Is It Abuse?
Allegations of child abuse have very serious implications for all parties involved. The importance of a thorough history of the injury, medical history of the child, and a complete medical work-up are crucial to determine the most likely cause of the injury or injuries to the child. The following information was gleaned from the literature to assist attorneys in understanding some of the most important elements to look for in an alleged child abuse case.
Work-ups for a child with a diagnosed brain bleed should include:
- A skeletal survey
- Testing for bleeding disorders such as hemophilia
- Testing for metabolic diseases such as glutaric aciduria type 1 which can present with brain bleeding
- Complete birth history for neonates
- Was the birth complicated by vacuum extraction and/or forceps? Both techniques can cause brain hemorrhages.
- Was there any other occult birth trauma?
For children with bruising, the following conditions should be considered:
- Mongolian spots – these appear as bruises but are birthmarks, usually a bluish-gray color, most commonly located just above the gluteal cleft. These marks do not fade or change color. These spots should be documented in well-child visits.
- Idiopathic thrombocytopenia purpura, Henoch-Schonlein purpura and leukemia – these conditions can all cause bruising that may arouse suspicions of abuse.
- Bleeding disorders – one such example is hemophilia. Appropriate lab tests should be obtained.
Children with skeletal injury should be given the following considerations:
- Is there one fracture or multiple fractures?
- What is the age of the child? Accidental fractures are rare in babies and toddlers.
- Was a skeletal survey completed? There should be two views of each area of the body for a total of at least 20 images.
- Does the child have a history of osteogenesis imperfecta or is it a possible diagnosis? Is there a family history of OI?
The provider who makes a diagnosis of child abuse must take a detailed and thorough history. The following should be included in the H&P:
- A timeline of what occurred and when
- Who saw the child last when he or she looked well
- Who was there when the injury/injuries were discovered
- Details of the mechanics of the alleged injury
- Details of the child’s health prior to the alleged injury
- If the child is a neonate, obtain thorough birth history
What does this have to do with criminal cases?
Attorneys should be aware that there are conditions that can be mistaken for abuse in children and it is imperative that the right questions are being asked to rule out or mitigate abuse. Important also are a thorough history and exam, and testing which are clearly documented in the records to show that all possible causes of the injuries have been examined. This checklist can help to assist attorneys in cases of alleged child abuse.
Pomeranz, E. S. (2018). Child abuse and conditions that mimic it. Pediatric Clinics of North America, 1135-1150.
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