By: David Bloomberg Re: Medical Problems that look like child abuse Chicago Tribune, 5/30/
By: David Bloomberg
Re: Medical Problems that look like child abuse
Chicago Tribune, 5/30/95
Medical Conditions can look like child abuse
By Marie McCullough
After Kim Amitin's husband died of cancer last June, she
found solace in caring for their three young sons.
Then it happened, the terrible mistake she always figured
her husband would know how to handle. A child-abuse
investigator appeared on her doorstep without warning to ask
about their 5-year-old son, Jordan.
"I kind of knew one day someone was going to say, 'Why
does this kid have so many scabs?'" the San Diego woman
She was interrogated, then Jordan was photographed and
"My heart was going a hundred miles an hour," Amitin
recounted. "You think, 'What if they don't believe me and
take this child away?'"
Fortunately, she said, it was only a matter of hours until
her pediatrician and others backed up her explanation:
Jordan has epidemolysis bullosa, a rare disease he inherited
from his father that causes his skin to blister easily.
It's one of numerous conditions that people sometimes
mistake for child abuse. Others range from common bacterial
infections and birth marks to rare blood-clotting and bone
Usually, child-abuse experts say, the confusion lies with
lay people, such as day-care workers or teachers, and is
quickly dispelled when child-protective professionals
investigate the suspicions.
But not always. In Tennessee, a physician accused of abuse
has been trying since December to get her 21-month old son
out of foster care, at one point briefly abducting him.
Cheryl Bryant-Bruce contends her son's internal bleeding,
slow growth and other medical problems are due to a
debilitating liver disorder called Alagille's syndrome.
Tennessee officials acknowledge he has the rare disorder,
but maintain he was abused.
A medical journal tells of another case in which a father
was kept from his family for a year before his daughter was
diagnosed with bullous pemphigoid, a rare autoimmune
condition that caused raw, red skin around her vagina.
In another case, a Vietnamese father committed suicide
after being jailed despite his explanations that his son's
bruises were caused by a folk-healing practice.
Such stories--the little-known flip side to heartrending
stories of actual child abuse--illustrate the intricacies of
the problem experts say. Even classic signs of mistreatment
such as bruises, burn marks, sores, swelling, vaginal
bleeding and broken bones may not be caused by abuse. Or, I
children may suffer from conditions that mimic abuse while
they are being abused as well.
It's important to recognize that investigations can be
traumatic for families and suspected abusers, but the
paramount concern, I authorities say, is protecting
"When there is doubt, we do tend to err on the side of pro
tecting children," said Cindy Christian, medical director of
child-abuse services at Children's Hospital of Philadelphia.
Anyone may report suspected child abuse or neglect, but
those who work with children are mandated by state laws to
report their suspicions.
In many unsubstantiated cases, caseworkers discover the
problem is overzealous or inappropriate discipline, which
they try to remedy with education, said Deirdre Jacques, a
children-and-youth-services official of Delaware County, Pa.
The number of mistaken reports of abuse is "surprisingly
few," said Jan Bays, chairwoman of the American Academy of
Pediatrics Committee on Child Abuse and Neglect.
Reviewing the world's medical literature for a new
handbook, "Child Abuse: Medical Diagnosis and Management,"
Bays found about 100 cases reported as abuse, involving
about two dozen conditions. Among them:
* Mongolian spots--blue-gray areas found on the backs, but
tocks, legs and shoulders of 95 percent of African-American
babies and most Asian, Latino and American Indian babies--
have been mistaken for bruises. The spots usually fade
during childhood. Only 10 percent of white babies have them.
* Asian folk medicine can cause bruises and superficial
burns mistaken for abuse. Coining--the practice used by the
Vietnamese father who committed suicide--involves rubbing or
scratching the child's skin with a spoon or coin. Cupping is
an ancient therapy in which a heated cup is applied to the
skin at specific points.
* Phytodermatitis is a fairly common allergic reaction
that occurs when skin is exposed to the juice of certain
plants--including lime, lemon parsnip and celery and then to
the sun. Children playing on a beach, eating lemon or being
handled by parents making gin-and-tonics, have been reported
as having hand marks and bruises.
* Coagulation disorders such as hemophilia and Von
Willebrand's disease can cause massive bruising and bleeding
after only minor injuries. Vitamin K deficiencies also can
cause abnormal bleeding, including in the skull.
* Impetigo, a contagious bacterial infection, causes round
sores that have been mistaken for cigarette burns.
* Osteogenesis imperfecta, a rare disease that causes
bones to fracture easily, has been confused with battering.
* Ehlers-Danlos syndrome is a rare hereditary disorder
that causes the skin to be fragile, thin and elastic. After
only minor bumps and falls, a child may suffer bruising,
scarring and swelling that heal poorly.
* Lichens sclerosis et atrophicus, a rare disorder that
causes red, itching, bleeding skin and a characteristic
whitish area around the vagina, has been mistaken for sexual
* Congenital indifference to pain, a rare genetic
disorder, has been confused with abuse because afflicted
children have so many injuries--bruises, burns, cuts, eye
damage, teeth loss and fractures. Parents have described
smelling burning flesh and finding their child leaning
casually against a hot stove.
Sorting the truth from suspicions, child-welfare officials
and physicians say, often takes cultural sensitivity,
insight, detective work--and medical specialists. A
dermatologist, radiologist, dentist, even a geneticist may
be needed for a diagnosis.
"When you think of abuse, it's a puzzle," said Martin
Finkel, founder and medical director of the Center for
Children's Support at the University of Medicine and
Dentistry of New Jersey in Strafford.
In one puzzling case Bays cited, an emaciated, bruised,
poorly developing 4-month-old infant was diagnosed as
neglected until, by chance, someone noticed a salty taste to
his skin. It turned out he had a vitamin K deficiency, and
his symptoms reversed with appropriate diet and vitamins.
In another case, a 6-week-old girl with bleeding in her
brain and eyes was hospitalized. Battering was suspected,
but she actually had an aneurysm--a weak spot in her
cerebral artery that was bleeding.
Miscommunication sometimes complicates confusion. Howard
Pride, a pediatric dermatologist at Geisinger Medical Center
in the Philadelphia suburb of Danville, Pa., recalled a type
of case of perianal streptococcal dermatitis--a strep
infection that turns the buttocks bright red and raw--which
led to an abuse report against a daycare worker.
"A kid said the daycare worker hurt him," Pride said. "The
worker just wiped the kid's bottom after changing his
Authorities often try to discourage questionable, albeit
well-intentioned, cultural practices. But it's a
double-edged issue. One pediatrician, writing in a medical
journal, recalled that she was going to lecture a Vietnamese
parent about inflicting unnecessary pain on his child when
she realized she had to give the child three shots and a
finger prick. And circumcision, which is accepted in this
country, is considered barbaric by some cultures.
Child-abuse experts disagree about whether the average
family physician is prepared to distinguish real abuse from
what only appears to be abuse.
While Bays thinks most are "well-equipped," Finkel sees
obstacles. It's difficult for doctors to keep up with
medical literature on child abuse and to recognize rare
conditions. And many, he said, are uncomfortable with the
issue of sexual abuse.
While there's room to improve child-abuse investigations,
there is no way around the process, however upsetting it may
be for families, the experts agree.
"My experience is, good parents want you to help figure
out what's happened to their child," Bays said. "It's the
parents who have actually abused the child who get their
knickers in a knot; If it's handled right--and I'm not
saying all cases are--most parents are grateful for the
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