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.
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 and discussion on next page.)
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).1
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.4 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.
THE KEY POINTS
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. *