Dear Editor:
Kemp et al.[1] attempted to retrospectively study the characteristics
and modes of bruising in children less than six years of age who had been
referred to two child protection teams. These children were placed in
physical abuse (PA) and physical abuse excluded (PAE) categories. An
important criterion used by Kemp et al. to select a child for the PA
category was the absence of a history of an accidental traumatic event;
however, the absence of a history of trauma is not diagnostic of physical
abuse. The lack of a history cannot universally be assumed to be due to
the caretakers' withholding of information regarding an abusive event[2].
Minor bruising and petechiae in children (including infants) are
commonly seen by office-based primary care physicians. Many do not have an
apparent explanation. The majority are not medically significant and are
appropriately not reported as concerning for abuse. Investigators should
not automatically include these cases in a PA category.
Importantly, Kemp et al.[1] did show that, despite an inherent
population bias and problematic selection criterion, 19.2% of pre-mobile
babies diagnosed as PAE had bruising. Even the Sugar et al.[3] study,
which has similar problems with selection bias, showed that 6 of a
thousand normal non-abused pre-mobile infants will have bruises. This
finding supports the concept that is known to experienced primary care
physicians: those who don't cruise can bruise without having been abused.
I support the authors' conclusion that when evaluating for child
abuse, not every bruise is necessarily abusive in etiology[4-5]. I agree
with the authors' assertion that their study population is skewed because
its population consists entirely of children who were initially suspected
to be victims of child abuse. When considered alongside the problematic
selection criterion noted above, this fact prompts me to question the
article's statistical conclusions.
REFERENCES
1 Kemp AM, Maguire SA, Nuttall D et al. Bruising in children who are
assessed for suspected physical abuse. Arch Dis Child. Published Online
First: 16 September 2013. doi: 10.1136/archdischild-2013-304339
2 Caffey J. Significance of the history in the diagnosis of traumatic
injury to children. Howland Award Address. J Pediatr 1965;67(5 Suppl):1008
-14S.
3 Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers:
those who don't cruise rarely bruise. Puget Sound Pediatric Research
Network. Arch Pediatr Adolesc Med 1999;153:399-403.
4 Laposata ME, Laposata M. Children with signs of abuse: when is it
not child abuse? Am J Clin Pathol 2005;123(Suppl 1):119-24.
5 Minford AM, Richards EM. Excluding medical and haematological
conditions as a cause of bruising in suspected non-accidental injury. Arch
Dis Child Educ Pract Ed 2010;95:2-8.
Conflict of Interest:
I do clinical research and medical legal evaluation regarding infant injury.
Dear Editor:
Kemp et al.[1] attempted to retrospectively study the characteristics and modes of bruising in children less than six years of age who had been referred to two child protection teams. These children were placed in physical abuse (PA) and physical abuse excluded (PAE) categories. An important criterion used by Kemp et al. to select a child for the PA category was the absence of a history of an accidental traumatic event; however, the absence of a history of trauma is not diagnostic of physical abuse. The lack of a history cannot universally be assumed to be due to the caretakers' withholding of information regarding an abusive event[2].
Minor bruising and petechiae in children (including infants) are commonly seen by office-based primary care physicians. Many do not have an apparent explanation. The majority are not medically significant and are appropriately not reported as concerning for abuse. Investigators should not automatically include these cases in a PA category.
Importantly, Kemp et al.[1] did show that, despite an inherent population bias and problematic selection criterion, 19.2% of pre-mobile babies diagnosed as PAE had bruising. Even the Sugar et al.[3] study, which has similar problems with selection bias, showed that 6 of a thousand normal non-abused pre-mobile infants will have bruises. This finding supports the concept that is known to experienced primary care physicians: those who don't cruise can bruise without having been abused.
I support the authors' conclusion that when evaluating for child abuse, not every bruise is necessarily abusive in etiology[4-5]. I agree with the authors' assertion that their study population is skewed because its population consists entirely of children who were initially suspected to be victims of child abuse. When considered alongside the problematic selection criterion noted above, this fact prompts me to question the article's statistical conclusions.
REFERENCES
1 Kemp AM, Maguire SA, Nuttall D et al. Bruising in children who are assessed for suspected physical abuse. Arch Dis Child. Published Online First: 16 September 2013. doi: 10.1136/archdischild-2013-304339
2 Caffey J. Significance of the history in the diagnosis of traumatic injury to children. Howland Award Address. J Pediatr 1965;67(5 Suppl):1008 -14S.
3 Sugar NF, Taylor JA, Feldman KW. Bruises in infants and toddlers: those who don't cruise rarely bruise. Puget Sound Pediatric Research Network. Arch Pediatr Adolesc Med 1999;153:399-403.
4 Laposata ME, Laposata M. Children with signs of abuse: when is it not child abuse? Am J Clin Pathol 2005;123(Suppl 1):119-24.
5 Minford AM, Richards EM. Excluding medical and haematological conditions as a cause of bruising in suspected non-accidental injury. Arch Dis Child Educ Pract Ed 2010;95:2-8.
Conflict of Interest:
I do clinical research and medical legal evaluation regarding infant injury.