Overview of 2018 surveillance methods

NICE's surveillance team checked whether recommendations in child maltreatment: when to suspect maltreatment in under 18s (NICE guideline CG89) remain up to date. The 2018 surveillance followed the static list review process, consisting of:

Feedback from topic experts via a questionnaire.
A search for new or updated Cochrane reviews
Consideration of evidence from previous surveillance
Examining related NICE guidance and quality standards and NIHR signals
A search for ongoing research
Examining the NICE event tracker for relevant ongoing and published events
Consulting on the proposal with stakeholders (this document).

For further details about the process and the possible update decisions that are available, see ensuring that published guidelines are current and accurate in developing NICE guidelines: the manual.

Evidence considered in surveillance

Cochrane reviews

We searched for new Cochrane reviews related to the whole guideline. We found no relevant Cochrane reviews published between January 2012 and July 2018.

Previous surveillance

The previous surveillance in 2012 did not identify any new evidence or ongoing studies.

The guideline was placed on the static list in 2014.

Related NICE guidance

The NICE guideline child abuse and neglect (NICE guideline NG76) was published in 2017. It builds on child maltreatment: when to suspect maltreatment in under 18s (NICE guideline CG89) with a broader scope. There is some overlap between the guidelines and minor edits were made to NICE guideline CG89 to bring recommendations in line with NICE's child abuse and neglect guideline. It is recommended that the two undergo surveillance together in future.

Ongoing research

We checked for relevant ongoing research. No relevant studies were identified.

Views of topic experts

We considered the views of topic experts, including those who helped to develop the guideline. For this surveillance review, topic experts completed a questionnaire about developments in evidence, policy and services related to NICE guideline CG89.

We sent questionnaires to 14 topic experts and received 7 responses. All 7 topic experts suggested that the guideline should be updated.

Topic experts identified 23 pieces of evidence. Six of these were not included due to the type of evidence (case study of a single case or opinion piece) or because the evidence was out of scope. Seventeen of these were of an adequate study type and within scope:

Royal College of Paediatrics and Child Health (RCPCH) child protection systematic reviews on: bites, fractures, burns, ear, nose and throat, oral injuries, retinal findings, spinal injuries, visceral injuries, bruising, dental neglect, early years neglect, neurological injuries, parent child interaction and school-aged neglect.
The updated RCPCH 'Purple Book': Physical signs of child sexual abuse: An evidence-based review and guidance for best practice (2015)
Studies on childhood bruising (Hibberd et al 2017, Kemp at al 2015)

The abstracts or summaries of key findings of these pieces of evidence support the recommendations in NICE guideline CG89. There was not sufficient evidence identified to update the guideline due to a lack of large, comparative studies. The RCPCH 'Purple Book' and topic expert feedback suggest that the term 'anal gaping' should be replaced by the term 'anal dilatation'. This can be addressed via editorial amendments.

Topic experts commented that risk factors for child maltreatment, children's response to injury and factors that make disclosure of abuse difficult are not covered by the guideline. However, these are out of the remit of NICE guideline CG89 which covers when to suspect child maltreatment only.

Experts commented that the following are not covered by the guideline:

Child sexual exploitation
Female genital mutilation
Trafficking
Slavery
Criminal exploitation
Differences between non-physical consequences of different subtypes of maltreatment
Distinguishing between younger children and young people
Fabricated and induced illness

There was either no evidence or insufficient evidence identified on these topics in this surveillance review to indicate the guideline should be updated.

It was suggested that weight gain should be included in NICE guideline CG89. The guideline development group (GDG) considered obesity when developing the NICE guideline CG89 and decided not to include it. There was insufficient evidence identified in this review to update this decision.

It was highlighted that NICE guideline CG89 should include excessive feeding of salt as a feature of child maltreatment. Recommendation 1.2.7 in NICE guideline CG89 encompasses excessive feeding of salt.

Topic experts suggested that the evidence for bruising, thermal injuries, dental aspects, head injuries and spinal injuries be reviewed. The abstracts and summaries of key findings of the evidence identified did not invalidate current recommendations and provided insufficient evidence to update NICE guideline CG89.

It was suggested that NICE guideline CG89 should include a reference to NICE guideline NG55. The guidelines are both referenced on the NICE pathway on recognising child abuse and neglect.

It was identified that the terminology for local safeguarding children's boards needs to be updated. It was also identified that the definition for unsuitable given in footnote 4 is incorrect. These can be addressed via editorial amendments.

Views of stakeholders

Stakeholders are consulted on all surveillance reviews except if the whole guideline will be updated and replaced. Because this surveillance proposal is to not update the guideline, we are consulting on this.

Equalities

Topic experts highlighted equalities issues including:

A view that prevalence of child poverty is increasing which may affect parenting capacity
Looked after children remain vulnerable but social care teams are reluctant to accept safeguarding referrals for this group

The aim of the guideline is to identify maltreatment when a child presents to healthcare services regardless of their background. Linked to this, recommendation 1.3.4 in the guideline notes: 'Be aware that it may be difficult to distinguish between neglect and material poverty. However, care should be taken to balance recognition of the constraints on the parents' or carers' ability to meet their children's needs for food, clothing and shelter with an appreciation of how people in similar circumstances have been able to meet those needs.'

Furthermore, both these issues were identified in the equality impact assessment for the related NICE guideline on child abuse and neglect and have been considered when recommendations were made.

Editorial amendments

During surveillance of the guideline we identified the following points in the following guidelines that should be amended:

Child Maltreatment: when to suspect maltreatment in under 18s (NICE guideline CG89)

'Using this guidance': The section headed '4. Consider, suspect or exclude maltreatment' states 'If an alerting feature or considering child maltreatment prompts a healthcare professional to suspect child maltreatment they should refer the child or young person to children's social care, following Local Safeguarding Children Board procedures.'
- The reference to local safeguarding children board procedures will be replaced with reference to local multi-agency safeguarding arrangements.
- An explanation of multi-agency safeguarding arrangements will be added to the 'definitions of terms used in this guidance' section.
Recommendation 1.1.19: This states 'Consider sexual abuse if a gaping anus in a girl or boy is observed during an examination and there is no medical explanation (for example, a neurological disorder or severe constipation).'
- The reference to anal gaping will be replaced by anal dilatation in line with the terminology used in the RCPCH 'Purple book'.
Footnote 4: Footnote 4 states 'Unsuitable means implausible, inadequate or inconsistent.'
- Footnote 4 will change to footnote 5 to reflect the additional footnote and will be amended for clarity.

Harmful sexual behaviour among children and young people (NICE guideline NG55)

Recommendation 1.1.4: This states 'Use established mechanisms, such as the local safeguarding children board, to develop local safeguarding policies and procedures and agree a harmful sexual behaviour operational framework between agencies.'
- The reference to local safeguarding children board procedures will be replaced with reference to local multi-agency safeguarding arrangements.
- An explanation of multi-agency safeguarding arrangements will be added to the 'terms used in this guidance' section.
Recommendation 1.1.5: This currently states 'Local safeguarding children boards should ensure:'
- The reference to local safeguarding children board procedures will be replaced with reference to local multi-agency safeguarding arrangements.
- An explanation of multi-agency safeguarding arrangements will be added to the 'terms used in this guidance' section.

Overall surveillance proposal

After considering all evidence and other intelligence and the impact on current recommendations, we decided that no update is necessary.

How are you taking part in this consultation?

Question on Consultation

Question on Consultation

Question on Consultation

2018 surveillance of Child Maltreatment: when to suspect maltreatment in under 18s (NICE guideline CG89)