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The incidence and pattern of injuries to children in public playgrounds presenting to the accident and emergency department were reviewed over two six month summer periods in Cardiff. A total of 178 children (mean age 7'5 years) attended with a playground injury representing 1.01% of all the children attending.One hundred and five children fell from equipment, of which the commonest was the climbing frame; 125 children had playground surface related injuries, 86 on bark and 30 on concrete. The pattern of injuries on the playground surfaces was different: fractures and sprains were more common on bark surfaces and lacerations and abrasions on concrete surfaces. Comparison of total injury rates showed there were fewer injuries on modernised playgrounds than expected but these differences were not significant. Modernised playgrounds are more popular, have new exciting equipment, and offer good play opportunities for children. However, the high fracture rate on modernised bark playgrounds is concerning and requires further research.

Non-accidental bath drowning is an infrequently reported form of child abuse. Details of 44 children who suffered from drowning or near drowning in the bath were analysed from a two year (1988-

IntroductionNeonatal fractures raise concern about non-accidental injury (NAI). This case series explores the characteristics of fractures on a neonatal intensive care unit (NICU).MethodBabies admitted to a regional NICU from 1998–2007with a radiological fracture during their inpatient stay were identified. Possible aetiology for fractures was identified from in-patient records.ResultsFifty-one fractures were identified in 22 (14 male) infants, median (range) gestational age 28 (26–43) weeks and birthweight 1581 (485–4875) g. Fractures occurred at median age of 53 (0–106) days and the sites included 19 anterior or lateral rib, 14 posterior rib, 3 humeral, 2 ulnar, 3 radial, 6 femur, 1 tibial, 2 clavicular and 1 skull. 17 cases had explanations for their fracture including osteopaenia of prematurity, birth trauma, thoracotomy and a witnessed accidental fall. Rib fractures occurred significantly later than other fractures (75.5 vs 21 days, p=0.03) and posterior rib fractures were found in the more preterm babies (26 vs 29 weeks, p=0.04). Babies with rib fractures were more likely to have had a surgical procedure (p=0.01) but fewer had a history of birth trauma (p=0.02).ConclusionFractures sustained during an inpatient stay on a NICU are unlikely to be associated with NAI. However, this case series demonstrated that fractures occur for a variety of possible associated factors. Careful consideration to causation needs to be given to fractures in babies after discharge from a NICU. Although they could be caused by NAI, prematurity and/or low birthweight and previous treatment needs to be considered.

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Child sexual exploitation (CSE) is often characterised by a power imbalance between the abuser and the child. Age difference is one of the power imbalances observed. However, there is no clear guidance on what age difference should raise concern. This article provides empirical evidence on age difference observed between: (a) teenagers (13–17‐year‐olds) who have attended a sexual health clinic and their partners; and (b) teenagers who are already known to children's services owing to significant concerns of sexual exploitation and their partners. The findings provide recommendations on age cut‐offs that are more likely to be suggestive of the risk of CSE. The paper concludes that an age difference of four years or more for 13–16‐year‐olds and six years or more for 17‐year‐olds should alert professionals to the possibility of exploitation. Overall, about two per cent of teenagers seen in a general sexual health clinic population had partners meeting these age cut‐offs compared with 31.4 per cent of those for whom there were already significant CSE concerns. These age cut‐offs can support professionals, especially those with little or no experience or knowledge of CSE, to make an informed professional judgement. Key Practitioner Messages A holistic approach to determining a young person's risk of sexual exploitation should include consideration of the age of the partner. Age ‘cut‐offs’ can help professionals decide what age difference should trigger concern and support decision‐making. We recommend age difference ‘cut‐offs’ of four years or more for 13–16‐year‐olds and six years or more for 17‐year‐olds.

Key Practitioner Messages Peer review involves a group of peers engaged in a discussion and providing an opinion on an individual's case that the individual can accept or reject while retaining ultimate responsibility for providing their opinion. Each health organisation employing paediatricians working in child protection should establish peer review processes in line with the recommendations and standards contained within this document and RCPCH Peer Review in Safeguarding (May 2012).

The probability of physical abuse (PA) is high in children with occult rib fractures. Other causes include non-intentional trauma, post surgery and cardiopulmonary resuscitation. Bone fragility increases the risk of fractures, namely metabolic bone disease of prematurity (MBDP), osteogenesis imperfecta, rickets and rare metabolic bone diseases.This case series describes 61 children under two years of age with rib fractures and associations with clinical and radiological features and aetiology. There were 20 cases of PA, 11 post surgical and three non-intentional trauma. Two cases had fractures following cardiopulmonary resuscitation, 18 MBDP and one metabolic bone disease. In six cases, the cause remained unknown. The number and distribution of rib fractures and the age of infants did not discriminate between MBDP and PA. Fractures were predominantly posterior, postero-lateral or lateral. All cases of MBDP had a gestational age of 31 weeks or less and birth weight < 1.25 kg. Each child with MBDP had at least one additional risk factor. Chronic lung disease was recorded in seven, prolonged total parenteral nutrition in ten, steroid use in four, furosemide medication in eight and necrotising enterocolitis in three. All PA cases had other associated injuries or signs of neglect.We recommend a comprehensive assessment of infants with occult rib fractures including an examination to exclude associated trauma, a child protection assessment and a full clinical assessment to exclude risk factors for co-existing bone fragility. Copyright KEY PRACTITIONER MESSAGES:• The number and distribution of rib fractures and the age of infants do not discriminate between PA and rib fractures seen in MBDP.• Assessment of infants with occult rib fractures should include an examination to exclude associated trauma, a child protection assessment and a full clinical assessment to exclude risk factors for co-existing bone fragility.KEY WORDS: rib fractures; physical abuse; metabolic bone disease of prematurity; investigation R ib fractures are said to have the highest specificity for physical abuse (PA) of all childhood fractures. A systematic review of the international scientific literature estimated that in the absence of a motor vehicle accident or witnessed trauma, the probability of child abuse in a young child with rib fractures was as high as 71 per cent (Kemp et al., 2008). However, occult (not clinically evident) rib fractures in infants or young children often pose a clinical diagnostic