Be careful characterizing conditionsas child abuse. There are a number of great masqueraders, including neuroblastoma
Be careful characterizing conditionsas child abuse. There are a number of great masqueraders, including neuroblastoma: Excerpt from Avoiding Common Pediatric Errors
Author:
Elizabeth Wells, MD
What Do to - Make a Decision
Although child abuse continues to be a major concern for clinicians working
in emergency departments, urgent care centers, and in primary care settings,
it is important for pediatricians to recognize other medical conditions of the
skin, bone, brain, and retina that may mimic the appearance of child abuse.
Bruises are the most common type of injury seen in abused children,
but bruising can indicate a medical disorder. For instance, it may indicate
a coagulopathy, such as hemophilia (factors VIII and IX deficiencies), or a
clottingdisorder,such asvonWillebranddisease. Bruisingcanalso becaused
by low platelets, as in idiopathic thrombocytopenic purpura or thrombocytopenia, due to leukemia. Bruising may also be a sign of a vasculitis. Henoch-
Schönleinpurpurashouldbeconsidered,especiallyifthe"bruising"appears
in dependent parts of the body (i.e., buttocks and legs in children and back
and buttocks in infants). Salicylate ingestion can cause bruising, due to decreased platelet adhesion and increased capillary permeability, and should
be considered in a child presenting with vomiting and metabolic acidosis.
Mongolian spots are bluish-green areas of skin discoloration caused by a
dense collection of melanocytes usually on the buttocks and lower back that
are often differentiated from bruising by their indistinct borders.
Severalmedicalconditionspresentwithburnlikelesionsthatmaymimic
child abuse. Phytodermatitis can occur when sunlight interacts with photosensitizing compounds found in certain fruits, vegetables, and skin products.
The lesions appear as erythematous lesions and bullae, often in a pattern resembling handprints or around the hands and mouth after a child handles
or ingests lime or lemon juice. Staphylococci and streptococci impetigo may
be mistaken for burns; however, they usually are superficial and heal cleanly,
distinguishing them from cigarette burns, which usually are deeper (fullthickness),haveraisedmargins,andhealwithscarring.Otherskinconditions
thatcanmimicburnsincludeherpes,eczema,contactdermatitis,andchronic
bullous disease. In addition, cultural practices, such as cupping, coining, and
spooning, may cause skin lesions that may be mistaken for child abuse.
Pediatriciansshouldbeabletorecognizemedicalcausesofradiologicabnormalities. The evaluation of suspected physical abuse in children younger
than 2 years and in nonverbal children mandates a skeletal survey. The radiographic appearance of a fracture may be found in patients with normal
variant changes in their bones, such as nutrient canals, cortical irregularities,
metaphyseal beaks and spurs, distal ulnar cupping, normal symmetric peritoneal changes seen in infants, and ossification defects of the ribs. Neoplastic
disease may also present with unexpected fractures. Metabolic bone disease
that can lead to fractures includes rickets, a bonediseasecaused by vitaminD
deficiency and resulting in osteopenia, metaphyseal cupping, physeal widening, and pseudofractures. Another source of multiple fractures is vitamin C
deficiency (i.e., scurvy) in which children present with irritability; failure to
thrive; coiled, fragmented hair; prominent hair follicles on the thighs and
buttocks; and gingival hemorrhage. Other metabolic causes of pathologic
fractures include McCune-Albright syndrome and Gaucher disease. Infectious etiologies of bone disease should be considered in a child who presents
with a warm, swollen, and tender extremity. Proper diagnosis may require
multiple radiographs, a pediatric radiologist, and, sometimes, a bone scan.
Osteogenesis imperfecta, an inherited disorder of collagen formation
thatincreasesthelikelihoodofrepeatedfractures,maypresentwithfractures
in various stages of healing. Although this condition is often considered, it is
a rare disorder, occurring in only 1 in 20,000 births; self-inflicted injuries do
not occur until a child is toddling or walking. Characteristic features, which
may or may not be present, include blue sclera, scoliosis, hearing loss, and
a positive family history. Testing for mutations in collagen types COL1A1
and COL1A2, and culture of biopsied fibroblasts should be considered if
there are no other signs of abuse and if the mechanism of injury seems too
minor to have caused a fracture. Taking a careful history and referring to a
geneticist and pediatric orthopedic surgeon are most helpful in confirming
or excluding the diagnosis of osteogenesis imperfecta.
Congenital insensitivity to pain is a rare hereditary sensory autonomic
neuropathy in which the peripheral nerves fail to detect pain or temperature
and may lead to multiple injuries, including fractures of varying ages. A
careful neurologic examination can point a clinician to this diagnosis.
The bucket-handle fracture that occurs as a result of the indirect shearing forcesgenerated whenan extremity ispulled,pushed,twisted,or shaken,
is considered specific for child abuse. However, these metaphyseal fractures
may also be seen in infants undergoing serial casting for treatment of equinovarus deformity. Once again, an accurate and thorough history is essential
in determining the cause of this fracture.
A subdural hemorrhage raises the clinical index of suspicion for child
abuse, particularly when it coexists with retinal hemorrhages, fractures, and
multiple traumatic injuries. Birth trauma and vitamin K deficiency may be
the source of this hemorrhage in infants. A congenital malformation (e.g.,
arteriovenous malformation, aneurysm, arachnoid cyst) may cause spontaneous bleeding. Disseminated intravascular coagulation, or hemophilia or
other bleeding disorders may cause subdural hemorrhages. Metabolic disorders that may cause bleeding include glutaric aciduria type 1, hemophagocytic lymphohistiocytosis, and Menkes disease. Vasculitides, including
moyamoya, should also be considered. Brain tumors, cranial radiation, and
chemotherapy may cause subdural hemorrhage, as well.
Any infant or child, who has intracranial hemorrhages suspicious for
nonaccidental trauma, should be evaluated by a pediatric ophthalmologist
to detect retinal hemorrhages (RHs). Although RHs, unilateral or bilateral,
occurin50%to80%ofabusiveheadinjuries,theyarenotpathognomonicfor
abuse and may occur in association with other medical conditions. Although
most birth-related RHs resolve within 8 days, they may persist for up to
3 months. RHs can occur in meningitis and other infectious illnesses, such
as Henoch-Schönlein purpura and other vasculitides. Severe hypertension
canalsocauseRHsinchildren.IatrogenicetiologiesofRHsincludetheuseof
extracorporeal membrane oxygenation. Although the issue is controversial,
researchindicatesthatRHsarenotcausedbycardiopulmonaryresuscitation.
Child maltreatment causes significant childhood mortality and morbidity. Although steps should be taken to ensure a clinician does not miss
medical conditions that mimic as child abuse, such considerations should
not preclude a thorough evaluation to rule out nonaccidental trauma.
Suggested Readings
Child abuse and the eye. The Ophthalmology Child Abuse Working Party. Eye. 1999;13(Pt
1):3–10.
Coleman H, Shrubb VA. Chronic bullous disease of childhood–another cause for potential
misdiagnosis of sexual abuse?Br J Gen Pract. 1997;47(421):507–508.
Diagnostic imaging of child abuse. Pediatrics. 2000;105(6):1345–1348.
Grayev AM, Boal DK, Wallach DM, et al. Metaphyseal fractures mimicking abuse during
treatment for clubfoot. Pediatr Radiol. 2001;31:559–563.
Heider TR, Priolo D, Hultman CS, et al. Eczema mimicking child abuse: a case of mistaken
identity. J Burn Care Rehabil. 2002;23(5):357–359; discussion 357.
Karmani S, Shedden R, De Sousa C. Orthopaedic manifestations of congenital insensitivity to
pain. J R Soc Med. 2001;94:139–140.
Nimkin K, Kleinman PK. Imaging of child abuse. Radiol Clin North Am. 2001;39:843.
Sirotnak AP, Grigsby T, Krugman RD. Physical abuse of children. Pediatr Rev. 2004;25:264–
277.
Book Source Details
- Book Title: Avoiding Common Pediatric Errors
- Author(s): Anthony D Slonim MD, DrPH; Lisa Marcucci MD
- Year of Publication: 2008
- Copyright Details: Avoiding Common Pediatric Errors, Copyright © 2008 Lippincott Williams & Wilkins.
More About Child abuse
More Medical Textbooks Online about Child abuse
Review other book chapters online related to Child abuse:
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
|
|
More About This Book:
Title: Avoiding Common Pediatric Errors
Authors: Anthony D Slonim MD, DrPH; Lisa Marcucci MD
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7489-6
|
|
» Next page: Provide anticipatory guidance at well-child visits (Avoiding Common Pediatric Errors)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
