This is the first in a three part series on child abuse. This issue covers Bruising and Fractures; the July issue will cover Failure to Thrive, Neglect and Munchausen’s by Proxy; the October issue will cover Shaken Baby Syndrome or Abusive Head Trauma.
The purpose of these newsletters is to aid criminal defense attorneys in early recognition of cases that should be investigated further by medical experts. Regardless, no case should simply be written off as child abuse until every alternative explanation can be ruled out.
Child abuse comes in many forms: sexual, physical, emotional. It also has many associated phrases: abusive head trauma, shaken baby syndrome, neglect, failure to thrive, molestation, Munchausen’s by proxy, and several others. It is the responsibility of the persons involved in the child’s care and the referring agencies, such as Child Protective Services in California, to fully investigate the injuries before charges are filed. It is unfortunate that many times charges are brought before a full medical evaluation has been done to rule out other causes of the injuries or the condition of the child. There are many “mimics” or other contributing factors that could explain why the child was flagged as a possible abuse victim, such as bruising and bone fractures.
Bruising There are many reasons why children get bruises that are not related to abuse. Blood and other disorders should be investigated and ruled out before that child is considered an abuse victim. Some of the things to look for are hemophilia, sickle cell disease, some types of anemia, Vitamin K Deficiency in combination with hypoprothrombinemia, Hermansky-Pudlak Syndrome (standard blood tests are normal in this disorder) and Scurvy (see more below). Also, many medications cause a tendency to bleed, such as ibuprofen (Advil, Motrin) and Prednisone. Other medications that pass through the breast milk may cause bleeding in an infant, such as Warfarin.
Bone Fractures There are several classifications of fractures that are considered highly suspicious of abuse including metaphyseal lesions, posterior rib fractures, scapular fractures, fractures of the spinous process, spiral fractures (humerus/femur), and ternal fractures. There are also increased concerns over multiple fractures, especially when they are of different ages or on both sides of the body (Alexander, 2010).
Fractures in children can often be explained away by the caregiver’s story. It is the case in which the fracture can’t be explained or the explanation doesn’t seem to fit the injuries that enters into the legal system. In these cases, criminal defense attorneys must seek out other potential causes.
Below is a brief description of a few of the mimics and what to look for:
- Osteogenesis Imperfecta (OI): Also known as Brittle Bone Syndrome, this is actually a disease of the connective tissue commonly associated with weak bones. It was previously thought to be solely genetically inherited. It is now recognized that new mutations can cause the disorder. There are 4 types in which two are classified into sub-types, making a total of 6 potential classifications of OI. The birth incidence is approximately 1 case in 20,000 births.
- Rickets/Vitamin D Deficiency: Rickets is a disease of growing bone that is unique to children and adolescents. Vitamin D deficiency rickets occurs when the metabolites of vitamin D are deficient. Less commonly, a dietary deficiency of calcium or phosphorus may also produce rickets. Natural sources of Vitamin D are limited to fatty, ocean-going fish and natural sunlight exposure. Cow’s milk in the US is fortified with Vitamin D. Therefore, the children at highest risk of Vitamin D Deficiency Rickets are infants who are solely breastfed and children who are fed a vegan diet, especially those with dark skin. Except in pediatric patients with chronic malabsorption syndromes or end-stage renal disease, nearly all cases of rickets occur in breastfed infants who have dark skin and receive no vitamin D supplementation.
- Scurvy: Scurvy is a dietary deficiency of Vitamin C that results in impaired collagen synthesis. It is most commonly associated with sailors in the Renaissance eras. It has been recognized in infants that had heated formula, pasteurized milk and a lack of orange juice in their diet. Hemorrhaging is a hallmark feature of scurvy and can occur in any organ, leading to bruising. Hair follicles are one of the common sites of cutaneous bleeding. Bone involvement is also common in infantile scurvy. Bruising and fractures together make Scurvy highly suspicious in abuse cases when unrecognized. Although scurvy is uncommon, it still occurs and can affect adults and children who have chronic dietary vitamin C deficiency. Infants and children on restrictive diets because of medical, economic, or social reasons are at risk for scurvy. Occurrence of scurvy is uncommon in those younger than 7 months. Most cases of infantile scurvy occur when the infant is aged 6-24 months.
To continue reading about what to watch for in suspected child abuse cases, click here.