Two Missed Cases of Abuse: Lessons Learned

THE CASES

CASE 1 A 7-month-old male infant was brought to the emergency department (ED) by his biological mother, who reported noticing dried blood on the baby's penis and in his mouth. For several hours prior, he had been in the care of her boyfriend. On physical examination, there were severe ecchymoses and petechiae on the penile glans and shaft (Figure 1), ecchymoses on the right side of the soft palate, a laceration of the lingular frenulum, and a 2-cm bruise with dried blood over the right lip.

Figure 1

A report was made to child protective services and law enforcement, and a child abuse expert was consulted. The ensuing evaluation uncovered a right-sided occipital skull fracture without intracranial bleeding and healing anterolateral fractures of the right seventh and eighth ribs. There were no retinal hemorrhages, and results of a thorough workup for infectious, metabolic, and hematological causes of the injuries were unremarkable.

The comprehensive social services and forensic investigations revealed that the infant had been seen by his pediatrician 2 weeks earlier for a well-child visit. The pediatrician's note reported "ecchymoses at the posterior buttocks secondary to sitting in one position for too long" and estimated the timing of these bruises as "4 to 5 days of age" based on their appearance. Nothing further was noted or done regarding this finding. The mother's boyfriend was discovered to have recently been released from prison secondary to conviction for sexual offenses. Although the mother initially denied knowledge of his history, she was subsequently found to have been aware of this history and to have allowed her children to be in his care.

CASE 2 A 26-month-old boy was brought to the ED by his biological parents. The mother reported that the child had been "beaten" while in the care of other family members. Both parents reported that he had "multiple bruises all over his body" and that he was "walking with a limp" of the right leg; the mother said that she noticed the child's injuries after he returned from spending time with another family member

On physical examination, the child was noted to be malnourished, pale, and apathetic with multiple bruises and abrasions that were too numerous to count on the forehead, bilateral cheeks, anterior chest, torso, lower back, all 4 extremities, inner thighs, and genitals (Figure 2). Multiple curvilinear marks were visible on the chest (Figure 3), and unusual abrasions were seen on the inner thighs. The left upper extremity and right lower extremity exhibited tenderness and decreased range of motion. After initial stabilization and treatment, the child was transferred to a nearby university hospital and admitted for further care.

Figure 2

Figure 3

A report was made to child protective services and law enforcement. Further studies revealed a healing fracture of the right tenth rib with callus formation, an acute right proximal tibial fracture, a deep hematoma anterior to the right common femoral artery (identified on CT scan), and transient elevation of liver enzyme levels. Results of investigations to uncover occult intracranial and retinal hemorrhages were negative, as were the results of evaluations for metabolic and hematological abnormalities.

The comprehensive social services and forensic evaluations revealed that until the age of 20 months, the child was in foster care because of the biological mother's profound psychiatric disorder. He was placed back with his biological parents at 21 months of age. On further questioning at the hospital on the day of presentation to the ED, inconsistencies were noted in the parents' histories regarding the nature of the child's injuries, and the mother admitted that she had physically abused her son repeatedly during the 5 months that he had been back in her care. The mother had brought him to see a new pediatrician for a wellchild visit 3 months earlier. The pediatrician's notes documented the physician's having seen "a bruise to the right ear." Nothing further was noted regarding additional questioning about the cause of the bruise or about the medical/psychosocial history of the previous 23 months.

How might the abuse of these 2 children have been identified and stopped at an earlier, less harmful stage?

Answer on next page.

ANSWER: By Noticing and Following Up on Suspicious Bruises

DISCUSSION

Using information from a comprehensive multidisciplinary investigation (involving child protective services and law enforcement) and a review of medical records and medical literature, the child abuse pediatrician was able to offer an opinion on each of these cases. The child abuse expert's opinion in the first case was that the pattern of penile injury and the presence of petechiae on the posterior oropharynx were consistent with active and receptive fellatio. It was concluded that the infant's rib fractures and skull fractures were consistent with prior physical abuse. The expert noted that the presence of a large bruise to the buttocks was not explained by sitting in one position for a long time and represented additional evidence of ongoing abuse (furthermore, a specific time frame for this bruising could not be established based solely on appearance). Legally, this case resulted in the conviction and incarceration of the mother's boyfriend. After learning of the outcome, the infant's primary care pediatrician reported not having considered abuse at the time he noticed the bruise on the buttocks.

In the second case, the child abuse expert concluded that the patterns of skin bruising were consistent with inflicted injuries and that the unusual skin lesions represented human bite marks (see Figure 3), human hand grab marks (see Figure 2), and skin torn when duct tape was removed (Figure 4). The deep soft tissue and skeletal injuries were consistent with blunt force trauma that had occurred at various times in the past. This case resulted in the conviction and incarceration of the child's biological mother and termination of her parental rights. The child has since been adopted. After learning of the outcome in this case, the primary care pediatrician said she did not consider abuse at the time she noticed the ear bruise.

Figure 4 – A child abuse expert determined that the lesions shown here were the result of skin tearing when duct tape was removed.

THE IMPORTANCE OF RECOGNIZING AND RESPONDING TO SUSPICIOUS BRUISING

These 2 cases demonstrate how important it is for pediatric primary care providers to recognize "abuse identifiers," such as suspicious bruising patterns, in their patients. Suspicious bruises were evident in both these children weeks or months before the presentations documented here: in the first case, a bruise to the buttocks in a pre-ambulatory infant, and in the second case, a bruise to the outer ear. Although both patients were otherwise well-appearing and without complaints at the time of their office visits, these skin findings should have prompted consideration of the possibility of inflicted injury. In both cases, the abuse escalated in the weeks or months following the children's office visits.

Because bruises are common in healthy, active children, interpreting bruises can be a diagnostic challenge. Nevertheless, cutaneous injuries such as bruises are the most common and clearly apparent manifestations of child physical abuse.¹ Thus, it is important to become adept at distinguishing between normal and abnormal bruising patterns. When bruising in an unusual pattern or location is noted, give consideration to the possibility of abuse-as well as to an accident or another medical condition-as the cause.

Interpreting bruises requires consideration of contextual factors. These include:

• The age and development of the child.
• The history provided by the caregiver.
• The site and pattern of the bruise(s).

Certain locations and patterns of bruising are more highly correlated with non-accidental trauma.² Over the past decade, many reports have categorized the location and number of skin bruises in normal and abused children of varying ages. Accidental bruises are found in young children as they develop independent mobility, because of their tendency to bump into objects and to fall forward as they walk or run.³ These bruises are almost exclusively on the anterior bony prominences, such as the forehead and shins. Accidental bruising in infants younger than 6 months is extremely rare; this observation has resulted in the phrase "if you don't cruise, you don't bruise."⁴ At all ages, accidental bruising is reported as uncommon to nonexistent on the posterior body surfaces (including the buttocks and thighs), the torso (including chest and abdomen), and the ears.^5-7

In their landmark 2001 study, Labb and Caouette⁸ examined the skin of 1467 children and adolescents aged from newborn to 17 years to characterize skin injuries in a normal, healthy population of children. In infants younger than 9 months, at least 1 skin injury was visible in 11.4%, whereas in children aged 9 months or older, 75% exhibited 1 or more skin injuries. In children of all ages, less than 2% had bruises to the thorax, abdomen, pelvis, or buttocks, and less than 1% had bruises to the chin, ears, or neck. In fact, bruises to the ears (Figure 5) and buttocks have been associated statistically with injuries of abuse.⁶ Many authors have emphasized the extreme significance of bruises in either of these locations as a strong indicator of abuse.^9,10

Figure 5 – This bruise on another child's ear-like many ear bruises in children-was the result of abuse.

Evaluation of a bruise that either has no plausible explanation, is located on a suspicious area of the body, or does not match with the child's developmental stage must be addressed at the time of the visit.^4,11,12 Regardless of the reason for the office visit, undress the child and examine him or her fully for other bruises, other areas of injury, and evidence of other medical conditions that can result in bruising.^13,14 If questions or concerns remain about the cause of the injuries, it is imperative that the necessary steps be taken to involve the appropriate medical or social service experts.

ADDRESSING OBSTACLES TO THE RECOGNITION AND REPORTING OF ABUSE

Why did the pediatricians in the 2 cases presented here not recognize the significance of the bruises they saw?

Underreporting of child abuse by physicians has been well documented.^15-18 A 1999 study found that 31% of abusive head trauma cases were missed on initial presentation.¹⁸ When the diagnosis was finally established, 28% of the patients had been re-injured, 41% had medical complications related to the delay in identifying child abuse, and 9% had died. Inflicted head injury was more likely to be missed in very young, white infants with less severe symptoms and from intact families.

Many barriers to the recognition and reporting of child abuse by physicians have been identified.^15,17-20 Lack of experience can create a sense of discomfort and self-doubt on the part of the clinician when confronted with the possibility of child abuse. Familiarity with the family may lead a practitioner to conclude that a parent they have known for years is not capable of abusing a child. A family's race or socioeconomic status as well as the physician's personal biases may play a role.

Recognizing potential child abuse is only part of a physician's responsibility. Although the specific statutes vary somewhat from state to state, physicians are mandated to report child abuse in all 50 states.²¹ The statutes mandate that physicians make a report when there is a "reasonable suspicion" of abuse.²¹ Studies have found, however, that many physicians do not report their suspicions to child protective services even when they appropriately identify signs of abuse.^15,17,22-24 Physician surveys have identified reasons for underreporting, including fear of jeopardizing their relationship with the family, discomfort at the possibility of having to testify in court, and lack of understanding of the state mandate.^15,17,25 Absolute certainty that abuse has occurred is not required to trigger the mandated reporter's responsibility under state law-and there is considerable variability in how "reasonable suspicion" is defined by physicians, leading to inconsistent reporting.²⁶

Inadequate educational exposure to child abuse during and following training is often a factor in missed cases. Physicians who have received more training and education in child abuse are more likely to report suspected cases of child maltreatment.¹⁷ However, many residents have limited experience or training in recognizing and reporting child abuse. Only 41% of accredited pediatric residency programs in the United States have required clinical rotations in child abuse and neglect. In fact, 25% of residency programs have no child abuse rotation. ¹⁶ Pediatrics residency training programs and other training venues need to actively involve residents in the process of reporting concerns about child abuse to child protective services. Residents who are required to call child protective services as part of their training will be more comfortable with this process.

Continuing medical education in child abuse is also important.¹⁷ Physicians with some training in the field of child abuse after residency are more likely to report all suspected cases of child abuse to child protective services than are physicians without such continuing education.¹⁵

IMPORTANCE OF CONSULTATION WITH CHILD ABUSE SPECIALISTS

In addition to training and education, an important resource for pediatricians is accessible consultative services from a child abuse pediatrician. Once abuse has been identified and reported, a comprehensive review of the child's medical record by an expert in child abuse is critical. This comprehensive review includes obtaining and reviewing all past and current medical records of the patient and siblings as well as pertinent medical and social assessments of family members and other involved adults. The review process can be facilitated through child advocacy centers, where law enforcement, child protective services, victim assistance, and medical experts engage in multidisciplinary, coordinated assessments of cases. This process can ensure that a thorough medical evaluation for all potential causes of the injuries is completed and that other medical conditions are not misdiagnosed as child abuse. Information on child advocacy centers in your area is available at http://www.nca-online.org.

In addition, child abuse pediatricians can provide valuable and educational feedback on individual cases to the treating medical providers. If the retrospective record review reveals that a medical provider missed an abuse indicator, then this can be brought to his or her attention with the goal of preventing such an oversight from happening again. In the 2 cases presented here, the child abuse expert did provide this type of educational feedback to the pediatricians involved.

Finally, involvement with a child abuse expert can potentially improve communication between physicians and child protective services with the ultimate result of increasing physician reporting rates.²⁵

The American Board of Pediatrics designated child abuse pediatrics as a formal subspecialty in 2005. A list of child abuse pediatricians in your area is available at http://www.aap.org or at http://www.helfersociety.org.

The Key Points

Pediatricians have unique opportunities to identify child abuse before it escalates by recognizing abuse indicators, such as suspicious skin bruises. Education and experience with child abuse, both in residency and through continuing education, can increase rates of recognition and reporting by primary care pediatricians. Child abuse pediatricians can be an invaluable resource for community pediatricians, assuring that evaluations of suspected abuse are comprehensive and objective and providing educational feedback to primary care clinicians.

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• Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don’t cruise rarely bruise. Puget Sound Pediatric Network. Arch Pediatr Adolesc Med. 1999;153:399-403.

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