Transfer of critically ill patients with inhaled nitric oxide.

EDIToR,-We would like to respond to the commentary on our paper. ' The diagnosis of child sexual abuse (CSA) is a jigsaw which includes physical signs and in Leeds is multidisciplinary. The NHS, free at point of contact, health visiting, and case conference systems are important differences between British and US child protection practice.2 In the UK, early referral of cases for paediatric examination and follow up (including reexamination) has taught us much about the progression of abuse and evolution of signs. Agreement on physical signs in CSA is likewise evolving here,3 utilising experience on both sides of the Atlantic. Peer review and a national paediatric child protection interest group are established. Earlier publications, with photographs, have described our population and practice.57 An atlas of physical signs is in press.8 Psychosocial information is part of all assessments (and research) and our case categories reflect this. Our references' indicate agreement with US colleagues on the significance of many findings. However, we take issue9 with papersl' which do not follow usual clinical practice but suggest that most children have 'normal' findings. The commentary is misleading on a number of issues. For example, the statement: 'most [CSA] examiners would not agree that transverse hymenal diameter greater than 4 mm should be considered a sign of abuse', misconstrues the point. The Royal College report notes that 'the most commonly held view is that an orifice greater than 4 mm in the pre-pubertal girl is strongly correlated with abuse'. 3 "'-13 The fact that there are considerable differences in hymenal diameters in studies of non-abused girls is not quoted and it is unclear why those of McCann et al have been favoured. '4 Space does not allow a full analysis of every point but a further example of the commentary adopting an over inclusive and superficial approach is the statement that labial fusion is non-specific. It would be more informative to state that short labial adhesions may be common and innocent in infants in nappies but longer and thick fusion in older girls is much more unusual. Our paper is a detailed descriptive study of children in whom sexual abuse was the major concern. It is worrying that the commentary suggests that, as there are no American published series describing gaping vaginal openings or dilated urethras, our observations are invalid. Why have such obvious findings not been described by other examiners? Further, a gaping opening appears to be associated with loss of hymenal tissue and should be important. Common sense dictates that if objects are repeatedly inserted into children, gaping or dilated orifices may result. There is also evidence cautiously emerging that a prolapsed urethra (and anus) may follow trauma. While conflict remains in the literature on physical signs, it is hoped that those who would wish tO pUt a strait jacket around this area of paediatric practice should not be allowed to stifle careful observation based on sound clinical practice, which remains a vital part of good research. Physical signs will always have to be interpreted within the full clinical and social picture. We agree that there is still much for us all to learn.