Archives ofDisease in Childhood 1995; 73: 379
The Medical School,
1 Abbas AK, Lichtman AH, Pober JS. Effector
immune reactions. In: Abbas AK, Lichtman
AH, Pober JS,
Saunders, 1994: 279-92.
2 Brostoff J, Hall T. Hypersensitivity - type 1. In:
Roitt I, Brostoff J, Male D, eds. Immunology.
3rd Ed. St Louis: Mosby Year Book, 1993:
3 Tanaka T, Ben-Sasson SZ, Paul WE.
increases IL-2 production byT cells in response
to an accessory cell independent stimuli. J
Immunol 1991; 146: 3831-5.
4 Maeda K, Sone S, Ohmoto Y, Ogura T. A novel
differentiation antigen on human monocytes
that is specifically induced by granulocyte-
macrophage colony stimulating factor or IL-3. J
Immunol 1991; 146: 3779-84.
5 Lebedin YS, Raudla LA, Chuchalin AG. Serum
levels of interleukin-4, interleukin-6 and inter-
feron-gamma following in vivo isotype-spesific
activation of IgE synthesis in humans. Int Arch
Allergy Appl Immunol 1991; 96: 92-4.
6 Lawlor GJ, Tashkin DP. Asthma. In: Lawlor GJ,
Fischer TJ, eds. Manual of allergy and immun-
ology. 2nd Ed. Boston: Little Brown, 1988:
7 Schauer U, Kohl I, Jager R, Becker H, Rieger
CH. Coexpression of CD4 and CD8 on mito-
gen-activated peripheral blood T cells from
children with asthma: possible involvement of
interleukin-4. Ann Allergy 1992; 68: 354-9.
8 Bruijnzeel PL, Rihs S, Virchow JC Jr, Warringa
RA, Moser R, Walker C. Early activation or
'priming' ofeosinophils in asthma. SchweizMed
Wochenschr 1992; 112: 298-301.
9 Schleimer RP, Sterbinsky SA, KaiserJ,et al. IL-4
induces adherence of human eosinophils and
basophils but not neutrophils to endothelium.
Association with expression of VCAM-1. J
Immunol 1992; 148: 1086-92.
Cellular and molecular
A judicial comment on temporary brittle
EDITOR,-A recent reported judgment by Mr
Justice Wall' in the Family Division of the
High Court is relevant to the debate on
temporary brittle bone disease.2 The use of
this diagnosis to explain injuries in both child
protection and criminal court proceedings is
largely due to the work of Paterson.3 In the
case reported he was asked how two earlier
cases that had been before the courts had
been treated in his research data. In one case
there had been a criminal conviction and in
the other there had been a finding of non-
accidental injury by the Wardship Court. It is
reported that Paterson replied that both cases
were included in his research as proven cases
of brittle bone disease. Indeed, when asked
how he would log the case before the court
(the baby had suffered brain injury and
multiple fractures), should the judge make a
specific finding of non-accidental injury, he
replied that he would still regard the case as
being one in which the child had suffered
temporary brittle bone disease. In the words
of the judge 'Whilst courts of course accept
that there may be cases where there is a diver-
gence between judicial and clinical findings, I
Paterson's failure to record in his research
of cases of proven
disease judicial findings to the contrary. In my
judgment this is a factor which must cast the
gravest doubts on his findings'.
The judgment also reaffirms that the court-
room is no place to advance untested hypothe-
ses4 and emphasises the need
witnesses to provide independent assistance to
the court and not omit to consider facts which
Attention is also drawn to an earlier judgment
by Cazalet J,5 also involving brittle bone dis-
ease, which points out that a misleading opin-
ion from an expert may well inhibit a full
assessment by non-medical advisers, reinforce
parental denial, and thereby put a child at risk.
For future cases coming before the High
Court there will be awareness of previous
judgments relating to evidence on temporary
brittle bone disease, however, this may not be
so in the Family Proceedings Court. As Mr
Justice Wall comments: 'It is not difficult to
imagine circumstances in which a non-acci-
dentally abused child might be returned to
abusing parents on the false premise that the
child has not been abused. That in my judg-
ment is just as much an injustice as a false
finding that a parent has injured a child'.
During investigation of suspected child
abuse, even before legal action is considered,
possibility of temporary
disease may be raised and threaten to com-
promise or obstruct protection of a child or
therapeutic work with their family. By being
aware of and referring others to relevant law
reportsl5 paediatricians can help keep the
issues in perspective.
MARGARET A LYNCH
St Thomas Street,
London SE) 9RT
1 Wall J. Re AB (Child Abuse: Expert Evidence)
 1 FLR 181.
2 Smith R. Osteogenesis imperfecta, non-accidental
injury, and temporary brittle bone disease. Arch
Dis Child 1995; 72: 169-76.
3 Paterson CR, Burns J, McAllion SJ. Osteogenesis
imperfecta: the distinction from child abuse and
the recognition of a variant form. Am J Med
Genet 1993; 45: 187-92.
4 Williams C. Expert evidence in cases of child
abuse. Arch Dis Child 1993; 68: 712-4.
Evidence)  1 FLR 291.
J. Note Re R (A Minor)
Infant length measurements
EDITOR,-Dr Doull and colleagues presented
a paper on the reliability ofinfant length mea-
surements.' Hoorah! Some of us have for
many years tried, without much success, to
encourage the measurement of infant length.
In many studies it is a better measurement of
growth than weight and is a stable linear
Why the unsuccess? 'It's very difficult to
do; it's unreliable; you need a special appar-
atus; it's impractical to do in the field'. It has
been shown that none of these concerns is
valid,23 but Dr Doull has done so in an up-
to-date persuasive way including showing that
you do not need two professionals but only
one, mothers being excellent holders of their
For velocity growth in infancy it is an
important measure and there are a growing
number ofreference values available.4
School ofPublic Health,
and Department ofPediatrics,
Berkeley and San Francisco,
California 94720, USA
IJM, McCaughey ES, Bailey BJR, Betts
PR. Reliability of infant length measurement.
Arch Dis Child 1995;* 72: 520-1.
growth. Pediatr Clin North Am 1961; 8: 13-7.
3 Falkner F. Recommendations
growth in childhood: a human growth founda-
Health 1995; 6: 79-85.
4 Roche AF, Himes JH. Incremental growth charts.
Am J Clin Nutr 1980; 33: 2041-52.
Edited by William L Buntain. (Pp 788; ,C142
hardback.) W B Saunders Company, 1994.
This comprehensive book covers all aspects of
trauma care. It starts with a historical review,
discusses the philosophy and organisation of
paediatric trauma management, describes the
treatment of specific conditions, and looks to
There are 85 contributors (mainly sur-
geons) three of whom are Australian, all the
others being North American. The book was
more than six years in gestation and the chief
editor has done well to produce a book that
reads so fluently.
There are six separate sections. The first
covers the history of the subject, the bio-
organisation of services, and developing stan-
dards of care. The figures report the agencies
involved in prevention and some of the legis-
lative solutions suggested have an American
slant. Nevertheless, the principles of aetiology
The chapter on trauma care organisation is
excellent. Care of the injured starts at the
roadside or in the home and continues until
tertiary care is reached and provided. The
authors write with authority on the improve-
ment in care following the introduction of a
team approach to the injured child 'There is
providers'. The response teams are described.
Resuscitation and stabilisation are orthodox
and follow advanced paediatric life support
and advanced trauma life support (APLS,
ATLS) teaching. There are some exceptions:
for example, use of a trocar in introducing a
chest drain is deplored as dangerous by most
of us in emergency care. The radiological
evaluation is clear and uncontroversial, but
our anaesthetic colleagues may baulk at the
suggested use of ketamine
hypotensive, cerebrally injured children.
In fairness, the author admits to differences
of opinion over this. He is not dogmatic: 'No
singular approach should be considered the
only correct approach. Rather a protocol for
trauma care that is attuned to the institution's
geographic and urban demographics,
physical limitations of the building itself is
Chapters are devoted to trauma scores,
and blood products. There
injury and then to special situations such as
falls, birth injuries, non-accidental trauma,
farm and submersion injuries. My surgical
colleagues assure me that the operative pro-
cedures described are standard. A conserva-
tive approach is taken to urinary tract injuries
and liver damage, but a slightly more aggres-
sive approach than ours to splenic injury. A
... for competition amongst care