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van Gemert MJC, Vlaming M, Gabaeff SC, Nikkels PGJ, Neumann HAM. Asymptomatic Infant Rib Fractures Are Primarily Non-abuse-Related and Should Not Be Used to Assess Physical Child Abuse. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1827. [PMID: 38002918 PMCID: PMC10670409 DOI: 10.3390/children10111827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/27/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023]
Abstract
Finding infant rib fractures was for many years an almost undisputed proof that physical child abuse took place. Yet, these rib fractures are virtually always occult and asymptomatic and are only identified when looked for, usually with X-rays, from physical child abuse accusations related to, e.g., suspicion of the shaken baby syndrome. In a recent systematic literature review (searched in Cochran, Embase, PubMed and Sociological Abstracts), Güvensel questioned the diagnostic accuracy of rib fractures to be caused by abuse, due to lack of sufficient scientific evidence. Further, there is currently a world-wide disagreement between physicians considering themselves child abuse specialized, and physicians that explore non-abuse-related symptoms that may mimic physical abuse, which, it is hoped, will significantly reduce current unjustified child abuse diagnoses. In an attempt to help resolving this disagreement, we hypothesize that the probability of physical child abuse-related infant rib fractures is significantly lower than the probability of all other possible non-abuse-related causes of occult asymptomatic infant rib fractures, e.g., from birth trauma, prematurity, osteogenesis imperfecta, hypermobile Ehlers-Danlos Syndrome, severe chronic placental pathology (e.g., massive perivillous fibrin depositions and severe chronic histiocytic intervillositis), and vitamin-D deficiency. As method, we attempted to assess the incidence of these various causes of infant rib fractures, in the Netherlands and the USA. The results are that the estimated Dutch and USA physical abuse-related infant rib fracture incidences are at least about 250 and 45 times lower than the sum of all the non-abuse-related estimates. Because these latter rib fractures are occult and asymptomatic, it is likely that (many) more could be out there. In conclusion, occult asymptomatic rib fractures develop perinatally, virtually always as birth trauma, in infants with sufficiently weak bones due to vitamin D deficiency, transmitted by their vitamin D deficient pregnant mothers. This group also includes cortical rib cracks due to deformation forces, with an estimated 186/100,000 incidence. And, despite obvious uncertainties in all estimated incidences, we provided strong evidence that our hypothesis has relevance, implying that the abundant occult asymptomatic rib fractures, when found in infants, should not be used to assess potential physical child abuse.
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Affiliation(s)
- Martin J. C. van Gemert
- Department of Biomedical Engineering & Physics, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Marianne Vlaming
- Private Practice, Criminal Psychology and Law, 6986 CL Angerlo, The Netherlands;
| | | | - Peter G. J. Nikkels
- Department of Pathology, Wilhelmina Children’s Hospital, University Medical Center, 3584 CX Utrecht, The Netherlands;
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Radiologists' Diagnostic Performance in Differentiation of Rickets and Classic Metaphyseal Lesions on Radiographs: A Multicenter Study. AJR Am J Roentgenol 2022; 219:962-972. [PMID: 35792137 DOI: 10.2214/ajr.22.27729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND. Despite evidence supporting the specificity of classic metaphyseal lesions (CML) for the diagnosis of child abuse, some medicolegal practitioners claim that CML result from rickets rather than trauma. OBJECTIVE. The purpose of this study was to evaluate radiologists' diagnostic performance in differentiating rickets and CML on radiographs. METHODS. This retrospective seven-center study included children younger than 2 years who underwent knee radiography from January 2007 to December 2018 and who had either rickets (25-hydroxyvitamin D level < 20 ng/mL and abnormal knee radiographs) or knee CML and a diagnosis of child abuse from a child abuse pediatrician. Additional injuries were identified through medical record review. Radiographs were cropped and zoomed to present similar depictions of the knee. Eight radiologists independently interpreted radiographs for diagnoses of rickets or CML, rated confidence levels, and recorded associated radiographic signs. RESULTS. Seventy children (27 girls, 43 boys) had rickets; 77 children (37 girls, 40 boys) had CML. Children with CML were younger than those with rickets (mean, 3.7 vs 14.2 months, p < .001; 89.6% vs 5.7% younger than 6 months; 3.9% vs 65.7% older than 1 year). All children with CML had injuries in addition to the knee CML identified at physical examination or other imaging examinations. Radiologists had almost perfect agreement for moderate- or high-confidence interpretations of rickets (κ = 0.92) and CML (κ = 0.89). Across radiologists, estimated sensitivity, specificity, and accuracy for CML for moderate- or high-confidence interpretations were 95.1%, 97.0%, and 96.0%. Accuracy was not significantly different between pediatric and nonpediatric radiologists (p = .20) or between less experienced and more experienced radiologists (p = .57). Loss of metaphyseal zone of provisional calcification, cupping, fraying, and physeal widening were more common in rickets than CML, being detected in less than 4% of children with CML. Corner fracture, bucket-handle fracture, subphyseal lucency, deformed corner, metaphyseal irregularity, and subperiosteal new bone formation were more common in CML than rickets, being detected in less than 4% of children with rickets. CONCLUSION. Radiologists had high interobserver agreement and high diagnostic performance for differentiating rickets and CML. Recognition that CML mostly occur in children younger than 6 months and are unusual in children older than 1 year may assist interpretation. CLINICAL IMPACT. Rickets and CML have distinct radiographic signs, and radiologists can reliably differentiate these two entities.
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Milner JD, Hartnett DA, DeFroda SF, Slingsby BA, Silber ZS, Blackburn AZ, Daniels AH, Cruz AI. Orthopedic manifestations of child abuse. Pediatr Res 2022; 92:647-652. [PMID: 34819655 DOI: 10.1038/s41390-021-01850-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 10/19/2021] [Accepted: 10/28/2021] [Indexed: 11/09/2022]
Abstract
Child abuse is common in the United States but is often undetected. The incidence of this form of abuse is difficult to quantify, but children with a history of abuse are at risk of chronic health conditions. Medical providers are in the unique position of triaging trauma patients and differentiating unintentional from abusive trauma, as well as having the important position of being a mandated reporter of abuse in all states. Obtaining a detailed history and screening for risk factors can help identify children at risk of abuse. Certain orthopedic injuries may be related to abuse, which may trigger clinical suspicion and lead to further workup or intervention. By increasing awareness, through medical provider education and increased screening, earlier detection of abuse may prevent more serious injuries and consequences. This review evaluates current literature regarding the orthopedic manifestations of child abuse in hopes of increasing medical provider awareness. IMPACT: Child abuse is common in the United States but often remains undetected. Medical professionals are in the unique position of evaluating trauma patients and identifying concerns for abusive injuries. Certain orthopedic injuries may raise concern for abuse triggering clinical suspicion and further workup or intervention.
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Affiliation(s)
- John D Milner
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA.
| | - Davis A Hartnett
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Brett A Slingsby
- Department of Pediatrics, The Lawrence A. Aubin Sr. Child Protection Center, Hasbro Children's Hospital, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Zachary S Silber
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Amy Z Blackburn
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
| | - Aristides I Cruz
- Department of Orthopaedic Surgery, Brown University, Warren Alpert School of Medicine, 593 Eddy Street, Providence, RI, USA
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Charoenngam N, Ayoub D, Holick MF. Nutritional rickets and vitamin D deficiency: consequences and strategies for treatment and prevention. Expert Rev Endocrinol Metab 2022; 17:1-14. [PMID: 35852141 DOI: 10.1080/17446651.2022.2099374] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/05/2022] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Rickets is typically characterized by bone deformities due to defective bone mineralization and chondrocyte maturation in growing bones. However, infantile rickets often goes unrecognized, because the skeletal abnormalities are more subtle and often can only be detected radiologically. Nutritional rickets is a major public health concern in several regions worldwide. It is most commonly caused by vitamin D and/or calcium deficiency. AREA COVERED We provide an overview of historical perspective, epidemiology, and pathophysiology of nutritional rickets. Additionally, we outline diagnostic approaches and highlight challenges in radiographic diagnosis of rickets. Finally, we present strategies for prevention and treatment of rickets. EXPERT OPINION Despite the evidence from clinical databases that rickets is a rare disease, it is likely that rickets is clinically underdiagnosed as studies designed to screen healthy children for radiographic evidence of rickets reported surprisingly much higher prevalence. It has been reported that some of the radiologic features of rickets can be misinterpreted as fractures. To prevent nutritional rickets, most if not all infants and young children, should receive vitamin D from formulas and foods that are fortified with vitamin D or supplementation to achieve a serum 25-hydroxyvitamin D of at least 20 ng/mL as recommended by the Institute of Medicine. It has been recommended by the Endocrine Society that to achieve maximum bone health for children and adults, a serum concentration of 25-hydroxyvitamin D should be at least 30 ng/mL and preferably 40-60 ng/mL. Pregnant women who are unable to obtain an adequate amount of vitamin D from sunlight exposure and natural and fortified diets should take a vitamin D supplement of 1500-2000 IUs daily as recommended by the Endocrine Society since it has been demonstrated that 600 IUs daily will not maintain a circulating 25-hydroxyvitamin D of at least 20 ng/mL and most pregnant women. If lactating women take approximately 6400 IUs of vitamin D daily, they provide enough vitamin D in their milk to satisfy their infant's requirement thereby preventing rickets.
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Affiliation(s)
- Nipith Charoenngam
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- Department of Medicine, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
- Department of Medicine, Mount Auburn Hospital, Harvard Medical School, Cambridge, MA, USA
| | | | - Michael F Holick
- Section Endocrinology, Diabetes, Nutrition and Weight Management, Department of Medicine, Boston University School of Medicine, Boston, MA, USA
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Högberg U. Transfer of knowledge to diagnose infant abuse and its incidence - a time-series analysis from Sweden. Implement Sci 2022; 17:15. [PMID: 35120543 PMCID: PMC8815122 DOI: 10.1186/s13012-022-01188-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/05/2022] [Indexed: 12/04/2022] Open
Abstract
Aim To analyse the transfer of knowledge on how to detect physical abuse, especially shaken baby syndrome/abusive head trauma (SBS/AHT), and its association to trends in infant abuse diagnoses (maltreatment and assault). Methods Design: retrospective population-based and quasi-experimental. Setting: Sweden 1987–2019. Patients: Children below age 1 year, selected from the National Patient Register (n = 1150). Exposures: Literature search for transfer of knowledge by diffusion, dissemination and implementation, and whether supportive or disruptive of the SBS/AHT paradigm. Main outcome measure: Abuse diagnoses (maltreatment or assault). Analyses: Incidence rate, incidence rate ratio (IRR). Results The overall incidence rate of abuse was 32.23 per 100,000 during the years 1987–2019. It was rather stable 1987–2000. The SBS diagnosis was introduced in the late 1990s. A comprehensive increase of transfer of knowledge on physical abuse, specifically on SBS/AHT and dangers of shaking, took place from 2002 and onward through diffusion, dissemination and implementation. Maltreatment diagnoses, but not assault diagnosis, increased steeply during 2002–2007, peaking in 2008–2013 [IRR 1.63 (95% confidence interval 1.34–1.98)]. Transfer of disruptive knowledge on SBS/AHT during the period 2014–2019 was associated with a decline in maltreatment diagnoses [IRR 0.84 (95% confidence interval 0.71–0.99)]. Conclusion An increase in maltreatment diagnoses was associated with transfer of supportive knowledge of the SBS/AHT paradigm, while a decline occurred toward the end of the study period, which might indicate a burgeoning de-implementation process. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01188-6.
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Affiliation(s)
- Ulf Högberg
- Department of Women's and Children's Health, Uppsala University, SE-751 85, Uppsala, Sweden. .,Department of Epidemiology and Global Health, Umeå University, Umeå, Sweden.
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Vitamin D, rickets and child abuse: controversies and evidence. Pediatr Radiol 2021; 51:1014-1022. [PMID: 33999242 DOI: 10.1007/s00247-020-04893-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/15/2020] [Accepted: 10/19/2020] [Indexed: 11/27/2022]
Abstract
Suboptimal vitamin D status is a global health issue that affects children and adults worldwide. The prevalence of vitamin D deficiency and insufficiency has been well documented in the pediatric population in the United States. Although vitamin D deficiency is common, radiographic findings are uncommon and can be subtle. Additionally, because of the high prevalence of pediatric vitamin D insufficiency, it is commonly identified in young children with fractures. However, the majority of pediatric fractures are caused by trauma to healthy bones. Some, especially in infants and toddlers, are caused by non-accidental trauma. A small percentage is related to medical disease, including those associated with disorders of collagen, disorders of mineralization, and non-fracture mimics. Despite the scientific evidence, among disorders of mineralization, non-rachitic disorders of vitamin D have become a popular non-scientific theory to explain the fractures identified in abused children. Although infants and young children with rickets can fracture bones, the vast majority of fractures identified in abused infants are not caused by bone disease. Here we present a review of the literature on bone disease in the setting of accidental and non-accidental trauma. This context can help physicians remain vigilant about identifying vulnerable young children whose injuries are caused by non-accidental trauma.
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Bloemen EM, Rosen T, Lindberg DM, Krugman RD. How Experiences of Child Abuse Pediatricians and Lessons Learned May Inform Health Care Providers Focused on Improving Elder Abuse Geriatrics Clinical Practice and Research. JOURNAL OF FAMILY VIOLENCE 2021; 36:389-398. [PMID: 34121804 PMCID: PMC8189565 DOI: 10.1007/s10896-020-00143-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
The experience of physicians and other health care providers in child abuse pediatrics in the last six decades includes successes and failures, which can offer critical insights to inform the growing field of health care providers focusing on elder abuse clinical practice and research. We identify and describe in detail relevant lessons learned, including balancing an urgent call to action with a need for robust evidence to support clinical conclusions. We discuss solutions to research challenges, including the lack of a uniform gold standard for abuse diagnosis and how to ethically recruit subjects who may have cognitive impairment and also be crime victims. We offer recommendations on recruiting and training a specialized health care workforce. We make suggestions for health care providers about how to navigate the legal world including issues with expert testimony and also how to participate in policymaking and development of rational systems. We emphasize the importance of developing and supporting partnerships within the field, with allied fields inside and outside medicine, and internationally. We also highlight the value of connecting researchers and clinicians focused on different types of family violence.
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Affiliation(s)
- Elizabeth M. Bloemen
- University of Colorado School of Medicine, 13001 E 17th Pl, Aurora, CO 80045, New York, NY 10065, USA
| | - Tony Rosen
- Department of Emergency Medicine, Weill Cornell Medicine / NewYork-Presbyterian Hospital, 525 E. 68 St., Room M130, New York, NY 10065, USA
| | - Daniel M. Lindberg
- The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave. Mailstop B-215, Aurora, CO 80045, USA
| | - Richard D. Krugman
- The Kempe Center for the Prevention & Treatment of Child Abuse & Neglect, University of Colorado School of Medicine, 12401 E. 17th Ave. Mailstop B-215, Aurora, CO 80045, USA
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Miller AJ, Narang S, Scribano P, Greeley C, Berkowitz C, Leventhal JM, Frasier L, Lindberg DM. Ethical Testimony in Cases of Suspected Child Maltreatment: The Ray E. Helfer Society Guidelines. Acad Pediatr 2020; 20:742-745. [PMID: 32068125 DOI: 10.1016/j.acap.2020.02.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 02/03/2020] [Accepted: 02/08/2020] [Indexed: 11/26/2022]
Abstract
New guidelines for ethical testimony were developed by the Ray E. Helfer Society, the largest medical professional society for physicians working in the field of child maltreatment. Building on the foundation of ethical guidelines set forth by the American Academy of Pediatrics, these new guidelines set detailed standards for testifying in cases of suspected child maltreatment and recommend that hospitals, medical practices, academic institutions, and professional societies hold their members accountable for court testimony related to child maltreatment as with other forms of medical practice and expert testimony.
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Affiliation(s)
- Aaron J Miller
- Office of Ambulatory Care (AJ Miller), New York City Health + Hospitals, New York, NY.
| | - Sandeep Narang
- Department of Pediatrics (S Narang), Northwestern Feinberg School of Medicine, Chicago, Ill
| | - Philip Scribano
- Department of Pediatrics (P Scribano), Safe Place Center for Child Protection and Health, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Christopher Greeley
- Department of Pediatrics (C Greeley), Baylor College of Medicine, Houston, Tex
| | - Carol Berkowitz
- Department of Pediatrics (C Berkowitz), Harbor-UCLA Medical Center, Torrance, Calif
| | - John M Leventhal
- Department of Pediatrics (JM Leventhal), Yale School of Medicine, New Haven, Conn
| | - Lori Frasier
- Department of Pediatrics (L Frasier), Penn State Hershey College of Medicine, Hershey, Pa
| | - Daniel M Lindberg
- Department of Emergency Medicine (DM Lindberg), The Kempe Center for the Prevention and Treatment of Child Abuse and Neglect, Aurora, Colo
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Fortin K, Bertocci G, Nicholas JL, Lorenz DJ, Pierce MC. Long bone fracture characteristics in children with medical conditions linked to bone health. CHILD ABUSE & NEGLECT 2020; 103:104396. [PMID: 32135374 DOI: 10.1016/j.chiabu.2020.104396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/22/2020] [Accepted: 01/28/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND Knowledge of fracture characteristics among children with medical conditions affecting bone could help to distinguish medical causes from child abuse. OBJECTIVE Characterize long bone fracture morphology among children diagnosed with medical conditions linked to bone health. PARTICIPANTS AND SETTING Patients <18 years at a single pediatric hospital diagnosed with a medical condition linked to bone health and ≥1 long bone fracture were studied. METHODS This retrospective medical record review categorized underlying medical diagnoses as: metabolic bone disease, genetic disorder of connective tissue, neurologic disorder and other chronic disease. A pediatric radiologist reviewed plain films to determine fracture type and location. Descriptive statistics, as well as logistic regression were used to compare fracture types by clinical characteristics. RESULTS Ninety-four patients were included and their diagnoses were genetic connective disorder (19; 20.2 %), metabolic bone disease (16; 17.0 %), neurologic disorder (27; 28.7 %), and other (32; 34.0 %). A total of 216 long bone fractures were sustained; 52.1 % of children had >1 long bone fracture. Of the 216 fractures, 55 (25.5 %) were in children < 1 year, 118 (54.6 %) were associated with known trauma, and 122 (56.5 %) were in non-ambulatory patients. Lower extremity fractures occurred with greatest frequency and most fractures occurred at the mid-diaphysis. Transverse was the most common fracture type in all diagnostic categories. Children with metabolic disorders had highest odds of transverse fracture (COR 3.55, CI 1.45-8.67; neurologic disorders as reference group). CONCLUSIONS Diseases affecting bone health can influence fracture morphology. Transverse fractures were most common in bones impacted by disease.
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Affiliation(s)
- Kristine Fortin
- Perelman School of Medicine at the University of Pennsylvania, Division of General Pediatrics, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104, United States.
| | - Gina Bertocci
- Department of Bioengineering, University of Louisville, J.B. Speed School of Engineering, 500 S. Preston St., Louisville, KY 40202, United States.
| | | | - Douglas John Lorenz
- University of Louisville School of Public Health & Information Sciences, 485 E. Gray St., Louisville, KY 40202, United States.
| | - Mary Clyde Pierce
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, 225 E. Chicago Ave, Chicago, Il 60611, United States
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Servaes S, States L, Wood J, Schilling S, Christian CW. Rachitic change and vitamin D status in young children with fractures. Skeletal Radiol 2020; 49:85-91. [PMID: 31243488 DOI: 10.1007/s00256-019-03261-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2019] [Revised: 06/11/2019] [Accepted: 06/13/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To examine the association between rachitic changes and vitamin D levels in children less than 2 years old with fractures. METHODS Children less than 2 years old who were admitted to a large children's hospital for a fracture and underwent a skeletal survey were included. Two pediatric radiologists blinded to the children's vitamin D levels independently reviewed the skeletal surveys for the following rachitic findings: demineralization, widened sutures, rachitic rosary, Looser zones, and metaphyseal changes. Kappa coefficients were calculated to assess inter-rater agreement. Logistic regression was used to test the association between vitamin D level and rachitic findings. RESULTS There were 79 subjects (40 female and 39 male) with a median age of 4 months. Vitamin D levels ranged from 11.6 to 88.9 ng/ml and were low in 27. Questionable demineralization was noted in seven subjects; mild to moderate demineralization was observed in four subjects. Widened sutures were noted in seven subjects, many also with concurrent intracranial hemorrhage. Lower vitamin D levels were associated with increased odds of demineralization after adjusting for age, gender, and prematurity (P < 0.015). An association was not found between the vitamin D level and suture widening (P = 0.07). None of the cases demonstrated Looser zones, rachitic rosary, or metaphyseal changes of rickets. CONCLUSIONS Infants and toddlers with fractures frequently have suboptimal vitamin D levels, but radiographic evidence of rickets is uncommon in these children.
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Affiliation(s)
- Sabah Servaes
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Lisa States
- Department of Radiology, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Joanne Wood
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Samantha Schilling
- Department of Pediatrics, University of North Carolina, Chapel Hill, NC, USA
| | - Cindy W Christian
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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11
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Paterson CR. Broken bones and irresponsible testimony? Am J Med Genet A 2019; 179:2333-2334. [DOI: 10.1002/ajmg.a.61349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 06/01/2019] [Accepted: 06/11/2019] [Indexed: 11/10/2022]
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Miller M, Stolfi A, Ayoub D. Findings of metabolic bone disease in infants with unexplained fractures in contested child abuse investigations: a case series of 75 infants. J Pediatr Endocrinol Metab 2019; 32:1103-1120. [PMID: 31600139 DOI: 10.1515/jpem-2019-0093] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/05/2019] [Indexed: 12/22/2022]
Abstract
Background Infants who present with multiple unexplained fractures (MUF) are often diagnosed as victims of child abuse when parents deny wrongdoing and cannot provide a plausible alternative explanation. Herein we describe evidence of specific and commonly overlooked radiographic abnormalities and risk factors that suggest a medical explanation in such cases. Methods We evaluated such infants in which we reviewed the radiographs for signs of poor bone mineralization. We reviewed medical, pregnancy and family histories. Results Seventy-five of 78 cases showed poor bone mineralization with findings of healing rickets indicating susceptibility to fragility fractures that could result from a wide variety of causes other than child abuse. We found risk factors that could explain the poor bone mineralization: maternal and infant vitamin D deficiency (VDD), decreased fetal bone loading, prematurity and others. Most infants had more than one risk factor indicating that this bone disorder is a multifactorial disorder that we term metabolic bone disease of infancy (MBDI). Maternal and infant VDD were common. When tested, 1,25-dihydroxyvitamin D levels were often elevated, indicating metabolic bone disease. Conclusions Child abuse is sometimes incorrectly diagnosed in infants with MUF. Appreciation of the radiographic signs of MBDI (healing rickets), risk factors for MBDI and appropriate laboratory testing will improve diagnostic accuracy in these cases.
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Affiliation(s)
- Marvin Miller
- Dayton Children's Hospital, Department of Medical Genetics, 1 Children's Plaza, Dayton, OH 45404, USA.,Department of Pediatrics, Ob/Gyn and Biomedical Engineering, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - Adrienne Stolfi
- Department of Pediatrics, Wright State University Boonshoft School of Medicine, Dayton, OH, USA
| | - David Ayoub
- Clinical Radiologists, SC, Springfield, IL, USA
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Abstract
Claims that new science is changing accepted medical opinion about abusive head injury have been made frequently in the media, legal publications and in legal cases involving abusive head trauma (AHT). This review analyzes recently published scientific articles about AHT to determine whether this new information has led to significant changes in the understanding, evaluation and management of children with suspected AHT. Several specific topics are examined: serious or fatal injuries from short falls; specificity of subdural hematoma for severe trauma; biomechanical explanations for findings; the specificity of retinal hemorrhages; the possibility of cerebral sinus thrombosis presenting with signs similar to AHT; and whether vaccines can produce such findings. We conclude: a) that the overwhelming weight of recent data does not change the fundamental consensus b) that abusive head trauma is a significant source of morbidity and mortality in children c) that subdural hematomas and severe retinal hemorrhages are commonly the result of severe trauma d) that these injuries should prompt an evaluation for abuse when identified in young children without a history of such severe trauma and e) that short falls, cerebral sinus thrombosis and vaccinations are not plausible explanations for findings that raise concern for abusive head trauma.
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Rolfes MC, Deyle DR, King KS, Hand JL, Graff AH, Derauf C. Fracture incidence in Ehlers-Danlos syndrome - A population-based case-control study. CHILD ABUSE & NEGLECT 2019; 91:95-101. [PMID: 30856599 PMCID: PMC7064152 DOI: 10.1016/j.chiabu.2019.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 12/31/2018] [Accepted: 03/04/2019] [Indexed: 06/01/2023]
Abstract
BACKGROUND The differential diagnosis of non-accidental injury during childhood includes medical conditions that predispose to skeletal fragility. Ehlers-Danlos syndrome (EDS) has been proposed as one such condition despite little objective evidence in the medical literature. OBJECTIVE To investigate if EDS causes increased bone fragility during infancy and childhood. PARTICIPANTS AND SETTING Residents of an 8-county region in southern Minnesota using the Rochester Epidemiology Project (REP) medical records-linkage system. METHODS This retrospective, population-based, case-control study identified subjects with EDS from 1976 to 2015 who had complete records for at least their first year of life. Validity of diagnosis was ascertained using the 2017 International Classification of the Ehlers-Danlos Syndromes. Records were reviewed for fracture diagnoses that were characterized by age, location, type and mechanism. RESULTS Of 219 potential cases, 21 had complete records for the first year of life and sufficient evidence in the medical record to support an EDS diagnosis. Of these 21, there were 14 hypermobile, 2 classical, 4 vascular, and 1 arthrochalasia EDS subtypes. 11 of 21 EDS cases (52.4%) and 15 of 63 controls (23.8%) had one or more fractures during childhood. No fractures were identified in the first year of life. Comparing cases to controls, EDS was associated with having any fractures during childhood with an odds ratio of 3.4 (95% CI: 1.20-9.66). CONCLUSIONS We found no evidence that infants with common forms of EDS are predisposed to more frequent fractures. Ambulatory subjects with these EDS subtypes may have a higher incidence of fractures during childhood.
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Affiliation(s)
- Mary C Rolfes
- Mayo Clinic School of Medicine - Minnesota Campus, 200 First Street SW, Rochester, MN 55905, USA.
| | - David R Deyle
- Departments of Clinical Genomics and Pediatric and Adolescent Medicine, 200 First Street SW, Rochester, MN 55905, USA.
| | - Katherine S King
- Department of Health Sciences Research, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Jennifer L Hand
- Departments of Dermatology, Clinical Genomics, and Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.
| | - Arne H Graff
- Departments of Pediatric and Adolescent Medicine and Family Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Chris Derauf
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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15
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Culotta P, Greeley C, Mehollin-Ray A, Donaruma-Kwoh M. Letter to the Editor regarding "Multiple unexplained fractures in infants and child physical abuse". J Steroid Biochem Mol Biol 2019; 186:226-227. [PMID: 30665620 DOI: 10.1016/j.jsbmb.2018.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 07/30/2018] [Accepted: 08/08/2018] [Indexed: 11/19/2022]
Affiliation(s)
- Paige Culotta
- Sections of Public Health Pediatrics, Baylor College of Medicine, Houston, TX, USA.
| | - Christopher Greeley
- Sections of Public Health Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Amy Mehollin-Ray
- Edward B. Singleton, MD Department of Pediatric Radiology, Baylor College of Medicine, Houston, TX, USA
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16
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Cannell J, Holick MF. Response to Culotta et al. regarding Letter to the Editor about "Multiple unexplained fractures in infants and child physical abuse" by Paige Culotta MD, Amy Mehollin-Ray MD, and Marcella Donaruma-Kwoh MD. J Steroid Biochem Mol Biol 2019; 186:228-231. [PMID: 30665621 DOI: 10.1016/j.jsbmb.2018.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Mankad K, Chhabda S, Lim W, Oztekin O, Reddy N, Chong WK, Shroff M. The neuroimaging mimics of abusive head trauma. Eur J Paediatr Neurol 2019; 23:19-30. [PMID: 30527893 DOI: 10.1016/j.ejpn.2018.11.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 11/07/2018] [Accepted: 11/13/2018] [Indexed: 10/27/2022]
Abstract
Abusive head trauma (AHT) is a significant cause of morbidity and mortality in the paediatric population, typically in children under the age of two years. Neuroimaging plays a key role in the diagnostic work up of these patients as information regarding the mechanism of injury is often lacking and the findings on examination can be nonspecific. A number of conditions, both traumatic and atraumatic can mimic AHT based on neuroimaging features alone. The repercussions associated with a diagnosis or misdiagnosis of AHT can be severe and radiologists therefore need to be aware of and familiar with the imaging differentials of AHT. In this paper we review the imaging findings of the radiological mimics of AHT and focus on features that can help differentiate these entities from AHT.
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Affiliation(s)
- Kshitij Mankad
- Department of Neuroradiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, United Kingdom.
| | - Sahil Chhabda
- Department of Radiology, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
| | - Wanyin Lim
- Department of Radiology, Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London, SW10 9NH, United Kingdom
| | - Ozgur Oztekin
- Department of Neuroradiology, Tepecik Education and Research Hospital, Izmir, 35180, Turkey
| | - Nihaal Reddy
- Department of Radiology, The Royal Children's Hospital, Melbourne, Australia
| | - Wui Kean Chong
- Department of Neuroradiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, United Kingdom
| | - Manohar Shroff
- Department of Neuroradiology, SickKids, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada
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18
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Jennings E, Buckberry J, Brickley MB. Radiographically recognizable? An investigation into the appearance of osteomalacic pseudofractures. INTERNATIONAL JOURNAL OF PALEOPATHOLOGY 2018; 23:26-31. [PMID: 30527918 DOI: 10.1016/j.ijpp.2017.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 06/09/2023]
Abstract
Pseudofractures, lucent bands that occur due to a build-up of osteoid, are a key feature of osteomalacia. In paleopathology, pseudofractures are often marked by small, linear cracks in the cortex of the bone surrounded by irregular, bony spicule formation. Radiography can be used to help diagnose pseudofractures, both clinically and in paleopathology. A detailed understanding of the radiographic appearance of pseudofractures and their development is, therefore, necessary to aid a diagnosis of vitamin D deficiency. The present study examined the clinical literature to determine current ideas on the appearance of pseudofractures with the aim of applying this knowledge to paleopathology. A radiographic study of the characteristics of pseudofractures was performed on five individuals with clear skeletal features of osteomalacia from archaeological sites in Canada and the United Kingdom dating to the medieval period (5th to 15th centuries) and the 18th to 19th century. Results show that the radiographic appearance of pseudofractures could potentially reveal information about the cause of the deficiency and the chronicity of pseudofractures. This type of information has the potential to further our understanding of the lived experiences of archaeological individuals with osteomalacia.
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Affiliation(s)
- Emma Jennings
- Department of Anthropology, McMaster University, Hamilton, Ontario, L8S 4L8, Canada.
| | - Jo Buckberry
- Department of Archaeological and Forensic Sciences, University of Bradford, Bradford BD7 1DP, UK
| | - Megan B Brickley
- Department of Anthropology, McMaster University, Hamilton, Ontario, L8S 4L8, Canada
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19
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Affiliation(s)
- Peter J Strouse
- Section of Pediatric Radiology, C. S. Mott Children's Hospital, Room 3-231,Department of Radiology, University of Michigan Health System, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4252, USA.
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20
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Cannell JJ, Holick MF. Multiple unexplained fractures in infants and child physical abuse. J Steroid Biochem Mol Biol 2018; 175:18-22. [PMID: 27641737 DOI: 10.1016/j.jsbmb.2016.09.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 09/09/2016] [Accepted: 09/13/2016] [Indexed: 11/29/2022]
Abstract
When an infant presents with X-rays showing multiple unexplained fractures in various stages of healing (MUFVSH), the child is usually diagnosed with child abuse based on criteria of the Academy of Pediatrics' Committee on Child Abuse and Neglect (AAPCCAAN). Almost always, the infant is subsequently removed from the home and civil or criminal proceeding commence. It may be that healing infantile rickets or other poorly understood metabolic bone disorders of infancy are responsible for these x-rays. Activated vitamin D is a seco-steroid hormone, whose mechanism of action is genetic regulation. Lack of it can result in musculoskeletal defects known as rickets. Low calcium can also cause rickets. However, it is clear that experts for the state believe that the x-rays in these cases are so definitive as to be pathognomonic for child abuse. Therefore, if the caregivers deny abusing their infants, experts following American Academy of Pediatric's Committee on Child Abuse and Neglect. guidelines are essentially claiming that x-rays showing multiple unexplained fractures in various stages of healing are lie detector tests. However, it is not widely appreciated that the gold standard for the diagnosis of rickets is a bone biopsy, not x-rays, as radiologists miss biopsy proven rickets 80% of the time; that is, 4 out of 5 infants with rickets will have normal x-rays. In this article we provide reports of two cases and their outcomes. We discuss information about healing infantile rickets and an example of common sense medical conclusions in these cases. This information could lead to a significant reduction in the number of innocent parents having their infant removed or sent to prison.
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Affiliation(s)
- John Jacob Cannell
- Vitamin D Council Inc., 1411 Marsh Street, Suite 203, San Luis Obispo, CA, USA.
| | - Michael F Holick
- Professor of Medicine, Physiology, Endocrinology and Biophysics, Boston University School of Medicine, Boston, MA, USA
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21
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Spiral Fracture in Young Infant Causing a Diagnostic Dilemma: Nutritional Rickets versus Child Abuse. Case Rep Pediatr 2017; 2017:7213629. [PMID: 29057134 PMCID: PMC5625808 DOI: 10.1155/2017/7213629] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 08/07/2017] [Indexed: 01/27/2023] Open
Abstract
Fractures are uncommon in young, nonambulatory infants. The differential diagnosis includes nonaccidental injury (NAI) and metabolic bone disease, including rickets. While rickets typically present after six months of age, multiple cases have been reported in younger infants. We report a case of an 11-week-old male infant who presented with a spiral fracture of the humerus and no radiologic evidence of rickets. A detailed psychosocial assessment failed to reveal any risk factors for NAI. The patient had elevated alkaline phosphatase and PTH with low 25 hydroxyvitamin D and 1,25 dihydroxyvitamin D levels. Additionally, the mother was noncompliant with prenatal vitamins, exclusively breastfeeding without vitamin D supplementation, and had markedly low vitamin D levels 15 weeks postpartum. The biochemical data and history were consistent with rickets. Given the diagnostic dilemma, the working diagnosis was rickets and the patient was started on ergocalciferol with subsequent normalization of his laboratory values and healing of the fracture. These findings are consistent with nutritional rickets largely due to maternal-fetal hypovitaminosis D. This case highlights that in young infants rickets should be considered even in the absence of positive radiologic findings. Additionally, it illustrates the importance of maintaining adequate vitamin D supplementation during pregnancy and early infancy.
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22
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Abulebda K, Abu-Sultaneh S, Lutfi R. It is not always child abuse: multiple fractures due to hypophosphatemic rickets associated with elemental formula use. Clin Case Rep 2017; 5:1348-1351. [PMID: 28781857 PMCID: PMC5538045 DOI: 10.1002/ccr3.1052] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2017] [Revised: 05/18/2017] [Accepted: 05/24/2017] [Indexed: 11/05/2022] Open
Abstract
Rickets is not a disease of the past. We described a toddler who developed hypophosphatemic rickets associated with the use of elemental formula. This case highlights the importance of frequent monitoring of mineral metabolism in children receiving elemental formula and considering rickets in the workup of child abuse.
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Affiliation(s)
- Kamal Abulebda
- Department of Pediatrics Section of Pediatric Critical Care Medicine at Indiana University School of Medicine Riley Hospital for Children at Indiana University Health Indianapolis Indiana
| | - Samer Abu-Sultaneh
- Department of Pediatrics Section of Pediatric Critical Care Medicine at Indiana University School of Medicine Riley Hospital for Children at Indiana University Health Indianapolis Indiana
| | - Riad Lutfi
- Department of Pediatrics Section of Pediatric Critical Care Medicine at Indiana University School of Medicine Riley Hospital for Children at Indiana University Health Indianapolis Indiana
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23
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Walker A, el Demellawy D, Davila J. Rickets: Historical, Epidemiological, Pathophysiological, and Pathological Perspectives. Acad Forensic Pathol 2017; 7:240-262. [PMID: 31239976 PMCID: PMC6474539 DOI: 10.23907/2017.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/09/2017] [Accepted: 05/03/2017] [Indexed: 12/12/2022]
Abstract
Rickets was a common metabolic disease of bone a century ago in Europe, North America, and East Asia (mainly due to vitamin D deficiency) but was largely eradicated in growing children by use of cod liver oil and the introduction of vitamin D fortification of milk in the 1930s in the United States. Vitamin D deficiency (VDD) remains the most common form of metabolic bone disease that is entirely preventable and treatable. Historically, rickets has appeared in sporadic epidemics and, despite the introduction of numerous preventive strategies, VDD has remained a global health problem amongst children. Moreover, developed countries such as Canada, Australia, the United Kingdom, and the United States have not been exempt from this. The radiological and histological features of rickets are both distinctive and characteristic and they reflect the underlying pathophysiological issue of decreased mineralization of bone as a result of VDD. The radiological features include 1) metaphyseal cupping and fraying, 2) poor mineralization of epiphyseal centers, 3) irregular and widened epiphyseal plates, 4) increased distance between the end of shaft and epiphyseal center, 5) cortical spurs at right angles to the metaphysis, 6) coarse trabeculation, and 7) periosteal reactions. Fractures may also be evident. The histological features of rickets reflect the failure of cartilage to mineralize and undergo resorption. This results in 1) disordered proliferation of chondrocytes in the hypertrophic zone secondary to a lack of apoptosis, 2) loss of the columnar arrangement of chondrocytes that results in thickening and disorganization of the hypertrophic zone, 3) tongue-like projections of cartilage that extend into the spongiosa, 4) irregularity of the limit between the proliferative and hypertrophic zones, and 5) penetration of blood vessels into the hypertrophic zone. The case of a premature 3-month-old female infant, born in the winter months in the arctic region of Canada who died from a lobar pneumonia with an incidental finding of radiological and pathological evidence of rickets, is presented. The case is used to review the entity of rickets from historical, pathophysiological, radiological, and histological perspectives.
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Affiliation(s)
- Alfredo Walker
- Eastern Ontario Regional Forensic Pathology Unit - Department of
Pathology and Laboratory Medicine - University of Ottawa
| | - Dina el Demellawy
- Children's Hospital of Eastern Ontario - Pediatric Pathology and
University of Ottawa - Department of Pathology and Laboratory Medicine
| | - Jorge Davila
- Children's Hospital of Eastern Ontario - Diagnostic Imaging and
University of Ottawa - Division of Pediatric Radiology
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24
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Holick MF, Hossein-Nezhad A, Tabatabaei F. Multiple fractures in infants who have Ehlers-Danlos/hypermobility syndrome and or vitamin D deficiency: A case series of 72 infants whose parents were accused of child abuse and neglect. DERMATO-ENDOCRINOLOGY 2017; 9:e1279768. [PMID: 29511428 PMCID: PMC5832156 DOI: 10.1080/19381980.2017.1279768] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 12/16/2016] [Accepted: 01/01/2017] [Indexed: 11/25/2022]
Abstract
Objective: To increase the level of awareness that Ehlers-Danlos/hypermobility syndrome (EDS) and vitamin D deficiency are associated with infantile fragility fractures and radiologic features that may be mistakenly reported to be caused by non-accidental trauma due to Child Abuse and Neglect (CAN). Patients and Methods: We constructed a case series, the largest to date, of infants with EDS who were vitamin D sufficient, insufficient and deficient and infants without EDS but with documented vitamin D deficiency and radiologic evidence of rickets who presented with multiple fractures originally diagnosed as being non-accidental and caused by child abuse. These infants were referred to the outpatient Bone Health Care Clinic at Boston University Medical Campus over a 6-year (2010–2015) period. We also present 6 index cases in which the court concluded that there was no convincing evidence of child abuse and the infants were returned to their parents. Institutional Review Board (IRB) approval was obtained. Results: We present 72 cases of infants with multiple fractures diagnosed to be caused by non-accidental trauma. All infants were younger than one year of age. Among them, 93%(67) had clinical evidence of EDS and/or a family history with a confirmed clinical diagnosis of at least one parent having EDS and the other 7%(5) without evidence of EDS had vitamin D deficiency/infantile rickets. Three of the EDS infants were diagnosed as osteogenesis imperfecta (OI)/EDS overlap syndrome. The most common fractures noted at diagnosis were ribs and extremity fractures (including classic metaphyseal lesions). Serum levels of 25-hydroxyvitamin D [25(OH)D] were reported in 48 infants (18.0 ± 8.5 ng/ml) and in 30 mothers (21.3 ± 11.7 ng/ml). Sixty-three percent (27) of the EDS infants who had their serum 25(OH)D measured were vitamin D deficient 25(OH)D<20 ng/ml and 5 were vitamin D sufficient 25(OH)D>30 ng/ml. The mean serum level for infants with vitamin D deficiency/rickets was (10.2 ± 3.0 ng/ml) Conclusion: EDS, OI/EDS and vitamin D deficiency/infantile rickets are associated with fragility fractures in infants that can be misinterpreted as caused by non-accidental trauma due to child abuse.
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Affiliation(s)
- M F Holick
- Department of Medicine, Section of Endocrinology, Nutrition, and Diabetes, Vitamin D, Skin, and Bone Research Laboratory, Boston University Medical Campus, Boston, MA, USA
| | - A Hossein-Nezhad
- Department of Medicine, Section of Endocrinology, Nutrition, and Diabetes, Vitamin D, Skin, and Bone Research Laboratory, Boston University Medical Campus, Boston, MA, USA.,Osteoporosis Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - F Tabatabaei
- Department of Medicine, Section of Endocrinology, Nutrition, and Diabetes, Vitamin D, Skin, and Bone Research Laboratory, Boston University Medical Campus, Boston, MA, USA
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25
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Walker A, Kepron C, Milroy CM. Are There Hallmarks of Child Abuse? I. Osseous Injuries. Acad Forensic Pathol 2016; 6:568-590. [PMID: 31239932 PMCID: PMC6474500 DOI: 10.23907/2016.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 10/10/2016] [Accepted: 11/09/2016] [Indexed: 11/12/2022]
Abstract
Fractures are commonly found in cases regarded as child abuse. The most commonly encountered fractures are to the ribs and the metaphyses. This paper examines the specificity of the classical metaphyseal lesion (CML) and rib fractures as hallmarks of child abuse. Recently, vitamin D deficiency (rickets) has been proposed as an alternative cause for the appearances typically described in CML. The literature in this area is examined. Rib fractures have also been highly associated with child abuse, particularly posterior rib fractures. As well as metabolic bone disease, resuscitation has been examined as a cause of rib fractures in young children. The current literature remains strongly supportive of rib fractures and metaphyseal fractures being indicators of child abuse.
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Affiliation(s)
| | - Charis Kepron
- Ontario Forensic Pathology Service - Eastern Ontario Regional
Forensic Pathology Unit and University of Ottawa - Pathology and Laboratory
Medicine
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26
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Affiliation(s)
- Peter J Strouse
- Section of Pediatric Radiology, C. S. Mott Children's Hospital, Room 3-231, Department of Radiology, University of Michigan Health System, 1540 E. Hospital Drive, Ann Arbor, MI, 48109-4252, USA.
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27
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Edwards GA. Mimics of child abuse: Can choking explain abusive head trauma? J Forensic Leg Med 2015; 35:33-7. [PMID: 26344456 DOI: 10.1016/j.jflm.2015.06.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 04/29/2015] [Accepted: 06/13/2015] [Indexed: 11/17/2022]
Abstract
Choking is one of the alternative explanations of abusive head trauma in children that have been offered in courtroom testimony and in the media. Most of these explanations - including choking - are not scientifically supported. This article highlights four points. (1) The origins of choking as an explanation for intracranial and retinal hemorrhages are speculative. (2) Choking has been used in high profile court testimony as an explanation for the death of a child thought to have been abused. (3) A case report that proposes choking as an alternative explanation for the death of a child diagnosed with abusive head trauma includes omissions and misrepresentations of facts. (4) There was a decision by the editor of the journal that published the case report that it was not necessary to include all the facts of the case; moreover, the editor indicated that facts are not required when presenting an alternative explanation. The use of scientifically unsupported alternative explanations for abusive head trauma based on inaccurate and biased information constitutes further victimization of the abused child and represents a travesty of justice.
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Affiliation(s)
- George A Edwards
- Dell Children's Medical Center, Department of Pediatrics, UT, Austin, Dell Medical School, 4900 Mueller Blvd, Austin, TX 78723, USA.
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28
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Oestreich AE. Concave distal end of ulna metaphysis alone is not a sign of rickets. Pediatr Radiol 2015; 45:998-1000. [PMID: 25638244 DOI: 10.1007/s00247-014-3268-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/12/2014] [Accepted: 12/19/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Statements have been made in the literature and in legal testimony that misrepresent the radiographic finding of concave distal end of the ulnar metaphysis. OBJECTIVE To demonstrate that a concave distal end of the ossified ulna in infancy can be normal. MATERIALS AND METHODS Eighty distal wrists of randomly selected infants in the first year of life with radiographic evidence that ruled out rickets were reviewed. RESULTS In 16 of the cases (20%), mild or moderate concavity of the distal end of the ulna was seen. An intact metaphyseal collar of distal radius or ulna confirmed the absence of radiographic rickets. CONCLUSION The finding of 20% of concave distal ulnas in the first year of life confirms the widely acknowledged statements that concave distal end of the ulna alone is not indicative of rickets. Statements to the contrary are not justified.
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Affiliation(s)
- Alan E Oestreich
- Department of Radiology, 5031, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229-3039, USA,
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Abstract
Medics may consider worrying about their metaphysics and ontology to be a waste of time. I will argue here that this is not the case. Promiscuous realism is a metaphysical position which holds that multiple, equally valid, classification schemes should be applied to objects (such as patients) to capture different aspects of their complex and heterogeneous nature. As medics at the bedside may need to capture different aspects of their patients' problems, they may need to use multiple classification schemes (multiple nosologies), and thus consider adopting a different metaphysics to the one commonly in use.
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Affiliation(s)
- Nicholas Binney
- EGENIS: Centre for the Life Sciences, University of Exeter, Exeter, UK
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31
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Samsel A, Seneff S. Glyphosate, pathways to modern diseases III: Manganese, neurological diseases, and associated pathologies. Surg Neurol Int 2015; 6:45. [PMID: 25883837 PMCID: PMC4392553 DOI: 10.4103/2152-7806.153876] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 01/21/2015] [Indexed: 12/20/2022] Open
Abstract
Manganese (Mn) is an often overlooked but important nutrient, required in small amounts for multiple essential functions in the body. A recent study on cows fed genetically modified Roundup(®)-Ready feed revealed a severe depletion of serum Mn. Glyphosate, the active ingredient in Roundup(®), has also been shown to severely deplete Mn levels in plants. Here, we investigate the impact of Mn on physiology, and its association with gut dysbiosis as well as neuropathologies such as autism, Alzheimer's disease (AD), depression, anxiety syndrome, Parkinson's disease (PD), and prion diseases. Glutamate overexpression in the brain in association with autism, AD, and other neurological diseases can be explained by Mn deficiency. Mn superoxide dismutase protects mitochondria from oxidative damage, and mitochondrial dysfunction is a key feature of autism and Alzheimer's. Chondroitin sulfate synthesis depends on Mn, and its deficiency leads to osteoporosis and osteomalacia. Lactobacillus, depleted in autism, depend critically on Mn for antioxidant protection. Lactobacillus probiotics can treat anxiety, which is a comorbidity of autism and chronic fatigue syndrome. Reduced gut Lactobacillus leads to overgrowth of the pathogen, Salmonella, which is resistant to glyphosate toxicity, and Mn plays a role here as well. Sperm motility depends on Mn, and this may partially explain increased rates of infertility and birth defects. We further reason that, under conditions of adequate Mn in the diet, glyphosate, through its disruption of bile acid homeostasis, ironically promotes toxic accumulation of Mn in the brainstem, leading to conditions such as PD and prion diseases.
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Affiliation(s)
- Anthony Samsel
- Research Scientist and Consultant, Deerfield, NH 03037, USA
| | - Stephanie Seneff
- Spoken Language Systems Group, Computer Science and Artificial Intelligence Laboratory, MIT, Cambridge MA 02139, USA
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32
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Perez-Rossello JM, McDonald AG, Rosenberg AE, Tsai A, Kleinman PK. Absence of rickets in infants with fatal abusive head trauma and classic metaphyseal lesions. Radiology 2015; 275:810-21. [PMID: 25688889 DOI: 10.1148/radiol.15141784] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine if rickets is present in cases of infant homicide with classic metaphyseal lesions (CMLs) and other skeletal injuries. MATERIALS AND METHODS This study was exempt from the institutional human subjects board review because all infants were deceased. An archival review (1984-2012) was performed of the radiologic and histopathologic findings of 46 consecutive infant fatalities referred from the state medical examiner's office for the evaluation of possible child abuse. Thirty infants with distal femoral histologic material were identified. Additional inclusion criteria were as follows: (a) The medical examiner determined that the infant had sustained a head injury and that the manner of death was a homicide, (b) at least one CML was evident at skeletal survey, (c) CMLs were confirmed at autopsy, and (d) non-CML fractures were also present. Nine infants (mean age, 3.9 months; age range, 1-9 months) were identified. Two pediatric radiologists independently reviewed the skeletal surveys for rachitic changes at the wrists and knees. A bone and soft tissue pathologist reviewed the distal femoral histologic slices for rickets. RESULTS There were no radiographic or pathologic features of rickets in the cohort. CONCLUSION The findings provide no support for the view that the CML is due to rickets. Rather, they strengthen a robust literature that states that the CML is a traumatic injury commonly encountered in physically abused infants.
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Affiliation(s)
- Jeannette M Perez-Rossello
- From the Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115 (J.M.P., A.T., P.K.K.); Department of Pathology, Wake Forest Baptist Medical Center, Winston-Salem, NC (A.G.M.); and Department of Pathology, University of Miami Hospital, Miami, Fla (A.E.R.)
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Unusual diastatic separation of the sagittal suture: Avoiding confusion with inflicted head trauma. J Forensic Leg Med 2015; 30:14-5. [PMID: 25623188 DOI: 10.1016/j.jflm.2014.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 11/25/2014] [Accepted: 12/07/2014] [Indexed: 11/21/2022]
Abstract
Certain artifacts presenting on a fetus due to maceration or birth trauma, mimic inflicted head trauma (IHT) occurring post partum. In such cases, absent a thorough history and examination of the circumstances, the distinction may be impossible. This case report presents an unusual artifact occurring in a stillbirth delivered after the mother had complained of not feeling fetal movements for at least 24 hours. At autopsy, the macerated fetus presented with unusual widening of the sagittal suture and galeal/subgaleal hematomas. There were no other injuries. Review of the mothers antenatal, personal and social history combined with the absence of other injuries to the mother and fetus, helped distinguish the unusual birth-related diastatic separation from IHT. Consequently, in a case where the pathologist is presented with limited information for instance an abandoned fetus, a cautious approach to the determination of the cause and manner of death is strongly recommended.
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Kepron C, Pollanen MS. Rickets or abuse? A histologic comparison of rickets and child abuse-related fractures. Forensic Sci Med Pathol 2015; 11:78-87. [PMID: 25557084 DOI: 10.1007/s12024-014-9639-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2014] [Indexed: 11/28/2022]
Abstract
PURPOSE The bone changes of vitamin D deficiency rickets have been invoked as an alternate explanation for child-abuse related fractures identified through medical imaging. The lack of modern histopathologic comparisons between these two entities limits the abilities of the forensic pathologist to address this differential diagnosis, both in their autopsy reports and on the witness stand. METHODS We report a comparison of the histologic appearance of the bones in a two year old child with vitamin D deficiency rickets with fractures occurring in three young children with child abuse. RESULTS In the case of rickets, there was marked architectural disorganization of endochondral ossification at the costochondral junctions and growth plates of long bones. The child abuse-related fractures showed osteochondral callus at different stages of healing, either centered on a discrete fracture line or at metaphyses (e.g. classical metaphyseal lesions). In many instances, the healing fractures disrupted the line of endochondral ossification. In none of the child abuse-related fractures was there any similarity to the histologic appearance of rickets. CONCLUSION The maturation disturbance in the growth plate that occurs in rickets is a distinctive entity that cannot be confused histologically with healing fractures, including the classical metaphyseal lesion.
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Affiliation(s)
- Charis Kepron
- Ontario Forensic Pathology Service, Department of Pathology and Laboratory Medicine, University of Ottawa, Ottawa, Canada,
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Paterson CR, Ayoub D. Congenital rickets due to vitamin D deficiency in the mothers. Clin Nutr 2014; 34:793-8. [PMID: 25552383 DOI: 10.1016/j.clnu.2014.12.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/25/2014] [Accepted: 12/12/2014] [Indexed: 12/27/2022]
Abstract
BACKGROUND & AIMS We wished to review all published reports of congenital rickets to identify the causes and characteristics. METHODS 25 cases were identified in 19 published reports in which there was radiological and/or histological evidence of rickets in the first two weeks after birth. Cases of rickets associated with maternal renal failure were excluded as were infants born at less than 32 weeks gestation. RESULTS There was evidence of maternal deficiency in 24 of these cases. In 16 cases the diagnosis of the rickets led to the identification of symptomatic osteomalacia in the mothers. Of the 12 mothers who had assays for serum 25-hydroxyvitamin D (25OHD) 11 had values less than 10 ng/mL. Presentations in the infants included craniotabes, wide skull sutures, rachitic rosaries, enlargement of the wrists, tetany and convulsions. In two cases rickets had been suspected from antenatal X-rays. In five cases fractures were found at the time of initial presentation. Of the 16 infants with serum calcium assays 15 had values lower than 8.8 mg/dL. Of 13 infants who had serum alkaline phosphatase assays 12 had abnormally high levels. Of the seven infants in whom serum 25OHD was measured before treatment, all had values less than 10 ng/mL. CONCLUSIONS These reports provide strong support for the view that maternal deficiency leads to overt bone disease from before birth. Maternal deficiency probably also leads to impairment of bone quality in postnatal life. The importance of ensuring adequate vitamin D nutrition in pregnancy is emphasised.
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Affiliation(s)
- Colin R Paterson
- Formerly Department of Medicine, University of Dundee, Dundee, Scotland, UK.
| | - David Ayoub
- Clinical Radiologists SC, Springfield, IL, USA
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Kovacs CS. Bone development and mineral homeostasis in the fetus and neonate: roles of the calciotropic and phosphotropic hormones. Physiol Rev 2014; 94:1143-218. [PMID: 25287862 DOI: 10.1152/physrev.00014.2014] [Citation(s) in RCA: 129] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Mineral and bone metabolism are regulated differently in utero compared with the adult. The fetal kidneys, intestines, and skeleton are not dominant sources of mineral supply for the fetus. Instead, the placenta meets the fetal need for mineral by actively transporting calcium, phosphorus, and magnesium from the maternal circulation. These minerals are maintained in the fetal circulation at higher concentrations than in the mother and normal adult, and such high levels appear necessary for the developing skeleton to accrete a normal amount of mineral by term. Parathyroid hormone (PTH) and calcitriol circulate at low concentrations in the fetal circulation. Fetal bone development and the regulation of serum minerals are critically dependent on PTH and PTH-related protein, but not vitamin D/calcitriol, fibroblast growth factor-23, calcitonin, or the sex steroids. After birth, the serum calcium falls and phosphorus rises before gradually reaching adult values over the subsequent 24-48 h. The intestines are the main source of mineral for the neonate, while the kidneys reabsorb mineral, and bone turnover contributes mineral to the circulation. This switch in the regulation of mineral homeostasis is triggered by loss of the placenta and a postnatal fall in serum calcium, and is followed in sequence by a rise in PTH and then an increase in calcitriol. Intestinal calcium absorption is initially a passive process facilitated by lactose, but later becomes active and calcitriol-dependent. However, calcitriol's role can be bypassed by increasing the calcium content of the diet, or by parenteral administration of calcium.
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Affiliation(s)
- Christopher S Kovacs
- Faculty of Medicine-Endocrinology, Memorial University of Newfoundland, St. John's, Newfoundland, Canada
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Dubowitz H, Christian CW, Hymel K, Kellogg ND. Forensic medical evaluations of child maltreatment: a proposed research agenda. CHILD ABUSE & NEGLECT 2014; 38:1734-1746. [PMID: 25224781 DOI: 10.1016/j.chiabu.2014.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/18/2014] [Accepted: 07/22/2014] [Indexed: 06/03/2023]
Abstract
Physicians play an important role in the forensic evaluation of suspected child abuse and neglect. There has been considerable progress in the medical field, helping distinguish findings related to maltreatment from other conditions or circumstances. Nevertheless, important questions remain. This article covers several of these questions and proposes a research agenda concerning five main topics: sexual abuse, neglect, fractures, abusive head trauma, and physicians work in interdisciplinary settings. The suggestions are hardly inclusive, but offer suggestions the authors think are priorities, and ones that research could reasonably address. By providing some background to gaps in our knowledge, this paper should be of interest to a broader audience than just medical professionals.
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Affiliation(s)
| | - Cindy W Christian
- The Perelman School of Medicine at the University of Pennsylvania, USA
| | | | - Nancy D Kellogg
- University of Texas Health Science Center at San Antonio, USA
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Abstract
OBJECTIVE To determine the frequency of non-cutaneous mimics identified in a large, multicentre cohort of children evaluated for physical abuse. METHODS Prospectively planned, secondary analysis of 2890 physical abuse consultations from the Examining Siblings To Recognize Abuse (ExSTRA) research network. Data for each enrolled subject were entered at the child abuse physician's diagnostic disposition. Physicians prospectively documented whether or not a 'mimic' was identified and the perceived likelihood of abuse. Mimics were divided into 3 categories: (1) strictly cutaneous mimics, (2) strictly non-cutaneous mimics and (3) cutaneous and non-cutaneous mimics. Perceived likelihood of abuse was described for each child on a 7-point scale (7=definite abuse). RESULTS Among 2890 children who were evaluated for physical abuse, 137 (4.7%) had mimics identified; 81 mimics (59.1% of mimics and 2.8% of the whole cohort) included non-cutaneous components. Six subjects (7.4%) were assigned a high level of abuse concern and 17 (20.1%) an intermediate level despite the identification of a mimic. Among the identified mimics, 28% were classified as metabolic bone disease, 20% haematologic/vascular, 16% infectious, 10% skeletal dysplasia, 9% neurologic, 5% oncologic, 2% gastrointestinal and 10% other. Osteomalacia/osteoporosis was the most common non-cutaneous mimic followed by vitamin D deficiency. CONCLUSIONS A wide variety of mimics exist affecting most disease categories. Paediatric care providers need to be familiar with these conditions to avoid pitfalls in the diagnosis of physical abuse. Identification of a mimic does not exclude concurrent abuse.
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Affiliation(s)
- James B Metz
- General Pediatric Division, Seattle Children's Hospital & the University of Washington School of Medicine, Seattle, Washington, USA
| | - Kimberly A Schwartz
- Child Protection Team, Boston Medical Center, Boston Medical Center, Pediatrics, Shrewsbury, Massachusetts, USA
| | - Kenneth W Feldman
- General Pediatric Division and Children's Protection Program, Seattle Children's Hospital & the University of Washington School of Medicine, Seattle, Washington, USA
| | - Daniel M Lindberg
- Department of Emergency Medicine, Kempe Center for the Prevention and Treatment of Child Abuse, University of Colorado Medical School, Denver, Colorado, USA
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Miller M, Ward T, Stolfi A, Ayoub D. Overrepresentation of multiple birth pregnancies in young infants with four metabolic bone disorders: further evidence that fetal bone loading is a critical determinant of fetal and young infant bone strength. Osteoporos Int 2014; 25:1861-73. [PMID: 24696017 DOI: 10.1007/s00198-014-2690-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 03/12/2014] [Indexed: 11/29/2022]
Abstract
UNLABELLED The frequency of multiple birth pregnancies, mostly twin pregnancies, was overrepresented in four different groups of young infants with fractures and bone abnormalities. This finding suggests that fetal bone loading through fetal movement is an important determinant of fetal bone formation and its resultant bone strength. INTRODUCTION It has been suggested that intrauterine confinement related to the multiple birth pregnancy (MBP) may lead to an increased risk for fragility fractures in young infants as a result of decreased fetal bone loading. METHODS To objectively test this idea, the frequency of MBPs was evaluated in five groups of young infants with bone disorders: (1) infants exposed to prolonged in utero exposure to magnesium, (2) infants with dietary copper deficiency, (3) infants with rickets from vitamin D deficiency, (4) infants with temporary brittle bone disease, and (5) infants with multiple unexplained fractures in which child abuse was the most likely diagnosis. RESULTS Compared to a control group and controlled for preterm birth, there was a statistically greater frequency of MBPs in each group. CONCLUSIONS The results of this study suggest the following: (a) The overrepresentation of MBPs (95 % twins) in these five groups indicates that fetal bone loading is a critical determinant of fetal bone strength; (b) fetal and young infant bone strength is a multifactorial characteristic; and (c) infants from MBPs are at increased risk for fragility fractures during the first 12 months of life, and thus may be mistakenly diagnosed as victims of child abuse.
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Affiliation(s)
- M Miller
- Departments of Pediatrics, Ob/Gyn, and Biomedical Engineering, Wright State University Boonshoft School of Medicine, Dayton, OH, USA,
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A critical review of the classic metaphyseal lesion: traumatic or metabolic? AJR Am J Roentgenol 2014; 202:185-96. [PMID: 24370143 DOI: 10.2214/ajr.13.10540] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to review the hypothesis that classic metaphyseal lesions represent traumatic changes in abused infants and compare these lesions with healing rickets. MATERIALS AND METHODS Using a PubMed search, a multidisciplinary team reviewed studies that reported the histopathologic correlation of classic metaphyseal lesions. Selective studies of growth plate injury and rickets were cross-referenced. RESULTS Nine identified classic metaphyseal lesion studies were performed by the same principal investigator. Control subjects were inadequate. Details of abuse determination and metabolic bone disease exclusion were lacking. The presence of only a single radiology reviewer prevented establishment of interobserver variability. Microscopy was performed by two researchers who were not pathologists. Classic metaphyseal lesions have not been experimentally reproduced and are unrecognized in the accidental trauma literature. The proposed primary spongiosa location is inconsistent with the variable radiographic appearances. Classic metaphyseal lesions were not differentiated from tissue processing artifacts. Bleeding and callus were uncommon in spite of the vascular nature of the metaphysis. The conclusion that excessive hypertrophic chondrocytes secondary to vascular disruption were indicative of fracture healing contradicts the paucity of bleeding, callus, and periosteal reaction. Several similarities exist between classic metaphyseal lesions and healing rickets, including excessive hypertrophic chondrocytes. "Bucket-handle" and "corner fracture" classic metaphyseal lesions resemble healing rickets within the growth plate and the perichondrial ring, respectively. The age of presentation was more typical of bone fragility disorders, including rickets, than reported in prior child abuse series. CONCLUSION The hypothesis that classic metaphyseal lesions are secondary to child abuse is poorly supported. Their histologic and radiographic features are similar to healing infantile rickets. Until classic metaphyseal lesions are experimentally replicated and independently validated, their traumatic origin remains unsubstantiated.
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Flaherty EG, Perez-Rossello JM, Levine MA, Hennrikus WL. Evaluating children with fractures for child physical abuse. Pediatrics 2014; 133:e477-89. [PMID: 24470642 DOI: 10.1542/peds.2013-3793] [Citation(s) in RCA: 202] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Fractures are common injuries caused by child abuse. Although the consequences of failing to diagnose an abusive injury in a child can be grave, incorrectly diagnosing child abuse in a child whose fractures have another etiology can be distressing for a family. The aim of this report is to review recent advances in the understanding of fracture specificity, the mechanism of fractures, and other medical diseases that predispose to fractures in infants and children. This clinical report will aid physicians in developing an evidence-based differential diagnosis and performing the appropriate evaluation when assessing a child with fractures.
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Paterson CR, Monk EA. Clinical and laboratory features of temporary brittle bone disease. J Pediatr Endocrinol Metab 2014; 27:37-45. [PMID: 23950568 DOI: 10.1515/jpem-2013-0120] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Accepted: 07/15/2013] [Indexed: 11/15/2022]
Abstract
Temporary brittle bone disease has been described since 1990. It is a syndrome characterised by multiple unexplained fractures in early childhood. There is growing evidence that it has natural causes and does not represent inflicted trauma. We report the clinical and laboratory features of 104 patients investigated personally between 1985 and 2000. These patients had in aggregate 976 fractures or fracture-like lesions. Our patients included disproportionate numbers of infants born preterm or as a result of multiple pregnancy. The fractures were mainly identified in the first 6 months of life and entirely within the first year of life. Most fractures were asymptomatic, particularly the many rib fractures and metaphyseal lesions. Few patients had evidence of bruising at presentation; none had clinical evidence of inflicted injury commensurate with the fractures found. In 22 patients the fractures were found in the course of investigation for unrelated symptoms. In several cases fractures took place while the children were in hospital. Unexplained bruising and sub-conjunctival haemorrhages also occurred in hospital, suggesting collagen defects. Hernias were recorded; in most these resolved spontaneously, again suggesting transient collagen defects. Among the unexplained symptoms of the patients was a history of vomiting, often projectile vomiting. Some patients had unusually blue or grey sclerae for the child's age. Many patients had abnormally large anterior fontanelles. Laboratory findings included anaemia, neutropenia and an exceptionally high serum alkaline phosphatase. Our findings reinforce the view that children with temporary brittle bone disease have a distinctive and identifiable syndrome which probably includes osteopathy of prematurity. These patients do not have osteogenesis imperfecta and are not the victims of non-accidental injury. While the causes of this syndrome remain uncertain, its distinctive features should now be more readily recognised.
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Strouse PJ. ‘Keller & Barnes’ after 5 years — still inadmissible as evidence. Pediatr Radiol 2013; 43:1424. [PMID: 24077639 DOI: 10.1007/s00247-013-2810-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Accepted: 09/17/2013] [Indexed: 11/30/2022]
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Affiliation(s)
- David Ayoub
- Clinical Radiologists, SC, Memorial Medical Center, Department of Radiology, 801 N First Street, Springfield, Illinois USA 62781, E-mail:
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Paterson CR, Monk EA. Temporary brittle bone disease: association with intracranial bleeding. J Pediatr Endocrinol Metab 2013; 26:417-26. [PMID: 23412860 DOI: 10.1515/jpem-2012-0272] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2012] [Accepted: 12/18/2012] [Indexed: 11/15/2022]
Abstract
We report 20 infants aged between 1 month and 6 months found to have subdural bleeding and also multiple unexplained fractures in a pattern similar to that described earlier as temporary brittle bone disease. Child abuse seemed unlikely as a cause of the fractures as in no case was there clinical evidence of injury commensurate with the fracturing, as some patients had fractures while in hospital and as metaphyseal lesions, when present, were often symmetrical in distribution. Abuse seemed unlikely to have been the cause of the subdural bleeding in several patients; three had clear histories of accidental injury and five had evidence that the initial bleeding was likely to have taken place at birth. Abuse also seemed unlikely as the cause of the syndrome; the nine patients who were returned to their parents had no subsequent allegations of abuse with a mean follow-up period of 15.8 years. The finding of hypermobile joints in the parents of eight of the children is an additional pointer to a natural cause for this condition. The cause of this combination of fractures and subdural bleeding is not yet clear but it is important to be aware that it can result from natural disease.
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Abstract
This is the continuation of a two-part review of rickets. This part emphasizes the specific pathophysiology, clinical features, pathoanatomy and radiographic findings of vitamin D deficiency rickets. Other forms of rickets, differential diagnostic considerations and the potential relationship between low levels of vitamin D metabolites and unexplained fractures in infants are also discussed.
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The creation of non-disease: an assault on the diagnosis of child abuse. Pediatr Radiol 2012; 42:903-5. [PMID: 22669458 DOI: 10.1007/s00247-012-2425-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Accepted: 05/15/2012] [Indexed: 10/28/2022]
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