Blue Spots, Coining, and Cupping: How Ethnic Minority Parents Can Be Misreported as Child Abusers; Chin, William Y.
The mistaken diagnosis of child abuse: a three-year USAF Medical Center analysis and literature review.
Medical personnel who evaluate children for child abuse and neglect (CAN) must be familiar with the many pediatric conditions that resemble CAN in order to avoid over reporting. During a 3-year period, a total of 504 suspected child abuse patients were evaluated by our CAN team. After preliminary evaluation, 264 (52%) of these cases were unsubstantiated. Eighteen of these 264 (7%) were initially considered as cases of CAN but were later proven to be conditions that were misdiagnosed as CAN. Thirteen of the 18 (72%) were readily diagnosed after consultation with a pediatrician or other health care consultant. Investigation of the remaining 5 patients (29%) was more difficult and more extensive, requiring a period of separation from the parents with consequent emotional hardship to the family. These conditions included (1) a patient with osteogenesis imperfecta type IV, (2) a patient with Ehlers-Danlos syndrome, (3) two patients with benign external hydrocephaly of infancy, and (4) a patient with Crohn's disease, who was evaluated for sexual abuse because of chronic abdominal pain. A comprehensive literature review of pediatric conditions that may mimic CAN is presented by diagnostic categories to assist clinicians in differentiating medical conditions that may simulate CAN. Methods to support parents who have been incorrectly reported are discussed.
W. James King and colleagues1 report that bruising was noted on examination for 46% of the children in their study of shaken baby syndrome in Canada. Such a high proportion warrants attention, but we must ensure that the diagnosis is correct.
A few years ago, a mother brought to my office her 31/2-month-old child, who had ecchymosis of the left cheek and left pinna. The mother reported 3 separate episodes of bruising before the presenting episode. She suspected abuse by a babysitter, and the case was reported to the appropriate authorities. The child was investigated for bleeding disorders, but none were found. On the basis of the results of a pediatric examination arranged by social services, the child was removed from the mother's care. Subsequent medical care was provided by the family physician of the child's foster parent.
I next saw the child at 10 months of age during a day visit to the birth mother. The presenting problem at that time was described as recurrent impetigo of the left pinna. Infected eczema of the left pinna had been diagnosed on several occasions in the intervening period, and a dermatologist had confirmed the diagnosis of impetigo. This story sounded odd and led me to speculate that the child might have a herpes simplex infection. The dermatologist had taken a sample for culture, and a phone call to the local laboratory confirmed that the viral swab was growing herpes simplex I. In view of this information, I suspected that the episodes of ecchymosis of the left pinna seen in the first few months of life were actually the result of the original herpes infection.
After letters and phone calls to the Ministry of Children and Families, the child was finally returned to the birth mother in the second year of life. The lesson to be learned is that in our haste to ensure the safety, welfare and protection of our pediatric patients, we should remember that all that glitters is not gold.
A.J. Walter Physician Surrey, BC
Several medical conditions have been reported to mimic the physical manifestations of child abuse and neglect (CAN). These conditions include genetic, congenital, and other disorders that may result in poor weight gain, bone fracture, or skin lesions that appear to be bruises or burns. Society demands that medical personnel who care for children be aware of the many indicators that suggest CAN. This article is a review of 6 of 18 cases among 264 that were referred to a child abuse team over a 3-year period because of suspected abuse in which medical disorders were initially and erroneously diagnosed as CAN. This report also suggests ways to support aggrieved parents who have been mistakenly reported to be child abusers.