Greg Wallace, DO

A 3-year-old child was brought to her primary caregiver by her maternal grandmother. The child was a frequent patient at the indigent clinic, and it was well established that she was at the center of a heated custody dispute. The grandmother often provided care for the child and usually accompanied her to the clinic. The grandmother reported she had not seen the child for 7 to 10 days. Before this visit, the grandmother could not recall anything wrong with the child’s hand. She reported that when the child was dropped off to her on this day, she noticed this lesion 

 on the child’s hand. The mother allegedly stated that the lesion had appeared after a 2-day visit with the father (which had ended the day before).

The mother was called to complete the history but she was unavailable. When the grandmother was questioned about a possible cigarette burn, she stated the mother did not smoke but she thought the father might. The grandmother also verbalized her concern regarding the mother’s apparent lack of interest in treating the injury.

The lesion was 8 to 9 mm in diameter. There was cratering in the center of the lesion with a rolled border. There were no other similar lesions on any other body surface. The minimal bruising that was noted on exam was felt to be consistent with normal childhood bruising. The child did not say anything about the lesion.

The case was reported as a possible burn to Child Protective Service (CPS). The family was well known to CPS. There had been other reports of possible abuse but none had ever been substantiated.

Has this child been abused, or is there another explanation that mimics physical abuse?


A cigarette burn was strongly suspected. A cigarette burn is usually 8 to 10 mm; the wound is cratered, indicating that the burn is more severe in the center. This is because a cigarette burn is hotter at its center. Also, inflicted burns are round. Accidental burns generally involve a glancing blow and therefore assume an irregular shape.

In case reports of cigarette burns in abuse, most are reported on hands and feet. Accidental burns are more often on the face, neck or hands.

One must always consider what other conditions could look similar to this lesion. These include infection (bullous impetigo), moxibustion, and traumatized insect bites.

The intriguing thing about this case was the mother’s response. Normally in a custody battle, the mother would be calling attention to an injury-which in this child’s case allegedly occurred during visitation with the father-in the hope of gaining custody. The other concerning issue was that there was no blister to indicate a recent burn as alleged.

CPS found that neither the mother nor the father smoked. The mother later confessed that her boyfriend had burned the child “accidently” when she was threatened with the loss of her children.  Another child living in the home also had possible burns. The second child was referred back to the primary care clinic and the lesions were documented. This child identified the boyfriend as the abuser but implicated the mother as well. The boyfriend ultimately confessed to burning the children with a cigarette. 

Unfortunately, a clear answer is not always determined in abuse cases. This case ended well, with confirmation of the action by a child victim and with a confession by the perpetrators.

Follow-up is essential when etiology is uncertain. Typically a burn, from a cigarette or another source, takes several weeks to resolve compared to other conditions included in a differential diagnosis. In this case, the burn healed well in 4 to 6 weeks and resulted in a small scar 

Faller-Marquardt M S, Pollak S, Schmidt U. Cigarette burns in forensic medicine


Sibert JR, Maguire SA, Kemp MA. How good is the evidence available in child protection? 

Articles

  A 3-year-old child was brought to her primary caregiver by her maternal grandmother who was concerned about the infected lesion shown here. The child was at the center of a heated custody dispute and abuse was strongly suspected. But could the lesion’s origin be something else?   

An Infected Finger: Child Abuse – or Mimic?

A 3 ½-month old boy was brought to an outlying hospital after 12-hours of fussiness and poor feeding. The mother reported that the child had an upper respiratory tract infection a week earlier and had experienced periods of inconsolable crying during the previous day that lasted 10 to 15 minutes. There was no history of diarrhea, vomiting, fever, or trauma.

The prenatal course was unremarkable. The 25-year-old mother, gravida 2, para 1, denied taking any illict drugs or medications other than prenatal vitamins during pregnancy. The baby was born at term and weighed 3.2 kg (25th percentile). The newborn period was complicated by persistent pulmonary circulation, pulmonary hypertension, and mild respiratory distress. The baby required mechanical ventilation and dopamine/dobutamine for 24 hours while in the neonatal intensive care unit. Circumcision was done in the newborn period stay without significant bleeding.
  
Both parents were in good health. The child’s growth and development was within normal limits according to the primary care doctor’s history. Newborn screening test results were all within normal limits. The child was taking no medication and had been fed with formula since birth. There was no other pertinent medical, social, or social service history.

On physical examination the infant weighed 4.75 kg (third percentile for growth); temperature was 37.1 

C; heart rate was 124 beats per minutes; respiratory rate was 30 breaths per minute; and capillary refill was <3 seconds. The child’s mother reported that he had a weak suck, slept intermittently, and cried inconsolably when awakened. His cranial nerves appeared to be intact; pupils were 4 mm and reactive. There was no bruising on any body surface. There were no other abnormal findings.

Initial laboratory results were as follows: white blood cell count, 18.9/µL; hemoglobin, 7.9 g/dL; hematocrit, 23%; and platelet count, 455/µL. Renal profile was normal; transaminase levels were slightly elevated.

By the time these results were returned, a large hematoma was noted at the site of the blood draw. The infant’s condition was changing rapidly and a CT scan of the head was ordered. The scan revealed a large left parietal intraparenchymal hemorrhage (

. Edema was noted and a midline shift, with no herniation.

Following the CT scan the hemoglobin was rechecked and was 6.7 g/dL. Prothrombin time (PT) was >90 seconds (normal, 10.1 to 13.6 seconds); a partial thromboplastin (PTT) time was 181 seconds (normal, 26.4 to 35.9 seconds); and, fibrinogen level was 500 mg/dL (normal 200 to 400 mg/dL).

The infant was transferred to a tertiary care hospital where physical abuse was considered high on the list of differential diagnoses because of the negative trauma history.

Could a medical condition explain this patient’s symptoms - - or do the symptoms point to abuse? 

On arrival at the tertiary care facility, the PT and PTT were again measured and similar values were obtained. A thrombin time was 13.1 seconds (normal 14.2 to 21.3 seconds). The child was treated with Vitamin K. The PT and PTT corrected rapidly and the child’s condition stabilized without further intervention. Given the rapid change in clinical condition, the child abuse team was not consulted during the initial period of the admission. Hematology was consulted to evaluate the elevated coagulation factors.

 reflects the clinical thought process that guided the differential diagnosis.

Factors  II, V, and X  levels were all within normal limits. Two sweat chloride values obtained on admission both measured >125mEq/L (normal <60 mEq/L).

The social service team was subsequently consulted and found no risk factors for abuse in the family.

A diagnosis of cystic fibrosis (CF) was confirmed, based on the 2 abnormally elevated sweat test values. CF is an inherited multisystem disorder of ion transport typically characterized by exocrine gland dysfunction, obstruction and infection of airways, hepatic dysfunction, and by malabsorption and the associated consequences. Presenting manifestations are numerous, but pulmonary and gastrointestinal complaints usually predominate.

In a study of more than 20,000 CF patients in the United States, acute or persistent respiratory symptoms such as cough, recurrent respiratory infection and bronchitis, failure to thrive, and frequent bulky, greasy stools were the top 3 presenting complaints.

 At diagnosis, fewer than than 2% of patients registered with the Cystic Fibrosis Foundation exhibited the fat-soluble vitamin deficiency and coagulopathy found in this child.

Only 7% of patients with CF experience a mild prolongation of the PT.

Bleeding disorders in patients with CF are rare and literature on the topic is scarce. Without a thorough initial medical investigation, this case might easily have led to a lengthy social service inquiry.

Teaching points
1. Cystic fibrosis can rarely present as a bleeding disorder.
2. Symptomatic bleeding has many causes and must be thoroughly investigated before an abuse diagnosis can be made.

 Bergman A,  Blessing-Moore J, O’Leary J. An unexpected complication of cystic fibrosis. 

 Carpentieri U,  Gustavson L, Haggard M. Misdiagnosis of neglect in a child with bleeding  disorder and cystic fibrosis. 

 O’Hare A, Eden O.  Bleeding disorders and non-accidental injury. 

 1984;59:860-864.4. Rashid M, Durie P, Andrew M, et al. Prevalence of vitamin K deficiency in cystic fibrosis. 

This 3 ½-month-old boy was brought to an outlying hospital after 12-hours of fussiness and poor feeding.

Intraparenchymal Hemorrhage: Child Abuse-or Mimic?

A 3 1/2-year-old girl, who is nonverbal because of an underlying neurological disorder, presented to day care with a pelvic bruise. The day-care attendant feared abuse and reported the findings to Child Protective Services (CPS).

The parents told CPS that the child had been alone with her father and fell getting out of the bathtub. The child was taken to a busy general hospital emergency department (ED) by the parents and the CPS worker. The parents gave the same explanation about the injury to the ED physician; they also noted that the child had a history of easy bruising. The ED physician determined that the injury was compatible with the history after conducting a physical examination and no laboratory tests.

The CPS worker was concerned that the ED visit had been too hasty and the situation inadequately evaluated. Therefore, the child was brought to an advocacy center for a second opinion a day after the ED visit. A thorough history was obtained and the family's account of the trauma remained unchanged. However, in the review of systems, the mother added that the child was having some difficulty with toilet training.

The second examination showed that there was no other bruising except on the pelvis.  The pelvis appeared to have 3 individual bruises; however, no clear pattern could be identified. A complete genital examination was done. The hymen, posterior fourchette, and fossa navicularis were all normal and no acute injury could be identified. No laboratory tests were obtained at that time. Because of the slight additions to the history, a home visit was requested for scene evaluation.

Do you suspect abuse--or an underlying medical cause?

Answer: Bruising Inflicted by the Child's Father

The home visit revealed that the bathtub had a sharp metal shower track on its upper edge. However, the child could have easily stepped out of the tub (given its height) without injury. The remainder of the scene appeared as the family had described it.

With the history of developmental delay, difficulty in toilet training, and the 3 separate bruises (without a pattern), a diagnosis of possible abuse was made. Law enforcement confronted the father with the expressed concerns and he confessed to abusing his child. The father recounted his frustration over toileting issues and that he had "stomped" the child as she tried to scoot away on the floor as he prepared her bath.

Recognizing children who are at high risk for abuse is key to identifying and preventing physical harm. Toilet training can be a challenge for any child. In a child who is nonverbal and neurologically challenged, as in this case, toilet training is especially challenging. It has long been recognized that toilet training is closely associated with abuse (in some cases fatal).

The American Academy of Pediatrics offers an excellent guide for parents whose child is being toilet trained.

 have also written recommendations for the primary care doctor to use as part of anticipatory guidance during well-child visits.

Another key point in this case was the scene investigation. Inspection of the site was far better than a mental visualization of how the injury may (or may not) have occurred.

 In this child's case, the presence of the metal rail and the height of the tub rendered the father's description of the accident highly suspect given the injury pattern.

This case underscores the fact that numerous children who are brought to primary care offices or the ED with seemingly mundane case histories are actually victims of abuse. A complete history and thorough investigation can make the difference in the final outcome. Many abused children present for medical care with minor trauma and are not properly identified: they often present later with more serious trauma.	*

A 3 1/2-year-old girl, who is nonverbal because of an underlying neurological disorder, presented to day care with a pelvic bruise. The day-care attendant feared abuse and reported the findings to Child Protective Services (CPS). The parents told CPS that the child had been alone with her father and fell getting out of the bathtub.

Pelvic Bruising in a Young Girl

A 3-year-old girl, who is nonverbal because of an underlying neurological disorder, presented to day care with a pelvic bruise. The day-care attendant feared abuse and reported the findings to Child Protective Services (CPS). 

The parents told CPS that the child had been alone with her father and fell getting out of the bathtub. The child was taken to a busy general hospital emergency department (ED) by the parents and the CPS worker. The parents gave the same explanation about the injury to the ED physician; they also noted that the child had a history of easy bruising. The ED physician determined that the injury was compatible with the history after conducting a physical examination and no laboratory tests. 

The CPS worker was concerned that the ED visit had been too hasty and the situation inadequately evaluated. Therefore, the child was brought to an advocacy center for a second opinion a day after the ED visit. A thorough history was obtained and the family's account of the trauma remained unchanged. However, in the review of systems, the mother added that the child was having some difficulty with toilet training. 

The second examination showed that there was no other bruising except on the pelvis. The pelvis appeared to have 3 individual bruises; however, no clear pattern could be identified. A complete genital examination was done. The hymen, posterior fourchette, and fossa navicularis were all normal and no acute injury could be identified. No laboratory tests were obtained at that time. Because of the slight additions to the history, a home visit was requested for scene evaluation.

Do you suspect abuse-or an underlying medical cause?

The home visit revealed that the bathtub had a sharp metal shower track on its upper edge. However, the child could have easily stepped out of the tub (given its height) without injury. The remainder of the scene appeared as the family had described it. 

With the history of developmental delay, difficulty in toilet training, and the 3 separate bruises (without a pattern), a diagnosis of possible abuse was made. Law enforcement confronted the father with the expressed concerns and he confessed to abusing his child. The father recounted his frustration over toileting issues and that he had "stomped" the child as she tried to scoot away on the floor as he prepared her bath. 

The American Academy of Pediatrics offers an excellent guide for parents whose child is being toilet trained.2 Stadtler and colleagues3 have also written recommendations for the primary care doctor to use as part of anticipatory guidance during well-child visits. 

 Another key point in this case was the scene investigation. Inspection of the site was far better than a mental visualization of how the injury may (or may not) have occurred.

 In this child's case, the presence of the metal rail and the height of the tub rendered the father's description of the accident highly suspect given the injury pattern. 

This case underscores the fact that numerous children who are brought to primary care offices or the ED with seemingly mundane case histories are actually victims of abuse. A complete history and thorough investigation can make the difference in the final outcome. Many abused children present for medical care with minor trauma and are not properly identified: they often present later with more serious trauma. 

Schmitt BD. Seven deadly sins of childhood: advising parents about difficult developmental phases. Child Abuse Negl. 1987;11:421-432. 
    

Wolraich M. Guide to Toilet Training. Elk Grove Village, Ill: American Academy of Pediatrics; 2003. 
    

Stadtler AC, Gorski PA, Brazelton TB. Toilet training methods, clinical interventions, and recommendations. Pediatrics. 1999;103    (suppl 6):1359-1361. Available at: http://pediatrics.aappublications.org/cgi/content/full/103/6/S1/1359. Accessed December 21, 2007.

    Wagner GN. Crime scene investigation in child-abuse cases. Am J Forensic Med Pathol. 1986;7:94-99.    

Pelvic Bruising Caused by Child Abuse

A 23-month-old Hispanic boy was brought to an emergency department (ED) with ear pain and fever. The family had no other expressed concerns. Physical examination revealed inflammation of 1 tympanic membrane. The child had a temperature of 38.4°C (101.2°F).

On closer examination, the child had skin discoloration on the chest that looked like bruising. The findings from the remainder of the examination were normal, and there were no other indications of possible abuse. The family could offer no explanation for the bruising. The mother was certain that the discoloration had not been present when she took the child outside to play earlier in the day.

Results of a complete blood cell count, prothrombin time, and partial thromboplastin time were all within normal limits. Child Protective Services was notified of possible nonaccidental injury, and the child was referred to an advocacy center for consultation. The child was seen in consultation within 24 hours of the ED visit.

On close questioning, the child's mother volunteered that she had been preparing a meal with fresh limes on the day of the ED visit. She recalled that while cooking, she had repeatedly picked up her child without washing her hands and was certain that the child's bare skin had been touched in the process. This detail coupled with the results of the child's physical examination led to a diagnosis of 

 (PPD). The family was cleared of allegations of abuse.

The term "phytophotodermatitis" was first used to describe this condition in 1942 by Dr Robert Klaber.

 Much of what is still considered to be fact about this condition was written in his article. Dermatitis from plant material had been described for many years, but the connection with light--specifically UV light--had not been made. Klaber reviewed a number of case reports and clinical studies to describe the spectrum of the disorder.

Psoralen (from the furocoumarin family) in combination with UV light in the 320- to 380-nm range is the chemical photosensitizer responsible for PPD.

 Cell death and inhibition of mitosis are caused by the cross-linking of DNA with psoralen. Psoralen is present in a number of ordinary foods and in a variety of weeds and grasses that are common in urban areas (

 Cooks, grocers, and gardeners are prone to PPD. There are case reports of PPD caused by airborne plant particulate matter from lawn tools.

PPD occurs more frequently in the late summer when doses of UV light are high. The heat and humidity of summer months also accentuate the reaction. Typically, the onset of symptoms is within 24 to 48 hours after exposure. The first signs may be painful erythema and local edema. Other reactions may start with hyperpigmentation. More intense reactions may progress to blisters and ultimately to bullae. The degree of reaction is thought to be dose-related and dependent on a patient's skin pigmentation. Persons with light skin are more vulnerable to PPD.

PPD may last weeks to months in certain patients. In some, permanent scarring results. Treatment should be tailored to the intensity of the dermatitis. Patients with mild to moderate symptoms may benefit from high-potency topical corticosteroids. Those with severe manifestations are treated with systemic corticosteroids. For hyperpigmentation, no treatment is necessary, even if it persists for months.

While this patient's case was straightforward once all the facts were exposed, it illuminates the following key points:

•PPD can be initiated by a vast number of activities and exposures. Children have possible multiple exposures to psoralen on any given day.

•Abuse can often be included in the differential diagnosis in children who present to the ED. Thus, clinicians need to be aware of the conditions that mimic abuse.

 PPD can be included in any differential diagnosis in patients who present with burns or bruising.

This patient's case also points out the need for emergent/emergency referral resources to limit the disruption of daily family life by unfounded referrals.

 Hipkin CR. Phytophotodermatitis, a botanical view. 

 Photosensitivity and photoreactions. In: Hurwitz S, ed. 

Clinical Pediatric Dermatology. A Textbook of Skin Disorders of Childhood and Adolescence. 

2nd ed. Philadelphia: Saunders; 1993:89-90.

Oakley AM, Ive FA, Harrison MA. String trimmer's dermatitis. 

 Hill PF, Pickford M, Parkhouse N. Phytophotodermatitis mimicking child abuse.

Wallace GH, Makoroff KL, Malott HA, Shapiro RA. Hospital-based multidisciplinary teams can prevent unnecessary child abuse reports and out-of-home placements. 

Botash AS, Sveen AR, Frasier LD. Possible burns in 2 children. 

Child With "Bruising"

A 5-year-old girl was brought to her pediatrician after a "fall" 30 minutes before her arrival. The injury occurred in her home; she fell while straddling the back of a chair as she reached for something on a table. Her grandmother, who was serving as the child's foster parent, and an unrelated witness provided the initial history. The child independently confirmed the story provided by the adults.

The patient was well known to the pediatrician and was in foster care because of sexual abuse.

The child had signs of active bleeding on her clothing when she presented to the office. There was also evidence of bleeding on the labia majora. An approximately 1-cm in diameter bruise was seen on the labia majora. A 2-cm crush injury with splitting of the skin between the labia minora and labia majora was visualized with gentle traction. The injury did not need to be sutured. There were no other injuries (the posterior fourchette, fossa navicularis, hymen, and anus were normal).

Are these findings the result of abuse or trauma caused by an accidental fall?

In this case, straddle injury is the most straightforward diagnosis. The caregivers sought early medical care for the child; fresh blood was present on the patient's clothing. Also reassuring was the fact that the genital injury was predominantly external and unilateral--the classic characteristics of a straddle injury, not abuse.

The history verification by 3 sources (the grandmother, child, and an unrelated witness) is also reassuring. The only troubling element in this scenario was that the child was in foster care because of sexual abuse. The social history was considered by the pediatrician but was overshadowed by the factors mentioned above.

By definition, a straddle injury involves a fall onto or striking of an object with the force of one's weight. The injury pattern is caused from compression of the pelvic tissues by the underlying bony structures. The physical description of the injury depends on the type of fall and/or object that is involved.

 The typical injury is more anterior and unilateral and involves the external genitalia more often than internal structures. There would be more extensive internal injury if impalement had occurred.

In almost every case of straddle injury, there is usually an acute and "dramatic" history of the event. The most common chief complaint for females is bleeding followed by pain and bruising. Similar injuries occur in males but only half as frequently as in females.

 In males, the most common presenting complaint is pain and scrotal trauma.

In one study, the incidence of straddle injuries was found to be 2 in 1000 children younger than age 12 who presented to an emergency department.

 looked at the mechanisms of straddle injury. They found that 25% were related to bicycle injuries and 21% to falls on furniture. Another 30% were related to falls while climbing on objects, including playground equipment.

In an effort to differentiate innocent injuries from inflicted injuries, Greaney and Ryan

 proposed using the scoring system shown in the 

 describe recommendations for treatment of the more complex perineal injuries that require surgical intervention. The literature is devoid of treatment strategies for simple straddle injuries, however. The patient in this case was treated with daily sitz baths and topical antibiotic cream.

The history and physical examination remain the most important elements in differentiating straddle injuries from abuse. The presence of any history or physical findings that prompt one to include child abuse in the differential may mean that the genital complaint is not just a straddle injury. By using the algorithm proposed by Greaney and Ryan, one could, perhaps, answer the abuse/mimic question. If any doubt remains, however, the clinician is obligated to report possible child abuse.	*

Jones LW, Bass DH. Perineal injuries in children. 

Bays J, Jenny C. Genital and anal conditions confused with child sexual abuse trauma. 

Dowd M, Fitzmaurice L, Knapp JF, Mooney D. The interpretation of urogenital findings in children with straddle injuries.

Greaney H, Ryan J. Straddle injuries--is current practice safe? 