Mistakes in diagnosing non-accidental injury: 10 years' experience

Bone pathology mimicking non-accidental injury in a child - Bewildered by bones, case report and review of the literature

INTRODUCTION AND IMPORTANCE

Physical abuse of children is criminal conduct in the purview of medico-legal sciences and the confirmative diagnosis of 'child abuse' is imperative for further legal proceedings. Clinicians play a pivotal role in the protection of children by recognizing and reporting such cases and treating the victims of abuse.

PRESENTATION OF CASE

To the best of our knowledge, we present the first case report in literature where osteofibrous dysplasia resulted in a pathological fracture in a 10-month-old South-Asian child which resembled the picture of child abuse.

CLINICAL DISCUSSION

The challenges faced by clinicians in the process of analysis of presumed child abuse are numerous and careful formulation and elimination of medical conditions which may mimic non-accidental injury (NAI) is a must, prior to making an incontrovertible diagnosis.

CONCLUSION

The telltale signs of NAI such as soft tissue injuries and fractures in a victimized child should always be evaluated cautiously with the intent of excluding pathologies that may mimic them and the evidence in this regard is seldom in literature.

Child Abuse, Misdiagnosed by an Expertise Center: Part I-Medico-Social Aspects

Child abuse is a dangerous situation for an infant. Professionals need to weigh the risk of failing to act when children are seriously harmed against the serious harm done by carrying out safeguarding interventions. In severe cases, foster care might be advisable. The negative effects for the child's psychosocial development requires that such placement must be based on very solid evidence. Our aim is to identify why Dutch parents whose child may have a medical condition that could mimic symptoms of child abuse have a significant chance of being erroneously convicted and losing custody of their child. As a method, we describe and analyze the following case. An Armenian-Dutch newborn (uncomplicated term vaginal delivery), starting at two weeks after birth, developed small bruises on varying body locations. At two months, a Well-Baby Clinic physician referred the girl to a university hospital, mentioning that there were no reasons to suspect child abuse and that her Armenian grandmother easily bruised as well. However, before consultation by a pediatrician of the hospital-located Expertise Center for Child Abuse, the parents were suspected of child abuse. Based on the expertise center's protocols, skeletal X-rays were made, which showed three healed, asymptomatic rib fractures, while invalid statistics suggested, incorrectly, a 10-100 times more likely non-accidental than accidental cause of the symptoms (discussed in Part II of this series). The expertise enter physician ignored any argument that could show parental innocence, including the positive parent-child relationship reported by the Well-Baby Clinic and the general practitioner. The girl and her older brother were placed in a family foster home and then in a secret home. The case radically resolved when a large bruise also developed there, and an independent tissue disease specialist diagnosed a hereditary connective tissue disorder in the mother, implying that the girl's bruises and rib fractures could well be disease-related. In conclusion, if child abuse is suspected, and foster care placement considered, the patient and the parents should be thoroughly investigated by an independent experienced pediatrician together with an experienced pediatric clinical psychologist or psychotherapist to produce an independent opinion. Children deserve this extra safeguard before being separated from their parents.

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.

Heiße Spuren

Die Differenzialdiagnostik von Hautläsionen bei Lebenden gehört zum wesentlichen Aufgabenspektrum der „klinischen Rechtsmedizin“. Im vorliegenden Fall eines 10 Monate alten Jungen mit nichtjuckenden, jedoch geformt wirkenden Hautläsionen bat die behandelnde Kinderarztpraxis um rechtsmedizinische Mitbeurteilung wegen des Verdachts einer Misshandlung von Schutzbefohlenen mittels glühender Zigarettenspitzen. Auf Fotografien vom Tag der Erstvorstellung in der Kinderarztpraxis sowie von der Wiedervorstellung einen Tag später waren im linken oberen Rückenbereich mehrere rundliche Hautläsionen zu erkennen. Bei der nachfolgenden rechtsmedizinischen Untersuchung erschienen diese Läsionen nun mit goldgelb-braunen Krustenbildungen. Die Kenntnis der Läsionsentwicklung sowie der charakteristische Endbefund ermöglichten die sichere Diagnose einer Impetigo contagiosa. Der Fall verdeutlicht die Notwendigkeit der engen Kooperation zwischen Klinik und Rechtsmedizin bei Sachlagen und Befunden mit initial möglich erscheinender strafrechtlicher Relevanz.

Retinal hemorrhage and bleeding disorders in children: A review

BACKGROUND

Retinal hemorrhages (RH) are a common manifestation of abusive head trauma (AHT) resulting from acceleration-deceleration injury with or without blunt impact. Evaluation of a child with RH requires careful consideration of these differential diagnoses. The extent to which coagulopathy alone can cause RH would be useful to understand as coagulopathy may accompany AHT.

OBJECTIVE

In this systematic review, we sought to identify whether coagulopathies have been reported with RH similar to those of AHT.

METHODS

We performed a literature search for ocular manifestations of bleeding disorders in children less than 18 years old. We included clotting factor deficiencies, vitamin K deficiency, platelet function abnormalities, thrombocytopenia, disseminated intravascular coagulation (DIC), and trauma induced coagulopathy (TIC). We included only pediatric reports of intraocular bleeding or documented eye examinations that indicated no hemorrhages. We then re-examined cases for ocular and systemic findings that could potentially mimic abuse.

RESULTS

Our initial search yielded 816 results. Sixty-one articles met our inclusion criteria. Of these, there were 32 children within the AHT age range (less than 5 years old) who had RH and concomitant coagulopathy. Only 5 cases might potentially be confused for abuse. Of these, no classic characteristics of RH from abuse such as retinoschisis or retinal folds were found. Systemic features were inconsistent with AHT.

CONCLUSIONS

The presence of coagulopathy alone does not rule out the possibility that the child has been abused. Coagulopathy alone has not been reported as an etiology of RH that are consistent with AHT, especially when other findings are present.

A 6-Year Case-Control Study of the Presentation and Clinical Sequelae for Noninflicted, Negligent, and Inflicted Pediatric Burns

Inflicted burns are one of the leading causes of abuse-related fatalities in children. Between 30 and 60% of children accidentally returned to abusive homes suffer reabuse. Given the high chance for abuse recurrence and the associated morbidity/mortality, it is critical that inflicted burns are promptly identified to guide appropriate medical and child welfare management. Although previous studies proposed historical and mechanistic features using noncomparative or poorly powered data, this study utilized comparative data from a 6-year period (2009-2014) at a certified burn center along with expert analysis from Child Advocacy and Protective Services (CAPS) to provide higher level evidence supporting classical findings while elucidating new features with respect to burn severity and required interventions. A retrospective chart review of 408 pediatric burns was cross-referenced with the respective CAPS consultations to construct a multidisciplinary, deidentified database. The average age was 2.9 years (0.04-17 years) with 232 (57%) males and 330 (81%) African-Americans. CAPS investigations confirmed burn etiologies: noninflicted (346 [85%]), negligent (30 [7%]), and inflicted (32 [8%]). In comparing the three etiologies, statistical significance (P < .05) was observed for numerous variables including historical inconsistency, burn age, child welfare history, burn size and depth, distribution, concomitant injury rates, number of surgical interventions, infectious complications, and hospital length of stay. In addition to reaffirming classical features of abusive burns to fortify etiologic diagnoses, this study elucidated appreciable differences in burn severity, interventional sequelae, and burn-related complications, which will help guide medical and surgical interventions for future pediatric burn patients.

The importance of laboratory re-evaluation in cases of suspected child abuse - A case report

In order to accurately diagnose child abuse or neglect, a physician needs to be familiar with diseases and medical conditions that can simulate maltreatment. Unrecognized cases of abuse may lead to insufficient child protection, whereas, on the other hand, over-diagnosis could be the cause of various problems for the family and their potentially accused members. Regarding child abuse, numerous cases of false diagnoses with undetected causes of bleeding are described in the scientific literature, but, specifically concerning leukemia in childhood, only very few case reports exist. Here, for the first time, we report a case of a 2-year-old boy who got hospitalized twice because of suspicious injuries and psychosocial conspicuities, in a family situation known for repeated endangerment of the child's well-being. After his first hospitalization with injuries typical for child abuse, but without paraclinical abnormalities, medical inspections were arranged periodically. The child was hospitalized with signs of repeated child abuse again five months later. During second admission, an acute lymphoblastic leukemia was revealed by intermittent laboratory examination, ordered due to new bruises with changes in morphology, identifiable as petechial hemorrhages. This case elucidates the discussion of known cases of leukemia in childhood associated with suspected child abuse in order to provide an overview of possible diseases mimicking maltreatment. To arrange necessary supportive examinations, a skillful interaction between pediatrician and forensic pathologist is crucial in the differentiation between accidental and non-accidental injury.

Are There Hallmarks of Child Abuse? II. Non-Osseous Injuries

Certain conditions have been considered hallmarks of child abuse. Such pathognomonic conditions have led to an inevitable diagnosis of inflicted injury. Forensic pathologists are faced with complex analyses and decisions related to what is and what is not child abuse. In this review, we examine the literature on the specificity of five conditions that have been linked to inflicted injury to varying degrees of certainty. The conditions examined include tears of the labial frena (frenula), cigarette burns, pulmonary hemorrhage and intraalveolar hemosiderin-laden macrophages as markers of upper airway obstruction, intraabdominal injuries, and anogenital injuries and postmortem changes. Analysis of the literature indicates that frena tears are not uniquely an inflicted injury. Cigarette burns are highly indicative of child abuse, though isolated cigarette burns may be accidental. Pulmonary hemorrhage is seen more commonly in cases with a history suggestive of upper airway obstruction, but is not diagnostic in an individual case. Hemosiderin-laden macrophages may be seen in cases with inflicted injuries and in natural deaths. Abdominal injuries may be seen in accidents and from resuscitation, though panreatico-duodenal complex injuries in children under five years of age are not reported to be seen in falls or resuscitation. The understanding of anogenital injuries is increasing, but misunderstanding of postmortem changes has led to miscarriages of justice.

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.

Non-cutaneous conditions clinicians might mistake for abuse

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.

Cutaneous Findings Mistaken for Physical Abuse: Present but Not Pervasive

Incorrect diagnoses during child abuse evaluations are serious. Because skin lesions are common in abuse, it is important to consider cutaneous mimics of physical abuse. The current study prospectively identified cutaneous mimics in a cohort of children evaluated for possible physical abuse. This is a secondary analysis of data from the Examining Siblings To Recognize Abuse research network's prospective, observational, cross-sectional study involving 20 U.S. child abuse teams. Subjects were younger than 10 years old and were evaluated by child abuse physicians (CAPs) for concerns of physical abuse. CAPs prospectively documented whether mimics were identified during their physical abuse evaluations. Details of each patient with cutaneous mimics were evaluated to determine the types of mimics, which part of the evaluations identified mimics, and the perceived abuse likelihood. Of 2,890 children evaluated for physical abuse, 137 had at least one mimic identified and 69 had some cutaneous mimic components. Although 985 of 2,753 (39%) subjects without mimics had high levels of abuse concern, only 9 of 137 (6%) children with mimics had high levels of abuse concern (p < 0.001). Of 69 children with cutaneous mimics, 56 (81%) were diagnosed by history and physical examination. Cutaneous abuse mimics were identified in 2.4% of children evaluated for physical abuse. Although it was eventually determined that there was little or no concern for abuse in 84% of children with cutaneous mimics, a small number were physically abused. CAP evaluation may be valuable in recognizing children with cutaneous mimics who also were abused.

Dermatoses misdiagnosed as deliberate injuries

Examination of non-accidental injuries on a body should be done with caution, as often skin diseases can mimic deliberate injuries. Patients with active dermatoses or their residual/post-inflammatory spots seen during autopsy can generate false alarms or suspicion of burns, child abuse or battering, sexual assault or other medicolegal cases. The inability to distinguish between a mechanical injury and skin disease can cause unnecessary anxiety and can complicate medicolegal investigations. Many times, an elaborate history to find out the aetiology of the lesion is either unavailable or not reliable as in the cases of young children, insane or mentally subnormal patients or in medicolegal deaths. The greatest chance of misinterpretation may be in cases of extensive denudation of the skin seen in severe drug reactions like toxic epidermal necrolysis, which can be mistaken for scald burns. Other important cases include bruises diagnosed on seeing discoloured spots on the skin or genital lesions raising the suspicion of sexual abuse in children. This diagnostic dilemma can also lead to undue forensic investigations, imprecise expert opinions and distress to patients or their family members. This review aims to generate awareness about proper interpretation of findings with an open mind, the clues to differentiate between true and false injuries and the management thereof.

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.

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.

Cutaneous mimickers of child abuse: a primer for pediatricians

The annual incidence of child abuse was estimated to be 2.8 million by the national incidence study conducted in the USA in 1993, which is a two-fold increase compared to 1986. Awareness of child abuse has been increasing since the 1960s. Although most victims of child abuse present with cutaneous lesions, many genuine skin diseases may appear as non-accidental injuries which, if not recognized, may lead to misdiagnosis of child abuse. Here, we review the most common cutaneous mimickers of child abuse in order to increase awareness of these disorders and reduce erroneous diagnosis of child abuse.

Physical abuse and neglect of children

Child maltreatment includes physical abuse and neglect, and happens in all countries and cultures. Child maltreatment usually results from interactions between several risk factors (such as parental depression, stress, and social isolation). Physicians can incorporate methods to screen for risk factors into their usual appointments with the family. Detection of physical abuse is dependent on the doctor's ability to recognise suspicious injuries, such as bruising, bite marks, burns, bone fractures, or trauma to the head or abdomen. Neglect is the most common form of child maltreatment in the USA. It can be caused by insufficient parental knowledge; intentional negligence is rare. Suspected cases of child abuse should be well documented and reported to the appropriate public agency which should assess the situation and help to protect the child.

Staphylococcal scalded skin syndrome mimicking child abuse by burning

Child abuse by burning comprises 6-20% of all child abuse cases, but misdiagnosis may arise in cases of some medical conditions. We present two cases of suspected inflicted burns, later diagnosed as staphylococcal scalded skin syndrome (SSSS). In case 1, a 6-month-old girl was referred to hospital for small round ulcerations on the face and abdomen, resembling cigarette burns. Because of the inconsistency of the mother's report (insect bites) with the injury pattern and an unstable family history, hospitalization was decided. The following day, new bullous lesions were visible on the neck and nose, indicating the natural origin of the findings, finally diagnosed as SSSS. In case 2, a 2-month-old boy was hospitalized for erythema, with bullous lesions on the abdomen. He was transferred to another hospital, with suspected congenital or autoimmune skin disorder but negative searches led to a diagnosis of inflicted scalds: a report was sent to the judicial authorities, and the child was entrusted to his grandparents. In fact, a review of the clinical documentation showed that, in the second hospitalization, new erythematous and bullous lesions had been described, which could not be ascribed to inflicted injuries. Child abuse was finally ruled out, and SSSS was diagnosed. In cases of suspected inflicted child burns, observation during hospitalization may reveal changes in lesions, ascribed to the evolution of medical conditions. SSSS diagnosis is mainly based on clinical grounds but, if the suspicion of abuse remains, isolation and phage typing of Staphylococcus aureus from nasal, pharyngeal or cutaneous swabs may confirm the diagnosis.

Misdiagnosis of Burns: Herpes Zoster Ophthalmicus

Many conditions can mimic the presentation of burns. We present an interesting case in which the initial diagnosis of a chemical burn was later confirmed to be herpes zoster ophthalmicus.

Cutaneous manifestations of child abuse

Dermatologists and child abuse are not frequently associated in the minds of most physicians. Yet the most common manifestations of child abuse are cutaneous. This article reviews cutaneous manifestations of physical abuse, including bruises, lacerations, abrasions, human bites, and burns. It also discusses ways that dermatologists can differentiate abusive injuries from accidental ones as well as from the many dermatologic conditions that can mimic child abuse. Finally, we review what actions the dermatologist should take when suspecting abuse in a patient.

Bruising and bleeding in infants and children - a practical approach

Bruising and bleeding are commonly seen in children and are usually associated with minor injury and trauma. However, in two groups of children the bruising may be more significant than expected: those with an underlying haemostatic abnormality, such as an inherited bleeding disorder, or those who have been subjected to non-accidental injury (NAI). Diagnosing inherited bleeding disorders in children is fraught with difficulty, from venous access to interpretation of results; the possibility of NAI should be borne in mind, even in those children with proven significant bleeding disorders when the severity of the injury and the history are non-compatible. We describe the investigation of the haemostatic system in children with bruising and/or bleeding with emphasis on the key haemostatic disorders that need to be excluded.

Non-accidental burns in children—Are we neglecting neglect?

Although many studies have described burn abuse in detail, burns that have occurred as a result of neglect have been studied to a much lesser degree. A retrospective study of 440 hospitalised paediatric burns patients during 2000-2002 inclusive was performed. A multidisciplinary team investigation of suspicious cases was used. This included a home assessment. There were 41 cases of neglect (9.3%) and 395 cases of accidental burning (89.8%). Parental drug abuse, single parent families, delay to presentation and a lack of first aid were statistically more prevalent in the "neglect" group than in the "accidental" group. Children in the "neglect" group were also statistically more likely to have deeper burns and require skin grafting. 82.9% of children whose burns were deemed to be due to neglect had a previous entry on the child protection register. 48.8% were transferred into foster care. This study shows that burning by neglect is far more prevalent than abuse. We advocate a multidisciplinary investigation coupled with the use of home assessments to aid diagnosis. It may be possible to target preventative strategies on the children with the above risk factors.

Children with signs of abuse: when is it not child abuse?

Child abuse is a problem that is frequently underdiagnosed. Recognition that underdiagnosis of abuse exists has produced a high zeal for identifying cases of child abuse, which has inevitably produced cases of overdiagnosis. Overdiagnosis of child abuse is as catastrophic as underdiagnosis. In this case, a family member is often accused of injuring or killing a child at a time when the loss is felt most deeply. This review focuses on 1 specific presentation of child abuse--the child with bruises and bleeding. Many children and adults have coagulation or vascular disorders that predispose them to bruise or bleed excessively with minor trauma. It is very easy for a health care worker to presume that bruising and bleeding is associated with trauma, because the coagulopathies that may explain the findings are often poorly understood. The clinical cases reviewed in this article show the need for an extremely thorough analysis for an underlying bleeding disorder in the bruised or bleeding child being evaluated as a possible victim of child abuse.

The bleeding child; is it NAI?

As a paediatric haematologist, the question of whether a child has been abused or whether they might have a bleeding diathesis is a question that I am regularly asked. When I first became a consultant, I would often find that not enough information was available; for example, incomplete histories had been taken or investigations were incomplete and difficult to interpret. This inevitably led to delays in confirming the cause of the bleeding and meant that if parents or carers contested a diagnosis of abuse, excluding a bleeding disorder was extremely difficult. I was also aware that carers of several of my patients with haemophilia or other bleeding disorders had initially been under suspicion of abuse, most usually at the time of the first few presentations. By highlighting important questions in history taking, having a specific haematological screen for children being investigated for bleeding in the context of non-accidental injury, and encouraging discussion of abnormal results with a haematologist, these difficulties can, for the most part, be avoided.

Bruising, coagulation disorder, and physical child abuse

Child protection is a priority, and the medical community has a responsibility to detect cases of abuse and to intervene using the appropriate measures. Bruises are the most common manifestation of physical abuse, although their interpretation can be extremely challenging for paediatricians as the evidence base is limited. As a history of abuse is a strong risk factor for further non-accidental injury, a correct diagnosis is vital. Clearly, the diagnostic process must determine whether an underlying coagulation disorder exists. It is important to realize, however, that the presence of a coagulation deficit does not necessarily exclude abuse. A growing body of evidence suggests that the practice of estimating bruise age is unreliable; therefore, a key factor in diagnosing abuse is the pattern of bruise distribution, which must be linked to the child's history and stage of development. The paediatrician must also consider the combined probabilities of individual bruises being due to abuse. Our scoring system, which uses a Bayesian approach to evaluate these probabilities and assess bruising patterns, is a potentially useful tool for discriminating between abused and non-abused children. We recommend that paediatricians and haematologists should work together to reach a diagnostic consensus that is acceptable in both the clinic and a court of law.

Child abuse by burning: a review of the literature and an algorithm for medical investigations

BACKGROUND

Investigations of suspected child abuse must be conducted thoroughly to protect the abused child and to bring the abuser to trial. We have reviewed the literature on child abuse by burning and have synthesized, from the experience of ourselves and others, an algorithm that can be used by physicians, social workers, and nurses involved in the investigation of alleged child abuse by burning.

METHODS

A MEDLINE search was conducted for the years 1966 through 2000 for human studies written in the English language using the key terms "child abuse" and "burns."

RESULTS

Information from these articles was reviewed and included in this article. On the basis of our own experience and that cited in the literature, an algorithm was constructed to guide hospital-based personnel in their management of child abuse by burning.

CONCLUSION

Medical investigation of suspected child abuse by burning can be performed systematically using an algorithm, thereby minimizing the chance of either false-positive or false-negative reporting.

Eczema mimicking child abuse: a case of mistaken identity

Many skin conditions can mimic child abuse by burning. Multidisciplinary evaluation of suspicious burns helps prevent both the underreporting and the misdiagnosis of child abuse by burning. We report a case of pediatric eczema mimicking an abusive burn.

Emergency department evaluation of child abuse

Child abuse has been documented in various forms since the beginning of recorded history. This article reviews the legal aspects of reporting child abuse, the epidemiology of child abuse, various physical manifestations of child abuse, and effective treatment procedures. It is only with the appropriate interventions that physicians can begin to make an impact on the future of abused children.

The prevalence and distribution of bruising in babies

AIM

To obtain a prevalence rate and determine the distribution of accidental bruising in babies.

METHODS

177 babies aged 6-12 months were examined naked to look for bruises. They were seen in health visitor hearing test clinics and child health surveillance clinics. The site, size, shape, and colour of bruises were recorded on a skin map, and the parent's explanation noted. Any other injury was recorded. Data collection included the baby's age, mobility and weight, demographic details, and health visitor concerns.

RESULTS

Twenty two babies had bruises, giving a prevalence rate of 12%. There was a total of 32 bruises, 15 babies had one bruise. All bruises were found on the front of the body and were located over bony prominences. Twenty five of the bruises were on the face and head, and seven were on the shin. The babies with bruises on the shin were mobile. There was a highly significant increase in bruises with increase in mobility.

CONCLUSIONS

The study has produced a prevalence and distribution of bruising in babies and sets a baseline from which to work when assessing bruises. It also tested out the methodology, which could be used in further research, particularly of younger babies. Clinicians need to assess a baby's level of development when considering whether a bruise is accidental.

Late-form hemorrhagic disease of the newborn: a fatal case report with illustration of investigations that may assist in avoiding the mistaken diagnosis of child abuse

Hemorrhagic disease of the newborn (HDN) is usually a self-limiting hemorrhagic disorder of childhood that occurs as a result of vitamin K deficiency. It may be defined as early or late form depending on the time of onset related to birth. HDN is recognized as one of several bleeding disorders that can mimic the findings of nonaccidental head injury and may lead to a mistaken diagnosis of child abuse. We present a single fatal case of late-onset HDN with illustration of hematologic assays that can be performed to assist the pathologist in making the correct diagnosis of HDN.

Phytophotodermatitis mimicking child abuse

A 13-month-old girl presented with red finger marks on both shoulders thought initially to be secondary to child abuse. The appearance of the marks was not typical of bruising of the stated age and there were no social concerns or other medical features of child abuse. Direct questioning revealed that the mother had been gardening on a sunny day and had picked the child up prior to the appearance of the marks. The marks are thought to represent a phytophotodermatitis. Many paediatric skin conditions can mimic child abuse. Recognition of this further possibility will prevent avoidable errors of diagnosis.

Future role of the pediatrician in child abuse and neglect

This article reviews the recent history of responses to child abuse and the present roles of pediatricians. It outlines actions that are needed to protect children, recognizes the difficulties in effecting intervention, and concludes that pediatricians cannot afford to stand by while children continue to suffer harm.

The hand as a target organ in child abuse

The authors reviewed the abuse reports submitted by the staff of The Children's Hospital, Columbus, Ohio, to determine the incidence and types of injuries inflicted to children's hands. The authors did not study hand injuries in children who were not reported as physically abused. The authors examined two time periods to ascertain changes injury severity. Of the 631 abuse reports submitted from 1980 to 1982, there were 52 injuries (8.2%) involving the hands. From July 1987 to July 1988 there were 42 hand injuries (13.4%) among 313 reports. In the 94 total cases, 19 (2%) children sustained injury to the hand only, including eight with burns, two with bruises, two with human bites, two with erythema, two with fractures, and one with a laceration. Children with burns to the hand alone were significantly younger than those with other types of injuries. Of the 94 children with hand and other injuries, 18 (20%) required hospital admission. Of the 19 with injuries to the hand only, five required hospital admission. A variety of instruments were used to injure these children. The hand is a delicate organ, and it is frequently the primary or incidental target of child abuse. Familiarity with the patterns and types of hand injury suffered in child abuse is essential for early recognition, reporting, and child protection.