader than just only child rape. Um That is any use of a child for sexual gratification. So it can be sexual intercourse, but it can also be touching fondling or any other inappropriate contact with the child's um genitals or breast. It can also be masturbation in the presence of a child or masturbation of a child by an adult or other way around. Um It can also be any type of body contact with adult genitalia um as well as poor pornography, including um photography or erotic to when we look at other forms of Children abuse. This is normally the ones that we, we forget um to look for. The ones that we are not. Um That's not as easily, as easily um seen. So that can be failure to thrive. Um intentional drugging or poisoning, medical neglect, safety, neglect, emotional abuse or organized. So with the failure to thrive, um normally it's nutritional deprivation that happens mostly in the first two years and 50% of those cases is to due to maternal neglect. Um in the the two year age group with the drugging, that is when drugs um is given to a patient that is harmful or not intended for a child with the medical care. That happens when the chronic disease is worsened due to neglect of the condition by the, the um caretaker with safety. That's normally when we see a gross um gross lack of supervision and then emotional abuse. That is when the child gets blamed for incidents or when the child gets rejected or when there's severe verbal abuse. This is one of the most difficult abuses to prove because there's no physical signs that we can see um organized crime that can also be um present when there's multiple victims and perpetrators. So they can have um that can be the um pedophilic and pornographic rings, but it can also be spiritual or social objectives of any of the cult based groups. So when we first look a bit. Um with our physical abuse, how do we recognize this um, physical abuse? So we have to look at a few things, um, that can tell us that it is more abuse than an accidental injury. So that is when there is unexplained injuries. Um when the, the histories is not the same from the parent and the child or the caretaker when there is a significant delay in seeking medical care or when there's um, alleged self-inflicted injury or blaming of the third party. No, but I didn't hurt him. That person did. Um We can also recognize it when there's repeated injuries or when there's sexualized behavior or STD S, especially when the child is young. When the child shouldn't be um having any, sorry, any of that behavior, then we should think of it. Just a few examples. Um They can say that they just found a child like that or they don't, they're not sure the child might have fallen down or no, but this child bruises easily or things that doesn't explain the severity of the injury like the child rolled over the arm and fractured it when we look at it at predisposing factors. Um, there's a lot of factors that, that predisposes Children to child abuse. So if you look at personality traits, that is personality traits of the um the person um, abusing the child. So you'll see there, there's substance abuse, young parents when they get abused as Children, low self esteem, antisocial behavior. But with this, it's significant to note that 90% of the cases, the parents don't have any psychological problems or any criminal nature. So it's normal parents um that can also abuse with um the child characteristics on the right side. Three years, the reason is they are unable to defend. They are small in relation to the adult and they require constant care and attention. They're also in a learning phase. So they are not responding as expected and that can be frustrating with disabilities, they can have cognitive, emotional or physical disabilities and with the premature and low birth weight, it suggested that there's a um interference with the mother baby bonding. Let's say a pre mature baby is born, they need to stay in, in ICU, they don't breastfeed as often. So that can have a significant impact when we look at the family dynamics. It's a lot of things that happens in South Africa as well as Africa family breakdown, single parents with an absent father, large families that lives together and domestic violence when domestic violence is documented. Um there's also there's a 30 to 60% chance that that child is being abused at home as well when we look at environmental factors and they are connected to scarcity of social services. As you can see, that's also everything that's happening in South Africa as well as Africa. So that is why we have this high incidence um with us consequences of, of um abuse is not only the physical trauma but that it causes, but it causes also quite significant emotional trauma. So they can the, the um victims can have substance abuse and depression and those are 2 to 3 times more likely to happen in the Children abused than any other. They can also show physically aggressive behavior towards their peers and that can influence on their adulthood. So 30% of these Children will also abuse their own Children. Some people are suggestive, suggestive that this cycle um can be attributed to changes in the neuroendocrine system and that influence the child's arousal, learning, growth and pain threshold with the presentation. As you can see on this slide, there's a lot of different presentations. Um so the child can come in with, with various presentations. We won't focus on this slide, but we'll focus a bit more on physical and then look at a little bit on the other ones. So if we first look at the not physical presentations, because I feel these are mostly the ones that we don't pick up as easily. So when we look at emotional and behaviors, they can have aggression, withdrawal, and anxiety, irritability, um irritability, bullying, and they can also have an unwillingness or tearfulness when they undress. When we look at the physical psychological or sexual abuse. These um patients can have failure to thrive as we said, they can um have um stuttering when they speak, not reaching their developmental goals. And um when you look at them when they are away from home, you can see that they actually are thriving with the presence of the indicators of the deliberate neglect. These people, these um patients can be underweight, they can have bad sores, disorientation and sores in and around the mouth. A study was done um at Red Cross Hospital in January 2008 to December 2010. This was a retrospective study and um it reviewed Children, sorry. Um Between zero and 30 years, the aim of the study was to describe um the population of the Children that were um presented to the Red Cross Trauma unit with non accidental injuries. And in this three years, they had 522 cases of all these cases. Um The occurrence was more seen in males than in females except for sexual abuse where um there was 93% female and 6.7% male. So the highest number of in um non accidental injury cases was also recorded amongst the 5 to 9 year age group. Like we said, the the average um age of presentation or the average age of um abuse is at seven years. So that also we also found that in South Africa. So when we look at um, injuries that they present with the injuries are um mostly that they presented with was head injuries that you can see that 35.3% 2nd was face um, facial injuries, that was 16.3 genital injuries, that was 10.5. That is not the sexual assault, but genital um physical injuries and then um lower body injuries with the South African presentation again. Um where it happens, it's actually very shocking to see that even with the physical as well as the sexual assault, the um place that they had happened most oftenly was at home. Sometimes even with physical, um, they can happen at school, public places as well as other places when we look them at the physical injuries, um, per organ system. When we look at the skin first, they can present with bruises, burns and bites with the nervous system. They can present with head injuries as well as ocular injuries with the skeletal and they can present with fractures and they can also have abdominal injuries with the skin. As you can see with these photos when there's a bruise on the cheek and the face, it can indicate that the patient was slapped or hit with a fist. Um, the grip bruises is when a patient um gets shaken around or gets held there while something happens to them, the buttock and back bruises often um, is related to punishment and it's very difficult to determine the age of the bruises. You can see the cigarettes and the pinched bruises there as well with the maturation of bruises. You can see, it's very difficult when it's on a child. It always looks easy when you have it here like this in colors, but it's very difficult to distinguish between red and reddish purple and purple. So for the 1st 24 hours, it normally um presents as a red bruise within 24 hours, it changes then to a reddish purple with 24 hours to one week. It's more a purple color and then 1 to 3 weeks, you can see a combination of yellow, green and brown. This is secondary to the um degradation of the hemoglobin that you get. That combination of three colors with the burns. The way they present um is when there's force submersion into a fixed position. As you can see there, the bums is on the surface. So that is why you get that donut or sparing sign and then the abdominal um skin flaps is there where the zebras tribes are. So those are spared from the burn and the rest get AAA pattern like this when the child is also pushed um into a hot water um with the hands and the feet, they get a a glove and stocking pattern. Um And there's also specific things that you can look for like a clothes iron or a curling iron, cigarette burns. This is just a picture to show the glove and stocking um pattern. You should also look there with these. Um the patients normally has absence of splash marks because they are held there with force and they can also have signs of upper lane restraining while this um happened with bite injuries. Um, you can see distinct of tooth marks as well as um you need to photograph these tooth marks because they, it's very helpful to keep it for forensic evidence with head injuries. Um The incidence is about 70 to 40 per 100,000. The largest group of the head injuries in seen in infants um of age of 0 to 3 months and a third of them, we don't even recognize the reason is that it's very difficult to diagnose with trauma um below three years, especially when there's no external injury. Um You should always have a high index of suspicion of this and a worrisome history as when a child comes to him, the parent says no, it was a low fall. The child walked and fall, fell off a step and then the child comes in unconscious. We can also see with them skull fractures as well as sub as subdural he um hematomas. When there's repetitive injuries, they can also have brain atrophy when we look at the shaken baby syndrome. Um the name was changed, changed to abusive head trauma. Um This syndrome is caused by either shaking alone or shaking with impact um that magnifies in the forces of the acceleration and deceleration. This results into hie or the cervical nerve disruption or it can resolve into both. So as you can see there, the triad is retinal hemorrhaging brain swelling, which presents with encephalopathy as well as a subur hematoma. When we just look a bit at the mechanism, there's hyperextension and hyper flexion that causes them, that the great matter um moves over the white matter and that has the, the searing force causes them axon damage. As you can see here at the, the axonal she injury, the damage is then at the axon cell and then the brain cell above that dies as well as the, the axon. So then it causes uh um axonal injury for the brain. And that's why a common finding is saying that the child has brain edema with the loss of the normal white and gray matter differentiation. And that presents clinically as encephalopathy. The rapid acceleration and deceleration can also tear the bridging veins and that results into bleeding. And that's the cause. Then for the subdural hematoma, the subdural hematoma can then often be bilateral with this. When we discuss the triad, the retinal hemorrhages are nearly always present in a a shaken baby syndrome. So it's important to look for them with the ocular injuries. Um it's very difficult to diagnose this especially because we are working with Children, we might not be able to dilate the pupil and because we don't have dilated available. Um So it's very important to have an input from a specialist ophthalmologist because there's also a flexibility in diagnosing these injuries and we don't see them often. So the first one, as you can see the first picture, that is an example of a retinal hemorrhage. So you can see the um the two hemorrhages and the, the one with the white spots inside is called a Roth spot. The second one is um when there's lens dislocation, it can dislocate anteriorly. And the third one is retinal detachment. As you can see that the dusky area is where um it detached from the retina. So with the skeletal injuries, fractures is rare. Um in Children fractures of less than three years of age, you should always suspect abuse. And 25% of abuse cases involve um skeletal injuries. A patho no um fracture is a bucket handle fracture and which we'll look at now and some worrisome signs is when you find a child that has different stages of healing of the skeleton, all these um fractures of the di di pieces of long bones in the infants or the Children and they can't even walk. So with the skeletal fractures, this is an example of a bucket handle fracture. So you can see there on the left side, there's a a vulg fracture of the corner of the um metaphysis from the Periston um Periosteum, excuse me, that happens when the long bones get wrenched and then approximately 10 days after that injury. Um There's a calcification of that subperiosteal bleeding. That is when you'll see that classic uh classic double cortex line, which you can see there on the right because of that calcification. So if you see this, it's abused until otherwise proven. So they also did a study um at Red Cross. Uh it was during a 14 year study period, almost 100,000 trauma patients were treated at Red Cross that time and about 1% of them were confirmed as victims of non accidental injuries. More than two thirds of these cases were males. Um 64% of the cases. When we look um at the age groups, a quarter of these Children were younger than six months and 38% were older than than three years. When we look at which area, the um the uh anatomical areas most um frequently fractured. We could see that the head and neck was involved the most that was 53% and then the upper limbs that was 24% as well as the lower limbs that showed 18%. Only 7%. Uh 7 of these fractures were in the trunk. So we don't see them as often. It's mostly head, um upper limbs and lower limbs with abdominal injuries. Um solid organ rupture can happen when there's direct blood impact on the, the um abdominal organs. So they are high risk organs. The reason is that the abdominal muscles, the younger the child is, the more fragile they are and the less protection they, they offer, they are very easy to compress against the spinal column and they can have a variety of further injuries that can also even expect affect the small intestine. So, with our differential, um we should look at birth trauma, that is a history from birth congenital syphilis that will show other things like positive blood test, a chronic periosteal reaction and um metaphyseal widening as well as um osteogenesis imperfecta. But you will see the blue sclera, um osteopenia and multiple fracture. Ricketts disease. You might see the um bone, long bones as well as blood abnormalities and they have renal disease, scurvy. You can see with poor wound healing, bleeding gums and pia skin disease. You can see other types of skin disease like impetigo and then the accidental trauma. That's why we need to um get the history from the parents to look at the pattern of injury and then to see how the parents interact to try and differentiate that from, from non accidental with sexual abuse. We won't be talking a lot about this because this is a whole topic on its own. So just a few points on that um signs and symptoms that you should be thinking about um recurrent abdominal pain, difficulty walking or sitting, painful, maturation, fecal soiling. Um And the signs is when there's any discharge, any abnormal dilatation when there's lacerations and bruisings or bleeding. And then any signs of um STIs s you should also think about that with sexual abuse. Um The examination should never be taken lightly and they should be um performed under ideal circumstances because if it's performed under other circumstances, it might contribute to the secondary trauma of the child. So it should always be done by a qualified doctor and then um a specific protocol should be followed. So a private area is needed. Um a third person, either the mother, um or a sister, hopefully always a sister um can be present. You need to explain the procedure to the mom as well as the child. You need to first do a general exam to gain the child's trust. It should only be done once and you should know at the stage of sexual development if there, there's different um types of examination positions that you can use if it's a smaller child and there's pictures the child can be examined on the mom's lap, uh with the back to the mom and the mother holding the leg itself. Um All the Children can be then examined like that. The first picture of the frog leg um or the supine lit position, the anus should be examined in the lateral decubitus. And the right side that you can see here is the knee to chest. They advised against um using the knee to chest position because a lot of perpetrators uses this position themselves. So all Children with evidence with peripheral trauma should be examined under um anesthesia to determine the nature as well as to see if there is a need for surgical repair. When we look at the global incidence of sexual assault. Um In 2009, there was a study published um in the Clinical psychology review that showed the global prevalence of sexual abuse in Children was an estimated 9 15.7% for females and 7.9% for males. Africa then had the highest prevalence of sexual abuse. That was 34.4%. And of these countries, South Africa was the highest. So with the management um by pediatric surgery, the HLS protocols or um principles should be followed. So that would be your first, your primary survey. You need to resuscitate and treat lifethreatening injuries. So that's your ABCD E, then you need to do your adjuncts like a chest X ray, pelvic, X ray, your bloods, the F BCC and cross match and place an NGT if it's needed a urinary catheter and IV nine, the secondary survey should include a head to toe examination to see if there's any other um all the injuries and with the transfer, we are um mostly the serving facility. So we should ask for appropriate packaging and um accurate handover if we need to hand over. So with the history, um it is patients can present with poor eye contact, um withdrawal, um they can present with answers that they think will please us. Um We should have a look for or ask for predisposing factors. And it's very important to ask for previous medical and surgical history. The reason is that um possible medical causes like ITP should we should try and exclude that already on the history with the exam. As we said, a full head to toe exam, that's also to exclude other medical causes. Look at the growth parameters to see if there's a failure to thrive a general exam of all the systems. Detailed examination, fundoscopy which we normally um struggle with. Um when the child is is consciousness is suppressed. Look at the sexual development and look at an no genital exam for possible sexual abuse as well as signs of intoxication and drug abuse with the special investigation. So when we have bruising, we should do AF PC and cotton profile to see if it's not medical with fractures or lungs. Longstanding abuse, a skeletal survey where it's available, neglect and malnutrition, we should check the serum albumin and then alcohol levels of suspected um alcohol intake or serum glucose. When we look at the radiology, um we should do a skeletal survey. So that's a chest X ray, skull x-ray and the um A PS of the extremities. The radionuclear bone scans are more sensitive but under one year of age, they are unreliable. So for the X rays, um we look specifically for rib fractures, skull fractures, buccal handle fractures and old fractures. The bone scan can show us nicely if there's fractures in different stages of healing. It's also very important to refer because we need to have a multidisciplinary approach. One of our most valuable assets is the social worker because they can help us to ensure child safety and to organize a place of safety. This is very important um as sometimes when it happens and the perpetrator is at home, the child can't go back home. So then at that stage, the hospital stays the place of safety until the social worker can arrange a difference and place of safety. So that's why we see some patients stay very long with us when we look at the social medical legal management as well. Things that you should do and don't do so, we should recognize it early. We should document it a adequately because they use it for um prosecution and we should report all case all cases we shouldn't confront and accuse the parents um because it hinders treatment and rehabilitation and there's no place for that in our management. So with this, we should um be taking notes with detailed sketches of all injuries and scars, every page. We make, make sure that the child's name and date and f the number is there and that everything is legible. We are responsible for filling in the J 88. It's also advised to keep a copy for um ourselves and it's important to write down the name and address of the person accompanying or the police officer that brought the patient in with the healthcare worker responsibilities. We conduct the forensic medical examinations. We do, um, administer relevant tests. We collect the forensic evidence, we provide medication and we record all our findings when we look a bit at the South African law. Um, the South African Children's Act that was number 38 and um, 2005 defines a child as any person under the age of 18 years. According to South Africa's population, that um 38% of our population is Children. And all this, we have alarmingly high statistics for crimes against Children. Just for an example, in 2012 to 2013, there was almost 500 cases reported of crimes against um Children. The literature also indicates that these crimes are even un underreported and they say that they think the cases should be about nine times higher. The reason why that's underreported is that um there's a misunderstanding of the child abuse reporting. There's a lack of knowledge and um doctors have previous negative experiences with child protection services. Some doctors even believe that it's better to deal directly with the family and they may fear potential harming of their professional relationship. I feel that that is more um more for private sector with us. That's not, not um not one of our main fears research that was done into rape. Um In South Africa then revealed that 84% of these sexual crimes committed against the Children. Um The perpetrator was known. So further, if we look um at liability and accountability, according as well to the section 110 of the Child Amendments um Act, the professionals particularly health healthcare professionals can be held accountable if they are, don't report abuse of Children. This reporting um should then be done with the set of facts. So everything that you can pick up while you examine the child and it shouldn't be done under a mali's intent. If that happens, then um it will not give rise to any claims of liability with accountability. The HPCS A as well as the justice system can help, will can hold us accountable for this. So um the HPCS A can fine us or they can suspend us for a period of time or they can even remove our name from the register. If we get uh found guilty for not reporting. The justice system sees a failure to report sexual abuse um or exploitation of Children as well as mentally handicapped persons as an offense. So that is punishable then with a fine or imprisonment of up to five years um or both if the person is found guilty, something that's scary with this, that 30% of perpetrators end up in uh end up in court and only 7% of them face um prosecution. So with this, my take home message is that the definition um differs from the Western to African context Children are easy targets. Um There's different types of abuse. We are used to physical and sexual, but we, we often forget about the other type of abuse. Um, management of the abused patient is mostly multidisciplinary and the social worker is a very, very important um asset that we should use. We should identify Children at risk and any child um below three years of age are at the highest risk. The leading cause of mortality is head injury and we should suspect that in any cases of unexplained injuries, the discrepancy in history, delay in seeking care or repeated injuries. And we as healthcare professionals um are required by law to report these cases. So we do have a big responsibility, the doctors, the nurses, the multidisciplinary team, all of us have a big responsibility. So these are my references and it's our job to keep the Children safe. Thank you. That was an excellent presentation, a very good summary of, of uh problem of child abuse and non accidental injury. Unfortunately, uh we have a sad distinction of being the child abuse capital uh and sexual abuse capital in, in Africa. But uh anyway, uh very nicely presented. I will now just invite one after the other our consultants to comment and they can even ask questions first. I will invite Doctor Maren. Yes, sure that please you can unmute yourself and, and make comments or ask questions. Uh Yes, prof thank you. Uh Thanks Danielle. That is, uh, that was a very comprehensive, good talk. I think you covered most of the things II would have wanted you to. Um, it's a very cringe worthy topic. I think everyone was kind of probably very affected by everything you said there. It's not something we like to think about but it happens and we, um, like prof said, we, we, uh have a high incidence in this country and as you know, we've, we have a lot of cases coming to us. Um One of the things um you shared some of the statistics that are really shocking. Uh One of the statistics I came across with as 84% of all sexual crimes are against minors or Children under 18, which really shocked me. And then the other thing is that the children's act you talked about in 2005 in order for that to be implemented, we need at least uh 70,000 social workers according to the Minister of Social Development. And in 2012, I don't know what it is standing at now, but it was much, much less than that. It's only 16,000 registered social workers. So you can imagine what we're dealing with here. We we have high numbers, high incidents and poor um social services to deal with these things. Um So the other thing I wanted to ask you if you came across any indications for the skeletal survey. No doctor man, they the information II, read didn't say, um, they didn't speak and nothing specific about ages and things. No, they only said that the, the bone scan, the radionuclear bone scan is, um, not reliable under one year. And that's the only thing that I came across. Ok. So maybe what I've got is old, um, old stuff and you've been looking at newer stuff. But, um, I got that a less than two year old with any evidence of abuse should have a skeletal survey. Any child, less than five years old with a suspicious fracture and any older child unable to communicate. So mentally impaired um would need a skeletal survey if they come in with trauma and if the suspicion uh remains high, even after the skeletal survey, then you can do the bone scan because it's more sensitive. You didn't come across any of that. No, I didn't. This was ii did this talk a while back just looking at everything? Um So yeah, um it's a big problem and oh, the other thing I wanted to mention was that um you know, we had, we have Children coming in with unexplained incontinence. So you mentioned the fecal soiling but also urinary incontinence. Uh We had a girl recently actually who uh you know, we kept for a while after sexual abuse reporting and just by being in a safe place and away from that environment, she improved and even her mood and affect improved. So it's really important for us to pay attention to um these Children who are coming with symptoms that don't really fit in with the presentation because it could be psychosomatic, psychological and emotional. Um oh, and then the other thing I wanted to mention, you talked about the uh the retinal hemorrhages and ocular signs. So I also came across that you can do an MRI if that's proving to be quite difficult in a child. And it, it has an 80% sensitivity. So I don't know if you came across that, but that could solve a lot of problems. And the other thing was that there is a differential diagnosis, like you did mention like bone problems, metabolic problems and bleeding disorders. So I think you did go through that. Yeah, and I agree with you. It's uh it's our priority to keep the Children safe. It's a silent pandemic and we have to pay attention to red flags and we must remember that we are responsible for mandatory reporting. But thank you. That was a good talk. Thank you doctor. Yeah, thank you very much. Those are uh excellent comments and, and very pertinent and unfortunately, it's an ongoing silent pandemic um in our country and we uh we really, as you said, we have a lot of responsibility. Now. Um can I invite Doctor Majola to make comments please? Uh Doctor Majola, Doctor Moola, are you still there? Yes, I am here. Can you hear me please? Yeah, go ahead, please. Yeah. Um, hi, everyone. Thanks Danielle for a good talk. I agree with your shoulder when it comes to, um, a skeletal survey, as you said, um, what we mostly used to practice and what they practice at Red Cross is any injury that is, is uh not according to the given history, they will do a skeletal survey on that patient and for them it's quite easy cause they've got low do in the trauma unit. So any child with suspected um physical or abuse with probably uh suspection of fractures, then they will just do low doxes on, on those kids. And they have a high obviously pickup rate with uh multiple skeletal injuries on those patients. And then with the bone scan, it's more of an advanced. If they are, they still suspect they still have a high suspicion of uh uh of injury in the patient. But with the x rays or the low toes or the skeletal survey, they can't uh pick up any of those injuries, then they will do a bone scan on those kids. That's all for me. Uh Thank you. I I'm glad that you mentioned Lod. Um uh II believe we have Lod at hospital but its software has not been upgraded. So that is something which uh we will take it up with the radiology department. But thank you k uh Doctor Mach Sell. Please make comment. Oh, hi. Um Thanks for now. Good talk. Um covered um relatively everything. Um I just wanna um ask what do you think about um all the kids that come in, burnt in our unit? Um Is it just negligence abuse? Do you think we're doing enough to try and actually deal with this or is it just something that happens? People get burnt and get over it? What do you think? I think it's a very fine balance because the reason is in our African context. Um, we have a lot of people living in the same area as very close to each other, not having electricity. So it's, it's normal to have a, a fire going on and it's not always, I mean, you can't expect of any, any parent who always have their child on the direct vision. So with the, the circumstances that we have in South Africa and Africa, I feel that there's a, a balance between what we can expect and, um, what falls under negligence, let's say, um, there was a case that came in a few weeks ago where Children, um, played and then the one girl was playing with the fire, putting her, her dress, a part of her dress in and then it caught fire and then they will, um, put, um, sand again on and that will go away and they continued to do that for about five times and on the fifth time, her dress actually caught fire and they couldn't stop it. And I feel that is negligence because um with that, the, there should be someone supervising and the Children should be taught about that. But if it's AAA house fire and the, the fires inside was cooking and the pot fell over hot water and the child, I think in our South African context, it's very difficult to put a firm line between negligence and what is acceptable um, with the conditions that we live in. So it's a very, very difficult. Yeah, it's a fun light. Yeah, because yeah, it's very difficult because if you were to look at in a first world setting and look at our setting. Um Typical example is um someone gets shot um in South Africa. Um you hardly ever report that to the police. You just deal with it and you move on with your life in most of the other centers. Um It's a major thing. So I think the onus is on um showing or highlighting that um certain behavior cannot be tolerated. Fair enough people get burned by accident. That's fair. Sometimes though when you actually listen to the history, you can find out that there is some elements of negligence. Uh and it's unavoidable unfortunately because of the social economic status where maybe the mother was um not available at that time, just had to go to the shop to buy something left the child alone, the house burnt down. It's not, it's not necessarily something that we want, but it's completely preventable. And obviously, this has to go part and parcel with um improving social care. With outcome 81, you having to improve social um care within our environment. Because um with enough social worker, enough psychologists, you find that um we approach it in a more holistic fashion because um what 10, what happens now we have a tendency of sending people to the social worker just to say, OK, we get our part, we send them to, to the social worker. Let's move on. And that's, that's a bit of a problem because even the social workers sometimes they overloaded and they don't really try to actually address all the causes. They just want to make sure that where the child is going, it's safe, then they leave it at that where you find an instance where the perpetrator lives next door. Um But because the mom is saying, no, it's fine, you can go home. The social worker are very happy with the child going home with the mother as long as the mother will watch the child. But the problem is that the the uh the issue is not sorted because the perpetrator is next door. The social worker did not deal with the perpetrator and not enough um support is kind of um given not only to the patient but to also to the social worker um themselves. So I think with, in our context, um child abuse is rife because there's not enough support. Um um not just to social work but to every health care worker that's involved. And, yeah, I think the, the important thing with any kind of abuse is just to report it, any kind of suspicion reported. Because if, like you said, if there's no malice behind your reporting, you can't necessarily be prosecuted for it better to be proven um, wrong uh, with your suspicion than to actually leave a child to succumb to um uh systematic um abuse from the parents or the neighbors if it comes to that. Yeah, so I think the important thing just be able to suspect abuse mention or uh no, no men um then refer appropriately to the social worker or to the relevant people thereafter. OK. Thank you. Um So that, that was, that was very good. You brought out very pertinent ethical issues. There is a question for you from Kirsty knowing the lack of social workers, what other other options or ways are there for us to intervene? Can you answer that please? The, the the thing is that I think it's we try to remove the patient from the course. So from the source of the abuse. So the way we can do it um even with decreased uh amount of of social worker is by actually keeping the patient in the hospital for as long as possible because that just moving the patient away from the course is actually helping. Then it, that's why we have situations where patients stay for weeks end um in our units just because we are trying to make sure that the social worker addresses the issue properly. So I think that's the first step because um only if you uh I think you are really, really, really worried about the safety of the child. Um and the social worker is not necessarily helpful at that stage. Um obviously, with the consent of the parents, unless if the abuse is coming from the parents, then try to escalate it move higher than the social worker go maybe to um the police service just uh inquire. Um II don't think there's anything wrong with inquiring and saying that you are suspecting abuse. Um social worker is not, not necessarily not helpful but is not escalating things the way you want it. Um And if that's not working, you can go higher up to the court level because with certain situations where a child maybe needs a blood transfusion. But the Jehovah's weakness and the parents are refusing that you can go up to the high court and the high court can give you permission. Obviously, it will be detrimental to the child because the parents might end up disowning the child. But end of the day, we are trying to actually um be thinking in the child's benefit. We're not trying to push our own agenda onto the child. So we want the child to have a good outcome. We definitely would not want to have a child misplaced from home or to suffer from our um assessment. But I think with our social workers um keep them as long as possible within the hospital um so that they actually will get him as a social worker, involve a psychologist as well. And, and at the same time because it's not just the social worker needs to get involved, it's a psychologist as well just to give adequate support for that. So prolonged stay in the hospital. That would be my uh suggestion with um with no social workers and stuff around. Thanks. Yeah, th thank you, sir. I think II agree that just uh the girl who, who was admitted with urinary incontinence recently we did the same. Uh Thank you sir. Uh Just one more thing I would like to add is always as in any other injury. There is a pyramid. So what we actually see is is the tip of the pyramid. So under this, there are many, many more cases which are red flags but which are being missed in the community. And I think we need to be more alert and aware about recognizing those near miss cases which don't even present to the hospitals. Um Is Doctor Kola still around Funeka? If you are around, you can give comments please. Is Doctor Kala still here? I saw him joining but if he's not here, is uh Doctor Anna Marie Houghton still here, pediatrician. No, I think she has also left. Um Yeah, Kirsty is saying that Tula not only for sexual abuse but other abuse as well and they have cose counselors. Yes, we uh Tula centers are, are, are a blessing. They are a big help. So I think if there is uh are there any comments, any questions from our registrars medical offices? Any other questions from any of the guest people from outside East London? Profile a question? Yes. Um Yeah, Selo touched on it. One thing I found really difficult, not just here but also other hospitals I've worked in if we really do suspect a case like a burn patient that looks like he's been dunked in hot water or um really suspicious history of what has actually happened. We've referred many, many of those patients to social worker and they come back. Uh Social circumstances are fine but everything says no, it's not. II don't know if we can actually escalate that to the courts. Who do we talk to, who, who takes over from there? Because otherwise we just end up sending those Children home knowing that this is not a safe place to go home. Um I think Sello has partly answered that but maybe I will invite him to answer your question, Sello, please. Um I think uh the the ideal thing to do, as you said, we start off with the social worker because social worker should be able to connect us with the relevant parties. If not then um we, as, as you said, you think it's a criminal offense? So we have to report it to the police station. Um And should there come a point where the police people uh find that they are not necessarily helpful person because police would be able to link us up with, with further um people who are involved with child persecution and so forth. So they would ultimately be our end um cause because they will definitely link us with the, with the higher courts so that we can challenge anything if it comes to a situation where the parents um are fighting us. But we are actually pursuing this because for the better welfare of the child. So it would be a situation, it would be a long drawn out situation, but we would not necessarily be the ones pushing it per se because the social worker um would be able to, should be able to um guide us in this because one, the facilities um they'll probably want to put the child in a place of safety. And the only thing from the medical side that um we can do is definitely give adequate or right, adequate documentation and have adequate pictures if we need that so that our case is substantiated. But for us to go straight to the high court would be very difficult without going through the system of the social worker. Then the police station then move on that way. Yeah. It seems very, I don't know if I got time to go to a police station and report cases and follow up for months afterwards. No, I think, uh, we just can't give up the, these, these are the ways which we can, we can, um, tackle these situations. Um, the, the nice thing is that most, most hospitals, if not all, um, they actually have police services within the facility. So you don't necessarily have to drive out the hospital, some or generally most facilities should have police um services within the the facility. So that's, that's why I'm saying that. Um it's, it's, it's tedious. Yes. Um Sometimes where you, you have to be more proactive than usual because sometimes just writing social worker consult is where we always end. Um unfortunately, instead of social worker following what the social worker is saying, then escalating it higher up because throughout my experience, there has been very, very, very few cases where um the social worker has actually um escalated things to police service. They always try to uh um mitigate and actually see where the problem is. And I think the social worker ultimately wants to maintain the family dynamics by not splitting it up where when you look at certain um nations, the thing is to make the child safe first and the first thing they do is remove the child from the source and put them in a home, then they sort out the home issues then they bring the child back once it's safe versus us, where, um, should the child be removed from the home? They most likely won't find a place to stay and it will be very difficult um, to reintegrate them back into that family dynamics. So I think the way that our social workers operate might be a bit different, obviously, um, um, um, I can be corrected because I'm not a social worker, but I think it's a bit different from how um other units or other First world centers um do their thing. Oh, ok. I see good uh comments and, and advice from consultants in the chat box also. So I think if there are no further comments or questions, I would uh like to conclude and I would like to thank uh Daniel for presentation for all the consultants for their valuable advice and welcome all the uh people who from uh uh outside Eastern Cape have uh actually made an effort to join these meetings. We appreciate their presence and I hope they find the meetings helpful. So we will put out a message for next week. It will be Vasic Ureteric Reflux will be presented by Doctor Gautham, but I will set up uh invitation and send it to everybody. Thank you, everyone. We are in good time. Uh And luckily, Eskom didn't p play havoc and we had a good meeting. Thank you, bye-bye. Anybody who is not able to attend. I have recorded it and uh I will be uh putting a link on the group. There is a last comment from Doctor Majola that it is important to engage other parties uh as appropriately to manage the case. That's, that's also important. Ok, bye-bye. Now see you next week.