Cutaneous mimickers of child abuse: a primer for pediatricians

"Mimics" of Injuries from Child Abuse: Case Series and Review of the Literature

The phenomenon of child abuse/maltreatment is underestimated and often represents a difficult challenge for healthcare professionals and forensic pathologists who must proceed with the differential diagnosis with accidental or self-induced events, or with lesions due to pathologies that overlap with that of mistreatment, defined as "Mimics". This study presents a case series with the aim of discussing lesions that may mimic signs of physical abuse in children but are due to a different etiology to raise awareness and train healthcare professionals and forensic pathologists on possible confounding factors in order to avoid diagnostic errors. Six cases of "Mimics" out of 418 cases of suspected mistreatment (1.43% of cases) were identified, presenting skin lesions initially classified as injuries of abuse due to their location and type and, in particular, sexual abuse for three cases. Then, the lesions and the subjects, in particular the anamnestic history, were examined by a multidisciplinary team and the diagnosis of genital lichen sclerosus et atrophicus in three cases, and the results of popular healing techniques (i.e., "cupping") in the other three cases were ascertained. These situations require specific skills and a forensic background from healthcare professionals to conduct a correct differential diagnosis and the intervention of a multidisciplinary team to investigate every possible pathology or alternative therapeutic practice that could simulate child abuse. In particular, when "mimics" are due to alternative medicine, it should not strictly be considered child abuse, but professionals must be aware of the hypothesis of mistreatment in case of non-medical indication or potential personal injuries from other crimes, such as illegal practice of the medicine. This awareness is also crucial to direct the child toward appropriate medical care, and it is essential to recognize that these conditions can coexist within the same clinical presentation.

Knowledge of Child Abuse and Neglect among General Practitioners and Pediatricians in Training: A Survey

Child abuse and neglect is a common, underreported, and worldwide problem. Health care providers play an important role in detecting and reporting this problem. This study examined the knowledge on the clinical signs and mimickers of child abuse among Belgian trainees in family medicine and pediatrics. Participants filled out an anonymous online survey of 15 fictional but realistic cases with either suspicious or non-suspicious signs of abuse or neglect in the context of primary or emergency care. The overall score on all cases, the number of correct answers per case, and the median score were calculated, and the association of the participant's demographic characteristics with their score was examined using regression analysis. A total of 70 participants completed the survey. The overall median score was 73.3% (IQR 20.0%). The suspicious cases were solved more correctly than the non-suspicious cases (median: 85.7% versus 62.5%, p < 0.001). Regression analysis could not reveal a significant association of type and level of education with the performance on the survey. Knowledge of the clinical signs of child maltreatment among pediatricians and general practitioners in training is good, but there is still room for improvement.

The study on the prevalence of Mongolian spots in the neonates

Background

Mongolian Spots (MS) generally exist at the time or under the first few weeks of the neonate life-cycle, often considered a birthmark, characterized by hyper-pigmented marks especially bluish-black hue that cannot vanish easily and are generally found on the lumbosacral region. As this MS is reminiscent of bruises and appears to be caused by abuse, this may raise questions about the possibility of abuse. Hence, it is significant to identify MS bruises. The objective of the study was to assess the prevalence of MS in neonates by using the parameters like location, method of delivery, gestational age, and, weight at birth.

Methodology

500 neonates were enrolled in the study for the evaluation of the prevalence of Mongolian spots. The study design was cross-sectional, observational, and conducted for two and a half years. The neonate's whole skin surface, including the hand palms, scalps and soles, mucous membranes, genitalia, hair, and nails, was inspected in adequate light. The changes were seen (physiological and pathological) over the skin, so the details were reviewed, analyzed, and documented. Photographic records were kept to document the study. Descriptive statistics were analyzed by t-test and Chi-square test and the inferential statistics were analyzed by proportions and Chi-square test.

Results

From the 500 neonates, 408 (81.6%) were reported to have Mongolian spots. Based on the site of locations 337 (82.60%) neonates were found with spots maximum on the sacrococcygeal area and rarely on the extremities 4 (0.98%). 221 (54.1%) were found with normal vaginal delivery, and males have more predominance 247 (60%). Based on the gestational age full term was 366 (89.71%), with the birth at a weight of more than 2.5 kg found in 349 (85.54%).

Conclusion

The study concluded that the maximum number of neonates had been found with Mongolian spots and it is very common among neonates. This study will enlighten the awareness of the physician to distinguish the other lesions from other cutaneous skin conditions. The only drawbacks of this research study are a smaller sample size and limited study duration. The study of diameter, size, and dimensions of spots are not included. More intervention studies are required to compare MS with other skin conditions and their therapies. Further research is required for the study of the dimensions of marks on the neonate's body.

Cutaneous mimickers of physical child abuse: A brief overview

Child abuse is one of the medico-legal issues a physician may face during his/her clinical practice. It has devastating effects on both the child and family, especially psychological. If falsely identified as a child abuse case, it could result in detrimental consequences. Therefore, physicians must recognise and be able to rule out child abuse mimickers, which are often conditions that are mistakenly confused with true physical child abuse. Injuries like bruises and burns are common presentations and therefore it is important to consider cutaneous abuse mimics to avoid incorrect diagnosis of child abuse. This review article sheds light on the most common cutaneous conditions that can mimic physical child abuse, where patients present with patterns of various skin lesions that raise a suspicion of child abuse.

Cutaneous Mimics of Child Abuse & Neglect: Part II

Given that some cutaneous mimics of child abuse result from rare disease, they may be more prone to misdiagnosis. For possible child abuse cases in which diagnosis remains uncertain at time of initial dermatologic evaluation, it is important that dermatologists are prepared to distinguish true dermatologic conditions in cases of ambiguous skin findings. Additionally, this review will aid clinicians in recognizing the possibility of concurrent true dermatologic disease and skin findings related to abuse with the acknowledgement that they are not mutually exclusive. Proper recognition of mimics of abuse may prevent unnecessary stress and child protective service investigation.

Mongolian Spots - A challenging clinical sign

Mongolian Spots (MS) are the most common birthmarks in newborn children. The condition presents as greenish-bluish to greyish macules, particularly in the lumbosacral area. The incidents of MS can vary in different ethnic groups and normally fade in early childhood. MS can be misinterpreted as hematomas because of the color and the predilection site. This paper discusses the case of a two-month old female admitted to hospital under suspicion of child abuse. The clinical forensic examination of the infant and her two older sisters found the children were in good health and did not show signs of abuse, despite the infant presenting with multiple and extensive greyish-blue macules. Thirteen months later, a welfare officer requested another forensic examination on the now 15-month-old child after noticing greyish-blue macules. Following a second examination, no evidence of abuse was found. This case illustrates the issue of MS as a differential diagnosis of hematomas.

A Closer Look: Medical Conditions that Mimic Physical Abuse

The US Department of Health and Human Services statistics indicate that cases of child maltreatment are rising. This can be an extra burden on an already strained health care system. Although a call to child protective service may be warranted, a thorough history and initial testing may be sufficient to diagnose a child abuse mimic and rule out physical abuse. This testing can help facilitate the investigation and can also prevent unneeded stress on a family. The most common presentation of physical abuse is a skin finding, typically a bruise. A detailed history and physical examination can help differentiate between physical abuse and mimics of physical abuse. Familiarity with mimics can help one in establishing a differential diagnosis and facilitate the testing for physical abuse. As skin findings may be the first indicator of abuse, this article focuses on abnormal skin findings that can mimic abuse and how to differentiate them from abuse. [Pediatr Ann. 2020;49(8):e341-e346.].

Mongolian spots as a finding in forensic examinations of possible child abuse-implications for case work

Mongolian spots (MS) are congenital dermal conditions resulting from neural crest-derived melanocytes migration to the skin during embryogenesis. MS incidences are highly variable in different populations. Morphologically, MS present as hyperpigmented maculae of varying size and form, ranging from round spots of 1 cm in diameter to extensive discolorations covering predominantly the lower back and buttocks. Due to their coloring, which is also dependent on the skin type, MS may mimic hematoma thus posing a challenge on the physician conducting examinations of children in cases of suspected child abuse. In the present study, MS incidences and distribution, as well as skin types, were documented in a collective of 253 children examined on the basis of suspected child abuse. From these data, a classification scheme was derived to document MS and to help identify cases with a need for recurrent examination for unambiguous interpretation of initial findings alongside the main decisive factors for re-examination such as general circumstances of the initial examination (e. g., experience of the examiner, lighting conditions) and given dermatological conditions of the patient (e. g., diaper rash).

Severe Photo-oxidative Injury from Over-the-Counter Skin Moisturizer: A Child Abuse Mimic

BACKGROUND

The cutaneous manifestations of pathological conditions have been described to mirror findings commonly associated with child abuse. Although it is important for clinicians to report suspected abuse, vigilance is required to detect conditions that mimic abuse. Phytophotodermatitis, a phototoxic reaction to furocoumarin-containing plants, is a well-described mimicker of nonaccidental trauma. However, non-furocoumarin-containing chemicals may cause similar presentations through a process called auto-oxidation. Typically, these chemical reactions occur as a result of aero-oxidation or, less commonly, photo-oxidation.

CASE REPORT

We report the first pediatric case of photo-oxidative contact dermatitis from an over-the-counter skin moisturizer. A 12-month-old Hispanic boy presented to the Emergency Department with an apparent scald burn over his anterior chest and left shoulder. Given the lack of apparent cause, a nonaccidental injury was suspected. He was admitted to the pediatric service under the consult of Dermatology and the child maltreatment team. Further history and clinical progression strongly suggested a photo-oxidation reaction from chemical components in a widely available over-the-counter skin moisturizer. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case highlights an infrequently reported cause of pediatric contact dermatitis: a photo-oxidative reaction to chemical components in skin moisturizer. It is important for the clinician to be able to differentiate injuries secondary to nonaccidental trauma from conditions that mirror their presentation. The clinical features of this case mimicked child maltreatment and underscore the importance of an interdisciplinary team approach in the care of these children.

Blue scalp discoloration in infants caused by exogenous source

A blue patch on the vertex scalp of an infant has a broad differential diagnosis, including vascular malformations, melanocytic lesions, trauma, and exogenous or endogenous pigmentation. We present two cases of infants who developed blue patches on the scalp. Extensive examination including MRI and biopsy was recommended for one of the patients to further characterize the lesion and its possible medical implications. In both, the blue discoloration had been due to repetitive contact with the sticker on a tub of baby wipes that had rubbed off onto the scalp. We present these infants to highlight this exogenous and benign cause of blue pigmentation and help practitioners avoid unnecessary examination.

Dermatological Conditions Mimicking Trauma

A number of dermatological findings may mimic inflicted injury in forensic investigations and lead to false conclusions about the circumstances, manner, and mechanism of death. At times, organic dermatological phenomena involving the skin, hair, and nails are initially misidentified as trauma, sexual abuse, or burns. History, autopsy, and histopathology aid in correctly diagnosing these dermatological findings. Some of the resulting diagnoses include pruritic, ulcerating, and infectious skin diseases, skin disease localized to the anogenital area, malignancy, medication-induced dermatoses, alopecia, and age-related skin changes. We report several cases where police and/or the coroner initially attributed a finding to trauma, but it was subsequently determined that the finding represented a dermatological disease by the forensic pathologist upon autopsy. In addition, for completeness, we include examples of other dermatological conditions that may mimic trauma. Forensic investigators should maintain a broad differential for abnormal skin, hair, and nail findings when there is an incomplete or incongruent history surrounding a victim's death.

Child abuse: skin markers and differential diagnosis

Reports of child abuse have increased significantly. The matter makes most physicians uncomfortable for two reasons: a) Little guidance or no training in recognizing the problem; b - Not understanding its true dimension. The most common form of child violence is physical abuse. The skin is the largest and frequently the most traumatized organ. Bruises and burns are the most visible signs. Physicians (pediatricians, general practitioners and dermatologists) are the first professionals to observe and recognize the signs of intentional injury. Dermatologists particularly, can help distinguish intentional injury from accidental, or from skin diseases that mimic maltreatment.

Preventing child abuse and neglect in Saudi Arabia: are we ready?

Although child abuse and neglect (CAN) have been recognized by medical professionals for the last 20 years, child protection services and child maltreatment prevention programs are still emerging in Saudi Arabia. This paper will review the progress made in the country in terms of recognition and implementation of child protection services. Furthermore, it will draw attention to the essential steps required to start child maltreatment prevention programs, as CAN prevention is currently viewed as a global healthcare priority with an emphasis on evidence-based interventions. In addition, this paper will assess Saudi Arabia's readiness to prevent CAN and the challenges that will be faced by the professionals in implementing evidence-based CAN prevention programs.

Child abuse suspicion masquerading new onset insulin dependent diabetes mellitus

The identification and diagnosis of child abuse is a challenging task to the pediatrician. The increased awareness among both the public and medical personnel, while improving attentiveness to this important subject, can sometimes result in misdiagnosing medical conditions, thus causing distress and delay in required treatment. Numerous reports have described conditions mimicking non-accidental injuries; most of these include dermatological findings related to skin diseases, medical conditions causing pathological fractures, and rare diseases with unusual physical findings. We present a case of a 9.5-year-old child in which the workup for a suspected abusive event led to a delay in the diagnosis of insulin dependent diabetes mellitus later presented as diabetic ketoacidosis.

Child abuse and neglect in Saudi Arabia: journey of recognition to implementation of national prevention strategies

OBJECTIVES

To describe increased child abuse and neglect (CAN) reporting and the characteristics of the reports in the context of the development of a system of intervention for one of the hospital-based child protection centers in Riyadh, Saudi Arabia aligned with the United Nations Convention on the Rights of the Child (CRC) Article 19.

METHODS

A retroprospective collection of data on all children evaluated by the Suspected Child Abuse and Neglect (SCAN) team in King Abdulaziz Medical City for the National Guard from 2000 to 2008. The cases were further divided into 3 subgroups corresponding to the years 2000-2004, 2005-2006, and 2007-2008 parallel to the stages of development of the national child protection system.

RESULTS

During the study period, there were a total of 188 referrals to the SCAN team. Of these 133 (70.7%) were further investigated as CAN cases. The total number of referred cases increased 10-fold from 6.4 cases per year in the first period to 61.5 cases per year in the third period. The mean age was 5 years, evenly represented by males and females. Physical abuse was the most common form of abuse in the first (2000-2004) period at 61% and second (2005-2006) period at 76%, which changed to neglect (41.6%) as the most common form of maltreatment in the third (2007-2008) period. Parents were the perpetrators in 48.9% of cases throughout the 3 periods. Overall fatality rates were 4.4%, 14.3%, and 7.9% in the first, second, and third periods respectively.

CONCLUSION

Recognition of CAN is expanding in Saudi Arabia. This is due to the successful adoption of a system of intervention consisting of child protection centers in the medical facilities, in conjunction with mandatory reporting and data collection strategies. In addition, the changes in public attitudes towards a better understanding of CAN enhanced further recognition and reporting of neglect and milder forms of abuse. We believe that the number of reported CAN cases in Saudi Arabia will continue to rise, hence adequate multi-sectoral services for the abuse victims require further development and improvements throughout the country.