By: David Bloomberg Re: Medical Problems that look like child abuse Chicago Tribune, 5/30/

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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 Knight-Ridder/Tribune 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 said. She was interrogated, then Jordan was photographed and questioned separately. "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 disorders. 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 children. "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 abuse. * 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 diaper." 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 system."


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