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Tang B, Pophal S, Ganigara M, Funaki B, Robinette M, Ramaiah V, Ghanayem N, Hurley MC, Dyamenahalli U. Early Infantile Diagnosis of Hereditary Hemorrhagic Telangiectasia Complicated by Child Abuse. JOURNAL OF PEDIATRICS. CLINICAL PRACTICE 2024; 12:200111. [PMID: 38828001 PMCID: PMC11138255 DOI: 10.1016/j.jpedcp.2024.200111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 03/22/2024] [Accepted: 03/24/2024] [Indexed: 06/05/2024]
Abstract
We report a rare case of hereditary hemorrhagic telangiectasia (HHT) in a 4-month-old female infant with findings of child abuse. She presented with poor feeding, vomiting, and irritability after a short fall from the bed. Initial evaluation found subdural hematomas, persistent hypoxia, failure to thrive, a frenulum tear, facial lacerations, and bruising. The patient was admitted, and an extensive workup led to the diagnosis of brain and pulmonary arteriovenous malformations and finally the diagnosis of HHT. The subdural hematomas, cutaneous injuries, and oral injury were highly suspicious for child abuse and were reported to Child Protective Services and law enforcement for investigation simultaneous to the medical work-up. Her hospital course was complicated by progressive hypoxemia with radiographic evidence of several large pulmonary arteriovenous malformations, for which she underwent successful embolization. Her head injury was indeterminate for physical abuse in the setting of a medical condition predisposing to intracranial hemorrhage. A few weeks later, she was readmitted with repeat abusive injuries in the form of femur fractures. This case demonstrates the unique diagnostic dilemma when 2 diagnoses are occurring simultaneously-HHT and child abuse-and showcases the importance of a detailed family history, genetic testing, strong multidisciplinary collaboration with a holistic approach and medically informed Child Protective Services systems to ensure accurate diagnoses and safe disposition.
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Affiliation(s)
- Brittany Tang
- Department of Pediatrics, The University of Chicago, Chicago, IL
| | - Stephen Pophal
- Department of Pediatric Cardiology, The University of Chicago, Chicago, IL
| | | | - Brian Funaki
- Department of Vascular and Interventional Radiology, The University of Chicago, Chicago, IL
| | - Mckenna Robinette
- Department of Pediatric Cardiology, The University of Chicago, Chicago, IL
| | - Veena Ramaiah
- Department of Child Advocacy and Protective Services, Pediatric Child Abuse Specialist, The University of Chicago, Chicago, IL
| | - Nancy Ghanayem
- Pediatric Crtical Care, The University of Chicago, Chicago, IL
| | - Michael C. Hurley
- Department of Diagnostic and Interventional Radiology, The University of Chicago, Chicago, IL
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King A, Pope E. Dermatitis versus nonaccidental trauma: A systematic review of initial pediatric misdiagnoses. Pediatr Dermatol 2024; 41:215-220. [PMID: 38400817 DOI: 10.1111/pde.15556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 01/27/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND/OBJECTIVES Pediatric dermatitis and nonaccidental trauma (NAT) may have overlapping cutaneous presentations, posing a risk of misdiagnosis and subsequent emotional distress and further harm. Through a systematic literature review, we reviewed pediatric (<18 years old) patients investigated for both dermatitis and NAT. METHODS EMBASE and MEDLINE databases were searched. English publications with original data involving pediatric patients investigated for both dermatitis and NAT were included. Nonhuman studies and incomplete articles/conference abstracts were excluded. Data extracted included the first author, year of publication, study design, participant count, sex of the population, age of the population, cutaneous presentation, timing of presentation, Child Protective Services involvement, and case relation to dermatitis and NAT. RESULTS This review included 21 case reports or series encompassing 29 patients. Among 26 patients initially investigated as NAT (26.9% involving Child Protective Services), final diagnoses included irritant contact dermatitis (53.8%), phytophotodermatitis (30.8%), allergic contact dermatitis (7.7%), perianal infectious dermatitis (3.8%), and atopic dermatitis (3.8%). Three patients initially diagnosed with nontraumatic dermatitis were later found to be victims of physical (2/3; 66.7%) or sexual abuse (1/3; 33.3%). CONCLUSIONS Effective history-taking and physical examinations should encompass a history of laxative use, contact with furocoumarin-containing plants/fruit, parallel family/peer cutaneous presentations, caregiver involvement, financial burden, patient discomfort, birthmark assessment, and lesions aligning with diaper borders or toilet seats. Limitations of this review include potential underreporting and the inclusion of low-quality study designs and evidence.
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Affiliation(s)
- Aliyah King
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Elena Pope
- Section of Dermatology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Gupta H, Choudhary B. Caffey's disease in disguise: a child abuse mimic. BMJ Case Rep 2024; 17:e256998. [PMID: 38331449 PMCID: PMC10859985 DOI: 10.1136/bcr-2023-256998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024] Open
Abstract
A male infant was brought in a paediatric emergency with swelling in the right hand associated with restriction of wrist movements. Examination confirmed similar findings. The history of trauma was not forthcoming. Given the ambiguous history, the possibility of child abuse was kept. X-ray showed local soft tissue swelling with periosteal thickening and raised inflammatory markers in blood tests, which on review of the literature, was consistent with Caffey disease. Due to the self-limiting nature of the condition, the child was managed conservatively. Child abuse should be suspected in children with unexplained injuries, and before labelling abuse, its mimickers should be ruled out.
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Affiliation(s)
- Himanshu Gupta
- Pediatrics, All India Institute of Medical Sciences Jodphur, Jodhpur, India
| | - Bharat Choudhary
- Trauma & Emergency (Pediatrics), All India Institute of Medical Sciences Jodphur, Jodhpur, India
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Abder-Rahman H, Habash I, Hussein A, Al-Shaeb A, Elqasass A, Qaqish LN. Genital lichen sclerosus misdiagnosis: Forensic insights. Forensic Sci Med Pathol 2024:10.1007/s12024-024-00779-7. [PMID: 38294631 DOI: 10.1007/s12024-024-00779-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2024] [Indexed: 02/01/2024]
Abstract
In this case study, we present an instance of genital lichen sclerosus et atrophicus that was initially misdiagnosed as child sexual abuse. A 6-year-old female presented to the emergency department with complaints of vaginal bleeding accompanied by pruritus. The initial suspicion of child abuse was prompted by the presence of blood. However, a thorough physical examination conducted by the forensic department ruled out any traumatic injuries and instead suggested an underlying pathology, ultimately diagnosed as lichen sclerosus et atrophicus. This case report underscores the vital role of forensics in excluding abuse as a cause in similar presentations, guiding the case towards a more accurate diagnosis. Additionally, it emphasizes the significance of possessing a comprehensive understanding of pathologies that can mimic abusive injuries, thereby preventing the potential consequences of an incorrect abuse diagnosis.
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Affiliation(s)
- Hasan Abder-Rahman
- Pathology and Microbiology and Forensic Medicine Department, School of Medicine, University of Jordan, Amman, Jordan
| | - Ibrahim Habash
- Pathology and Microbiology and Forensic Medicine Department, Al-Zarqa Governmental Hospital, Ministry of Health and The Hashemite University, Zarqa, Jordan
| | - Ahmad Hussein
- Department of Dermatology, Al-Zarqa Governmental Hospital, Ministry of Health, Zarqa, Jordan
| | - Asma Al-Shaeb
- Pathology and Microbiology and Forensic Medicine Department, School of Medicine, University of Jordan, Amman, Jordan
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Vlaming M, Sauer PJJ, Janssen EPF, van Koppen PJ, Bruijninckx CMA, Akkerman-Zaalberg van Zelst MWM, Neumann HAM, van Gemert MJC. Child Abuse, Misdiagnosed by an Expertise Center: Part I-Medico-Social Aspects. CHILDREN (BASEL, SWITZERLAND) 2023; 10:963. [PMID: 37371195 DOI: 10.3390/children10060963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023]
Abstract
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.
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Affiliation(s)
- Marianne Vlaming
- Private Practice, Criminal Psychology and Law, 6986 CL Angerlo, The Netherlands
| | - Pieter J J Sauer
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center, 9713 GZ Groningen, The Netherlands
| | - Emile P F Janssen
- Private Practice, Rehabilitation Medicine & Consultancy, 6137 CL Sittard, The Netherlands
| | - Peter J van Koppen
- Department of Criminal Law and Criminology, Faculty of Law, VU University Amsterdam, 1081 HV Amsterdam, The Netherlands
| | | | | | | | - Martin J C van Gemert
- Department of Biomedical Engineering & Physics, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Manan MR, Rahman S, Komer L, Manan H, Iftikhar S. A Multispecialty Approach to the Identification and Diagnosis of Nonaccidental Trauma in Children. Cureus 2022; 14:e27276. [PMID: 36039273 PMCID: PMC9404682 DOI: 10.7759/cureus.27276] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 07/23/2022] [Indexed: 11/05/2022] Open
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Pilla NI, Nasreddine A, Christie KJ, Hennrikus WL. Rate of orthopedic resident and medical student recognition of nonaccidental trauma: a pilot study. J Pediatr Orthop B 2022; 31:407-413. [PMID: 34985011 DOI: 10.1097/bpb.0000000000000948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to evaluate the efficacy and accuracy of mandated reporters to identify child abuse in children presenting with fractures. An Institutional Review Board approved survey-based study between January 2017 and December 2017 was conducted at a tertiary care academic medical center. 10 cases were combined to create one survey. Each case had information on presentation history, radiographic data, and social history. This study assesses the ability of 13 orthopedic residents and 11 medical students to diagnose child abuse. Participants had the option to explain their reasoning for a given case. To evaluate decision-making reasoning, we split responses into three cohorts, encompassing objective evidence, subjective evidence, or social evidence. Twenty-four participants completed the survey; 203 out of 240 (85%) included the rationale for the diagnosis of child abuse. The observed diagnostic odds ratio was 0.83 for medical students, 0.93 for junior residents, and 0.96 for senior residents. There was no statistically significant difference in diagnosing child abuse between a participant's level of experience, age, or whether participants had their own children. Participants who used more than one source of evidence were significantly more likely to make the correct diagnosis (P = 0.013). Participant decisions were no more accurate than a coin toss. The use of several data sources led to increased diagnostic accuracy. There is low accuracy in correctly diagnosing child abuse in our cohort of mandated reporters. Participants who highlighted using several sources of evidence were more likely to diagnose child abuse accurately.
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Affiliation(s)
- Nicholas I Pilla
- Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Pendharkar H, Jabeen S, Pruthi N, Narasinga Rao KVLN, Shukla D, Kamble N, Jangam KV, Kommu JVS, Kandavel T, Amudhan S. Abusive head trauma in India: imaging raises the curtain. Int J Inj Contr Saf Promot 2021; 29:103-111. [PMID: 34913839 DOI: 10.1080/17457300.2021.2007955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The purpose of the study was to identify children at our institute who possibly suffered abusive head trauma (AHT). A retrospective study of CT imaging of children between one month to three years of age between January 2013 and May 2021 was carried out at a dedicated neurocentre in Southern India. We identified 48 cases of possible AHT. The demographics, clinical features at presentation, imaging and fundus findings were analyzed. Imaging revealed subdural hemorrhage (SDH) in 42 and sub dural effusion (SDE) in 5 cases, one case had only hypoxia. The location of SDH was studied as was hypoxia underlying SDH, global hypoxia and ischemia. Cases of subarachnoid hemorrhage (SAH), parenchymal hematoma & intraventricular hemorrhage (IVH) were also noted. Skeletal survey, chest X-ray and CT spine were reviewed. AHT needs to be paid attention to in the Indian scenario. An extensive work up is required to substantiate the claim and to work on prevention & management of these cases subsequently.
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Affiliation(s)
- Hima Pendharkar
- Department of Neuro Imaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Shumyla Jabeen
- Department of Neuro Imaging and Interventional Radiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India.,Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, India
| | - Nupur Pruthi
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - K V L N Narasinga Rao
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Nitish Kamble
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, India.,Department of Neurology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Kavita V Jangam
- Department of Psychiatric Social Work, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - John Vijay Sagar Kommu
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Thennarasu Kandavel
- Department of Biostatistics, National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Senthil Amudhan
- Department of Epidemiology, National Institute of Mental Health and Neuro Sciences, Bangalore, India
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Blangis F, Allali S, Cohen JF, Vabres N, Adamsbaum C, Rey-Salmon C, Werner A, Refes Y, Adnot P, Gras-Le Guen C, Launay E, Chalumeau M. Variations in Guidelines for Diagnosis of Child Physical Abuse in High-Income Countries: A Systematic Review. JAMA Netw Open 2021; 4:e2129068. [PMID: 34787659 PMCID: PMC8600386 DOI: 10.1001/jamanetworkopen.2021.29068] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 07/04/2021] [Indexed: 01/08/2023] Open
Abstract
Importance The highly variable practices observed regarding the early detection and diagnostic workup of suspected child physical abuse contribute to suboptimal care and could be partially related to discrepancies in clinical guidelines. Objective To systematically evaluate the completeness, clarity, and consistency of guidelines for child physical abuse in high-income countries. Evidence Review For this systematic review, national or regional guidelines that were disseminated from 2010 to 2020 related to the early detection and diagnostic workup of child physical abuse in infants aged 2 years or younger by academic societies or health agencies in high-income countries were retrieved. The definitions of sentinel injuries and the recommended diagnostic workup (imaging and laboratory tests) for child physical abuse were compared. Data were analyzed from July 2020 to February 2021. Findings Within the 20 included guidelines issued in 15 countries, 168 of 408 expected statements (41%) were missing and 10 statements (4%) were unclear. Among 16 guidelines characterizing sentinel injuries, all of them included skin injuries, such as bruises, hematoma, or burns, but only 8 guidelines (50%) included intraoral injuries and fractures. All 20 guidelines agreed on the indication for radiological skeletal survey, head computed tomography, and head magnetic resonance imaging but differed for those of bone scintigraphy, follow-up skeletal survey, spinal magnetic resonance imaging, cranial ultrasonography, chest computed tomography, and abdominal ultrasonography and computed tomography. Additionally, 16 guidelines agreed on exploring primary hemostasis and coagulation but not on the tests to perform, and 8 guidelines (50%) mentioned the need to investigate bone metabolism. Conclusions and Relevance These findings suggest that guidelines for the diagnosis of child physical abuse in infants were often clear but lacked completeness and were discrepant on major issues. These results may help identify priorities for well-designed original diagnostic accuracy studies, systematic reviews, or an international consensus process to produce clear and standardized guidelines to optimize practices and infant outcomes.
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Affiliation(s)
- Flora Blangis
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Slimane Allali
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Jérémie F. Cohen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Nathalie Vabres
- Unité d’Accueil des Enfants en Danger, Nantes University Hospital, F-44000, Nantes, France
| | - Catherine Adamsbaum
- Department of Pediatric Radiology, AP-HP, Bicêtre Hospital, F-94270, Le Kremlin Bicêtre, France
| | - Caroline Rey-Salmon
- Pediatrics and Forensic Unit, AP-HP, Hôtel-Dieu Hospital, F-75004, Paris, France
| | - Andreas Werner
- AFPA, Association Française de Pédiatrie Ambulatoire, F-30400, Villeneuve les Avignons, France
| | - Yacine Refes
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
| | - Pauline Adnot
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
| | - Christèle Gras-Le Guen
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of Pediatric Emergency Care, Nantes University Hospital, F-44000, Nantes, France
| | - Elise Launay
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Inserm CIC 1413, Nantes University Hospital, F-44000, Nantes, France
- Department of Pediatric Emergency Care, Nantes University Hospital, F-44000, Nantes, France
| | - Martin Chalumeau
- Obstetrical, Perinatal and Pediatric Epidemiology Research team, Centre of Research in Epidemiology and Statistics, Université de Paris, INSERM, F-75004, Paris, France
- Department of General Pediatrics and Pediatric Infectious Diseases, AP-HP, Necker-Enfants Malades Hospital, Université de Paris, F-75015, Paris, France
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Brown SD. Ethical challenges in child abuse: what is the harm of a misdiagnosis? Pediatr Radiol 2021; 51:1070-1075. [PMID: 33999247 DOI: 10.1007/s00247-020-04845-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/31/2020] [Accepted: 09/08/2020] [Indexed: 11/26/2022]
Abstract
In this article the author examines ethical tensions inherent to balancing harms of false-negative and false-positive child abuse diagnoses, and he describes how such tensions manifest in courtroom proceedings. Child abuse physicians, including pediatric radiologists, shoulder heavy responsibilities weighing the potential consequences of not diagnosing child abuse when it could have been diagnosed (false negatives) against the consequences of making the diagnosis when it has not occurred (false positives). These physicians, who practice under ethical obligations to serve children's best interests and protect them from harm, make daily practice decisions knowing that, on balance, abuse is substantially more underdiagnosed than over diagnosed. Legal justice advocates, however, emphasize that clinical decision-making around abuse is not disassociated from endemic injustices that unduly incriminate individuals from socioeconomically underprivileged populations. Some defense advocates charge that child abuse physicians are insufficiently sensitive to harms of erroneous diagnoses, and they have characterized these clinicians as frankly biased. To support their claims in court, defense advocates have enlisted likeminded physician witnesses whose credentials as experts flout professional standards and who provide consistently flawed testimony based upon deficiently peer-reviewed literature. This article concludes that, to help mitigate these unhealthy circumstances, child abuse physicians might build trust with criminal defense advocates by instituting measures to alleviate perceptions of biases and by more explicitly acknowledging the potential harms of erroneous diagnoses. Professional societies representing these physicians, such as the Society for Pediatric Radiology, could take concurrent measures to help better prepare their constituent clinicians for expert testimony and make them more available to testify.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave., Boston, MA, 02115, USA.
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Pfeifer CM. Evolving forensic controversies in child abuse imaging. Pediatr Radiol 2021; 51:1079-1083. [PMID: 33999249 DOI: 10.1007/s00247-020-04800-3] [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: 06/01/2020] [Revised: 06/01/2020] [Accepted: 08/05/2020] [Indexed: 11/29/2022]
Abstract
Child abuse is a common cause of morbidity and mortality in the pediatric population. Despite well-defined evidence establishing bona fide clinical and imaging indicators of child abuse, denialists have emerged on behalf of defendants utilizing unaccepted scientific positions based on literature that they have often authored themselves. This manuscript describes many of the trends in recent legal proceedings while highlighting the importance of consensus statements and professional ethics as they pertain to child abuse imaging. Knowledge of these cases and legal defense strategies is valuable to potential expert witnesses in relevant proceedings.
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Affiliation(s)
- Cory M Pfeifer
- Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX, 75390, USA.
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Quddusi FI, Vasquez A, Gregory S, Davis DMR, Derauf DC. Sucking Bruises in Infancy: A Mimicker of Child Abuse. Mayo Clin Proc 2021; 96:1369-1371. [PMID: 33958068 DOI: 10.1016/j.mayocp.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 02/18/2021] [Accepted: 03/01/2021] [Indexed: 11/26/2022]
Affiliation(s)
| | - Alejandra Vasquez
- Department of Pediatric and Adolescent Medicine; Department of Neurology, Division of Child and Adolescent Neurology
| | | | - Dawn Marie R Davis
- Department of Pediatric and Adolescent Medicine; Department of Dermatology
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Perales‐Clemente E, Hewitt AL, Studinski AL, Tillema J, Laxen WJ, Oglesbee D, Graff AH, Rinaldo P, Lanpher BC. Bilateral subdural hematomas and retinal hemorrhages mimicking nonaccidental trauma in a patient with D-2-hydroxyglutaric aciduria. JIMD Rep 2021; 58:21-28. [PMID: 33728243 PMCID: PMC7932861 DOI: 10.1002/jmd2.12188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 11/06/2020] [Accepted: 11/09/2020] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Nonaccidental trauma (NAT) is considered when pediatric patients present with intracranial injuries and a negative history of an accidental injury or concomitant medical diagnosis. The evaluation of NAT should include the consideration of possible medical causes including coagulation, hematologic, metabolic and other genetic disorders, as well as witnessed and unwitnessed accidental injuries. CASE PRESENTATION We present a 7-month-old male with spells and incidental findings of bilateral subdural hematomas, retinal hemorrhages, and secondary macrocephaly, leading to investigation for NAT. Biochemical analysis showed excretion of a large amount of D-2-hydroxyglutaric in urine consistent with a biochemical diagnosis of D-2-hydroxyglutaric aciduria, a rare neurometabolic disorder characterized by developmental delay, epilepsy, hypotonia, and psychomotor retardation. None of these symptoms were present in our patient at the time of diagnosis. Molecular genetic testing revealed a pathogenic splice site variant (c.685-2A>G) and a variant of uncertain significance (c.1256G>T) with evidence of pathogenicity in the D2HGDH gene, consistent with a molecular diagnosis of D-2-hydroxyglutaric aciduria type I (OMIM #600721). CONCLUSION Since several metabolic disorders, including D-2-hydroxyglutaric aciduria type I, can present solely with symptoms suggestive of NAT (subdural and retinal hemorrhages), an early metabolic evaluation by urine organic acid analysis should be included in clinical protocols evaluating NAT. A methodical and nonjudgmental approach coordinated between pediatricians and metabolic specialists is also necessary to ensure that rare genetic conditions are not overlooked to prevent devastating social, legal, and financial consequences of suspected child abuse.
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Affiliation(s)
- Ester Perales‐Clemente
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | | | - April L. Studinski
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | | | - William J. Laxen
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Devin Oglesbee
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
| | - Arne H. Graff
- Departments of Pediatric and Adolescent Medicine and Family MedicineMayo ClinicRochesterMinnesotaUSA
| | - Piero Rinaldo
- Biochemical Genetics Laboratory, Department of Laboratory Medicine and PathologyMayo ClinicRochesterMinnesotaUSA
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Lyme Disease Misinterpreted as Child Abuse. Case Rep Orthop 2021; 2021:6665935. [PMID: 33628554 PMCID: PMC7880705 DOI: 10.1155/2021/6665935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 01/23/2021] [Accepted: 01/27/2021] [Indexed: 11/17/2022] Open
Abstract
Child abuse is one of the most common causes for child fatality in the United States. Inaccurate reporting of child abuse combined with scarcity of resources for child abuse evaluations can lead to unintended consequences for children and their families. The differential diagnosis of child abuse is varied. To our knowledge, there are no reports in the literature on Lyme disease mimicking child abuse. The current study presents the case of a child from an endemic area for Lyme disease presenting with skin bruising, fracture, and swollen knee. The child was reported for child abuse by the pediatrician and then referred to the orthopaedic surgeon for fracture care.
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15
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Rey-Salmon C, de Boissieu P, Teglas JP, Adamsbaum C. Abusive Head Trauma in Day Care Centers. Pediatrics 2020; 146:peds.2020-013771. [PMID: 33172921 DOI: 10.1542/peds.2020-013771] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Abusive head trauma (AHT) warrants particular attention in terms of prevention. One of the key questions asked is how often AHT occurs in infant day care centers compared with private parental or nonparental homes. To investigate this, we studied the caretaking arrangement and child's location at the time of injury in a cohort of cases involving AHT from the courts. METHODS This multicenter retrospective study covering an 18-year period included all medical and court records of 323 children (2.5 months to 3 years) with AHT, confirmed by the authors acting as medical experts. All markers for abuse and forensic written reports were analyzed by using a standardized data collection tool. The usual child care arrangement and the child's location at the time of injury were noted. The percentage of day care centers found in the study was compared to the expected rate in the French population (19.5%) by using the χ2 test. RESULTS In 317 AHT cases (98.5%), the assault occurred in a private home (4 in other indoor settings and 1 with missing data). In only 1 case, shaking occurred in a day care center when the nurse was alone with the infant for a few minutes. In 317 cases (98.5%), the usual child care arrangement was by a single adult in charge of 1 or more children. CONCLUSIONS The fact that AHT is an unusual occurrence in day care centers could help social service agencies make decisions in terms of prevention. Recent government policies regarding stay-at-home orders during a pandemic have given this issue new relevance.
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Affiliation(s)
- Caroline Rey-Salmon
- Pediatrics and Forensic Unit, Hôtel Dieu Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
| | | | - Jean-Paul Teglas
- Centre for Research in Epidemiology and Population Health U1018, National Institute of Health and Medical Research, Paris, France
| | - Catherine Adamsbaum
- Faculty of Medicine, Paris-Saclay University, Le Kremlin-Bicêtre, France .,Pediatric Radiology, Bicêtre Hospital, Assistance Publique Hôpitaux de Paris, Le Kremlin-Bicêtre, France
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16
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Gregory KA, Fingarson AK. Bruising in Infants and Children: Minor Skin Injuries Can Have Major Implications. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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17
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Shaw J, Simonton K. Pediatric Fractures: Identifying and Managing Physical Abuse. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2020. [DOI: 10.1016/j.cpem.2020.100786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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Van Cauter S, Severino M, Ammendola R, Van Berkel B, Vavro H, van den Hauwe L, Rumboldt Z. Bilateral lesions of the basal ganglia and thalami (central grey matter)-pictorial review. Neuroradiology 2020; 62:1565-1605. [PMID: 32761278 PMCID: PMC7405775 DOI: 10.1007/s00234-020-02511-y] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 07/30/2020] [Indexed: 12/11/2022]
Abstract
The basal ganglia and thalami are paired deep grey matter structures with extensive metabolic activity that renders them susceptible to injury by various diseases. Most pathological processes lead to bilateral lesions, which may be symmetric or asymmetric, frequently showing characteristic patterns on imaging studies. In this comprehensive pictorial review, the most common and/or typical genetic, acquired metabolic/toxic, infectious, inflammatory, vascular and neoplastic pathologies affecting the central grey matter are subdivided according to the preferential location of the lesions: in the basal ganglia, in the thalami or both. The characteristic imaging findings are described with emphasis on the differential diagnosis and clinical context.
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Affiliation(s)
- Sofie Van Cauter
- Department of Medical Imaging, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium. .,Department of Radiology, University Hospitals Leuven, Herestraat 39, 3000, Leuven, Belgium.
| | - Mariasavina Severino
- Neuroradiology Unit, IRCCS Instituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Rosamaria Ammendola
- Neuroradiology Unit, IRCCS Instituto Giannina Gaslini, Via Gerolamo Gaslini 5, 16147, Genoa, Italy
| | - Brecht Van Berkel
- Department of Medical Imaging, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.,Department of Radiology, University Hospitals Leuven, Herestraat 39, 3000, Leuven, Belgium
| | - Hrvoje Vavro
- Department of Diagnostic and Interventional Radiology, University Hospital Dubrava, Avenija Gojka Šuška 6, Zagreb, Croatia
| | - Luc van den Hauwe
- Department of Radiology, University Hospital Antwerp, Wilrijkstraat 10, 2650, Edegem, Belgium.,Department of Medical Imaging, AZ KLINA, Augustijnslei 100, 2930, Brasschaat, Belgium
| | - Zoran Rumboldt
- Department of Radiology, University of Rijeka School of Medicine, Ulica Braće Branchetta 20, 51000, Rijeka, Croatia.,Department of Radiology, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
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19
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Ali-Panzarella AZ. A Diagnostic Approach to Conditions that Mimic Sexual Abuse. Pediatr Ann 2020; 49:e334-e340. [PMID: 32785717 DOI: 10.3928/19382359-20200717-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Primary care providers are often the first point of contact when there are concerns of child sexual abuse. The history is the key factor in making the diagnosis as most children who have experienced child sexual abuse do not have an abnormal anogenital examination. When anogenital symptoms precipitate concerns for sexual abuse, especially in the absence of a history of sexual abuse, it is important to be aware of conditions that mimic sexual abuse. Being familiar with such conditions allows the provider to determine appropriate management, differentiate an anatomical variant or medical condition from abuse, and provide reassurance to the patient and family. Unnecessarily reporting these cases can have detrimental effects on the patient and family. If any doubt arises, patients can be referred for further evaluation by an expert in child abuse. This article presents many common medical conditions that can mimic sexual abuse, with a focus on history, examination findings, and management. [Pediatr Ann. 2020;49(8):e334-e340.].
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20
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Turillazzi E, Toni C, Turco S, Di Paolo M. Finding the Victim of Abuse: A New Frontier of Physicians' Liability? Data From a Local Italian Experience on Minor Maltreatment. Front Pediatr 2020; 8:309. [PMID: 32637388 PMCID: PMC7316952 DOI: 10.3389/fped.2020.00309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/13/2020] [Indexed: 12/21/2022] Open
Abstract
Violence toward minors is a widespread phenomenon and effective programs are desperately needed to prevent it. Data from the literature showed that underreporting child/adolescents abuse has become a widespread phenomenon, exposing minors to additional harm from further potentially dangerous situations. It is proved that systematic screening and standardized procedures for minors presenting at emergency departments with the suspicion of abuse might increase the detection rate, reducing the risk of underreporting. In Italy a system of mandatory reporting is in place, and it is considered to be crucial in detecting abuse and preventing further harm to children. In this paper we report our experience with a regional (Tuscany) project named "Codice Rosa" (Pink code) introduced in 2014 with the aim to treat and protect the most vulnerable bracket of the population. We present data concerning the access of minors for suspected abuse at the emergency room of the local hospital, focusing on a case of omitted diagnosis leading to further violence episodes. According to our experience, since the introduction of the "Pink Code" there have been 43 cases of reported child abuse, with an increasing trend throughout these years (from 1 reported event in 2015 to 16 reported events in 2018). Despite the limited number of our population, the increasing trend in the reported events was particularly evident for bullying cases (n = 0 in 2015; n = 4 in 2018). Despite data are still limited, the procedure proved effective in preventing child abuse, though it could still be implemented. Minor abuse and maltreatment are important health issue globally which can lead to significant physical and psychological morbidity. Implementing knowledge of healthcare professionals on how to deal with child abuse and introducing educational programs on recognition, treatment and report of child abuse is mandatory not only to prevent missing diagnosis of child and minor maltreatment, but also to reduce the risk of professional liability on different bases.
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Affiliation(s)
- Emanuela Turillazzi
- Section of Legal Medicine, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Chiara Toni
- Section of Legal Medicine, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Sara Turco
- Section of Legal Medicine, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Marco Di Paolo
- Section of Legal Medicine, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
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Imaging findings of Menkes disease, a radiographic mimic of abusive trauma. Radiol Case Rep 2019; 14:993-996. [PMID: 31198482 PMCID: PMC6556522 DOI: 10.1016/j.radcr.2019.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Revised: 05/07/2019] [Accepted: 05/07/2019] [Indexed: 11/25/2022] Open
Abstract
Menkes disease is a rare X-linked recessive disorder caused by impaired copper absorption and transport. Presented here is a case of a 12-week-old male who presented with hypotonia and multiple metaphyseal fractures. Further imaging and workup revealed a diagnosis of Menkes disease. While nonaccidental trauma is a much more common cause of metaphyseal bone fractures, encephalopathy, and subdural hematomas in infants, Menkes syndrome should be considered in the setting of corroborating signs and symptoms, as early diagnosis and treatment can delay progression of the disease.
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22
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Abstract
PURPOSE OF REVIEW Despite an increasing understanding of the impact of emotional trauma and physical abuse on children, clinicians and hospitals still sometimes miss the diagnosis of abuse. The literature in 2017 focused on creating standardized approaches to recognition and diagnosis of physical abuse and occult injury, including using the electronic medical record to provide triggers for consultation of the hospital Child Protection Program. The American College of Radiology updated their standardized approach to the evaluation of physical abuse in the child, and other authors gave us screening tools for commercial exploitation, as well as guidance about how to recognize risks for emotional abuse in families. The opioid epidemic and legalization of marijuana are both impacting children, and providers are searching for ways to provide support for parents with substance use disorders whilst considering the safety of children.This article reviews relevant publications during the past year about issues of child maltreatment. It is intended to guide those providers in primary care or other medical disciplines who care for children and families. RECENT FINDINGS Child maltreatment cases are still not always diagnosed, either because of provider bias (leading to under evaluation), or because clinicians lack experience or understanding of proper evaluation approaches. There are many new tools to assist in recognition of abuse, including screening instruments and flags that can be used in the electronic medical record to trigger a consult with the Child Protection Program. The evaluation and diagnosis of sexual abuse continues to evolve, with the literature providing advice about what is or is not normal on physical exam, as well as advice for providers who work with adolescent sexual assault victims. The debate about the validity of abusive head trauma (AHT) diagnoses continues, with sweden being the most recent center of controversy. With the opioid epidemic having such a significant effect on families and children, clinicians are struggling to support parents with substance use disorder while protecting children from the impact of their parents' disease. SUMMARY The past year in child abuse literature has yielded increased clarity in screening and diagnostic recommendations across the fields of physical abuse, AHT, sexual abuse, and commercial sexual exploitation of children (CSEC). The body of literature surrounding emotional abuse and neglect continues to grow, especially in light of the burgeoning opioid epidemic. Critically, the year's research reflects an evolving understanding of effective prevention and intervention initiatives to address child maltreatment.
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