ABSTRACT
A 3-month-old baby girl was brought to the emergency department by her parents with a history of spitting up blood. Medical staff noticed some marks on her face and left eyelid. Her parents reported no history of trauma. Images 105a through 105d depict her face and the inside of her mouth. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig105a.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig105b.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig105c.jpg"/> https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig105d.jpg"/>
What do the images show?
What tests and imaging studies are important to further assess this infant?
240Image 105a shows an abrasion of her left hard palate at the junction with the soft palate. Image 105b shows bruises on the infant’s left side of her face and left upper eyelid. Image 105c shows a subconjunctival haemorrhage of her right eye and Image 105d shows further bruises on the right side of her face. On further questioning, her father stated he is not able to handle the baby’s crying. He added that when she cries, he wraps his finger with a towel and inserts it into her mouth to make her stop crying, which could explain the palatal abrasion. There was no explanation given by either parent for the facial bruises. However, based on their shape and location along with the history, they could be sustained when holding the baby’s jaw forcefully by the father to insert his finger in her mouth. It is important to determine whether the bruises in children resulted from abuse or an accident. Medical assessment starts with a thorough history and a complete physical examination with documentation of findings. 1 When child abuse is suspected, a report needs to be made to Child Protective Services to prevent further abuse and possibly death.
‘Those who don’t cruise rarely bruise’. 2 Bruises on the face and inside the mouth are particularly concerning for child abuse. Although the bruises were partially explained by the father’s actions, those actions are abusive in nature. To evaluate for associated injuries, she had blood drawn for a complete blood count, liver enzymes, prothrombin time (PT), partial thromboplastin time (PTT), all of which came back normal. She had skeletal survey x-rays, which showed multiple posterior rib fractures and metaphyseal corner lesions, both of which are highly specific for child abuse. Her head magnetic resonance imaging (MRI) scan was normal. A report to Child Protective Services was made based on the diagnosis of physical abuse and the infant was placed with her grandparents.
