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.
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.
- Ellerstein NS. The cutaneous manifestations of child abuse and neglect. Am J Dis Child. 1979;133:906-909.
- Hudson M, Kaplan R. Clinical response to child abuse. Pediatr Clin North Am. 2006;53:27-39.
- Carpenter RF. The prevalence and distribution of bruising in babies. Arch Dis Child. 1999;80:363-366.
- 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.
- Barber MA, Sibert JR. Diagnosing physical child abuse: the way forward. Postgrad Med J. 2000;76:743-749.
- Dunstan FD, Guildea ZE, Kontos K, et al. A scoring system for bruise patterns: a tool for identifying abuse. Arch Dis Child. 2002;86:330-333.
- Maguire S, Mann MK, Sibert J, Kemp A. Are there patterns of bruising in childhood which are diagnostic or suggestive of abuse? A systematic review. Arch Dis Child. 2005;90:182-186.
- Labbé J, Caouette G. Recent skin injuries in normal children. Pediatrics. 2001;108:271-276.
- Feldman KW. Patterned abusive bruises of the buttocks and the pinnae. Pediatrics. 1992;90:633-636.
- Kini N, Lazoritz S. Evaluation for possible physical or sexual abuse. Pediatr Clin North Am. 1998;45:205-219.
- Sirotnak AP, Grigsby T, Krugman RD. Physical abuse of children. Pediatr Rev. 2004;25:264-277.
- Wedgwood J. Childhood bruising. Practitioner. 1990;234:598-601.
- Johnson TL. Updates and current trends in child protection. Clin Pediatr Emerg Med. 2004;5:270-275.
- Lane WG. Diagnosis and management of physical abuse in children. Clin Fam Pract. 2003;5:493-514.
- Flaherty EG, Sege R. Barriers to physician identification and reporting of child abuse. Pediatr Ann. 2005;34:349-356.
- Narayan AP, Socolar RR, St Claire K. Pediatric residency training in child abuse and neglect in the United States. Pediatrics. 2006;117:2215-2221.
- Van Haeringen AR, Dadds M, Armstrong KL. The child abuse lottery— will the doctor suspect and report? Physician attitudes towards and reporting of suspected child abuse and neglect. Child Abuse Neglect. 1998;22:159-169.
- Jenny C, Hymel KP, Ritzen A, et al. Analysis of missed cases of abusive head trauma. JAMA. 1999;281:621-626.
- Hampton RL, Newberger EH. Child abuse incidence and reporting by hospitals: significance of severity, class, and race. Am J Public Health. 1985;75:56-60.
- Lane WG, Rubin DM, Monteith R, Christian CW. Racial differences in the evaluation of pediatric fractures for physical abuse. JAMA. 2002;288:1603-1609.
- US Department of Health and Human Services. Mandatory reporters of child abuse and neglect. 2003 Child Abuse and Neglect State Statute Series: Statutes-at-a-Glance. National Clearinghouse on Child Abuse and Neglect Information. http://www.childwelfare.gov/systemwide/laws_policies/statutes/ mandaall.pdf. Accessed June 19, 2007.
- Delaronde S, King G, Bendel R, Reece R. Opinions among mandated reporters toward child maltreatment reporting policies. Child Abuse Negl. 2000;24: 901-910.
- Saulsbury FT, Campbell RE. Evaluation of child abuse reporting by physicians. Am J Dis Child. 1985;139:393-395.
- Zellman GL. Report decision-making patterns among mandated child abuse reporters. Child Abuse Negl. 1990;14:325-336.
- Vulliamy AP, Sullivan R. Reporting child abuse: pediatricians’ experiences with the child protection system. Child Abuse Negl. 2000;24:1461-1470.
- Levi BH, Brown G. Reasonable suspicion: a study of Pennsylvania pediatricians regarding child abuse. Pediatrics. 2005;116:e5-e12.