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.
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.
