Barbara L. Knox

Facial Bruising as a Precursor to Abusive Head Trauma

Primary care providers may be presented with precruising infants who have unexplained bruising, a finding highly correlated with abuse. As such, primary care providers have a unique opportunity to prevent escalation of abuse if identified early and reported. The following case reports are described to emphasize the importance of recognizing bruising as a sentinel injury in precruising children.

Sublingual Hematoma: When to Suspect Child Abuse

A 7-month-old male presented to the emergency department with his biologic parents for concerns of tissue discoloration and swelling of the floor of the child’s mouth. The child’s mother reported that she was home alone during the day with the child and his 2-year-old female sibling. At noon, the mother stated that she was in the kitchen when she heard her son start crying in the living room. On entering the room, the mother noted the 7-month-old child lying prone on the floor. She reported that he appeared to have some blood in his saliva and on the “tissues connecting the tongue to the bottom of the mouth.” She picked the child up and noticed some swelling and redness in the floor of his mouth. The mother denied any known trauma, but thought perhaps the child had sucked too hard on his pacifier or had fallen down with a toy in his mouth. The mother reported that the child was not yet cruising but could pull himself up and stand along furniture. Following the injury, the mother reported that the child cried for about 10 minutes and then subsequently fell asleep. On awakening from his nap at 2:00 pm, the mother stated that the child had worsening swelling of the sublingual tissues. She reported that they had now turned purple, and stated that there was a noticeable deviation of his tongue, elevating off the floor of his mouth. The biologic father returned home at approximately 4:00 pm. The child and his parents presented to a local emergency department at 8:00 pm because of concerns of increased swelling in the floor of the child’s mouth and worsening tongue deviation. Because of concern for development of a compromised airway, the child was airlifted to a tertiary care hospital for further evaluation and treatment. On presentation to the emergency department at the tertiary care facility, the child was examined by an otolaryngologist who noted multiple bruises on the patient’s forehead bilaterally (the largest bruise measured 2 cm × 0.5 cm on the right forehead). Additionally, there was a 0.7 cm × 0.7 cm bruise noted on the patient’s left cheek approximately 1 cm anterior to the inferior portion of the ear lobule (Figure 1). The oropharyngeal exam showed a partial tear in the lingual frenulum and a large violaceous sublingual hematoma extending the full lateral width of the tongue (Figure 2). The remainder of the exam was unremarkable. Concern for nonaccidental trauma (NAT) led to consultation of the hospital Child Protection Program for further evaluation. Birth history of the patient was documented as a normal spontaneous vaginal delivery at term with no reported prolonged maternal vaginal bleeding or transfusion requirement in the peripartum period. Family history was positive for a maternal history of increased bruising and previous instances of facial petechiae following episodes of severe retching and emesis. The paternal family history was negative for bleeding disorders and coagulopathies.

Staphylococcal infection mimicking child abuse: what is the differential diagnosis and appropriate evaluation?

Twins with similar skin lesions are described. Although initially concerning for nonaccidental burn injury, further evaluation led to the diagnosis of bullous impetigo caused by Staphylococcus aureus. Thoughtful assessment is important in such cases to protect the child and prevent misdiagnosis.

Restrictive Diet Control as a Means of Child Abuse.

Abstract We have recently encountered a series of cases where an obese caretaker is juxtaposed to a severely starved, malnourished dependent. The cases described all share a common characteristic: that the primary perpetrator was an obese caretaker who tried to exert absolute control over their victims daily life in a way that included either a severe restriction or complete denial of food. Because the pathophysiology of both child abuse and obesity are incredibly complex and multifactorial, these cases are presented to encourage further discussion and more rigorous investigation into the validity of a hypothesis that has been derived from this set of cases: that the obesity of a childs caretaker may be an additional risk factor for child maltreatment by starvation.

Skin Lesions and Other Associated Findings in Children with Abusive Head Trauma

When Abusive Head Trauma (AHT) is suspected, the presence of extracranial lesions can be a decisive factor in confirming the diagnosis. In this article, we briefly review and illustrate some of the skin lesions and other extracranial injuries frequently associated with AHT.

Ophthalmologic Concerns in Abusive Head Trauma

When Abusive Head Trauma (AHT) is suspected in a child, a dilated eye examination by an ophthalmologist is an essential part of the medical workup, as the presence and pattern of retinal hemorrhages can have a high positive predictive rate for abusive head injury. This article proposes to review the clinical presentation, pathophysiology, natural history, sequelae, and differential diagnosis of retinal hemorrhages and other ocular lesions associated with AHT.

An Infant With a Unilateral Mandibular Fracture When to Consider Nonaccidental Trauma

A 3-month-old Albanian female infant presented to the emergency department with her biologic mother and father after allegedly falling from her swing onto her face. Through an interpreter, the biologic mother reported swaddling the baby and putting her in an electric swing. The swing was placed on a wooden stool. A few minutes after starting the mechanical swing, mother stated that it toppled off the wooden stool. The infant subsequently landed face down onto a carpet runner overlying the ceramic tile floor. The mother reported that the baby cried immediately and had blood coming from her mouth. She did not report loss of consciousness, apnea, or vomiting. Physical examination showed a sleeping 3-month-old girl resting comfortably. A blood clot was noted along a 1-inch skin flap that extended from the front to the middle of the upper right gum line. Conjunctiva were clear. Upper, lower, and sublingual frenula were intact. Her skin was significant for a rather faint petechial injury along the left upper lip vermilion border. The remainder of the exam was normal. The infant was born at term via spontaneous vaginal delivery without complications. Family history was negative for connective tissue disorders, frequent bone fractures, or other inherited bone diseases. Computed tomography (CT) revealed a minimally displaced comminuted fracture of the right mandibular ramus extending to the base of the condylar process; the study was negative for intracranial hemorrhage or other injury (Figure 1). A skeletal survey was performed and showed a questionable cortical irregularity of the right distal ulna that was seen on only one view. An ophthalmologist observed no retinal hemorrhages. Blood work, including serum electrolytes, liver function tests, and a complete blood count were all within normal limits. The pediatric plastic surgery service expressed concern that a mandibular fracture is exceedingly rare in infants. The pediatric radiologist queried whether this traumatic injury was induced nonaccidentally. Thus, given the rare nature of these fractures in infants and implausibility of the reported mechanism of injury, the primary team consulted the hospital child protection program for concern of nonaccidental trauma. Child Protective Services (CPS) was contacted and, in conjunction with law enforcement, conducted a scene investigation while the infant remained in the hospital. It was discovered that the electric swing had been placed atop four small wooden circular barstools that were 18 inches high; the total height of the stools and swing came to 40 inches (Figure 2). The swing initially appeared stable when placed on the stools; however, once turned on, it became unsteady. Further inspection revealed that the plastic grippers on the base of the swing were worn off in 3 locations. The child protection program concluded that the unilateral mandibular fracture was consistent with the accidental mechanism initially reported, and CPS formally cleared the infant for discharge to home in the care of her parents. The child protection program recommended a 2-week follow-up appointment with a repeat skeletal survey to reevaluate the distal ulna lesion, which proved to be normal.

Subdural Hematoma Rebleeding in Relation to Abusive Head Trauma

When cases of suspected abusive head trauma are adjudicated in courts of law, one of the theories often presented by defense experts is that a normal, healthy infant or child suddenly neurologically deteriorates or dies several weeks to months after birth or minor injury because a preceding subdural hematoma spontaneously rebleeds after a minor traumatic event. This article reviews the underlying scientific basis of subdural hematoma rebleeding as it applies to this courtroom theory.