1
|
van Gemert MJC, Vlaming M, Gabaeff SC, Nikkels PGJ, Neumann HAM. Asymptomatic Infant Rib Fractures Are Primarily Non-abuse-Related and Should Not Be Used to Assess Physical Child Abuse. Children (Basel) 2023; 10:1827. [PMID: 38002918 PMCID: PMC10670409 DOI: 10.3390/children10111827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/27/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023]
Abstract
Finding infant rib fractures was for many years an almost undisputed proof that physical child abuse took place. Yet, these rib fractures are virtually always occult and asymptomatic and are only identified when looked for, usually with X-rays, from physical child abuse accusations related to, e.g., suspicion of the shaken baby syndrome. In a recent systematic literature review (searched in Cochran, Embase, PubMed and Sociological Abstracts), Güvensel questioned the diagnostic accuracy of rib fractures to be caused by abuse, due to lack of sufficient scientific evidence. Further, there is currently a world-wide disagreement between physicians considering themselves child abuse specialized, and physicians that explore non-abuse-related symptoms that may mimic physical abuse, which, it is hoped, will significantly reduce current unjustified child abuse diagnoses. In an attempt to help resolving this disagreement, we hypothesize that the probability of physical child abuse-related infant rib fractures is significantly lower than the probability of all other possible non-abuse-related causes of occult asymptomatic infant rib fractures, e.g., from birth trauma, prematurity, osteogenesis imperfecta, hypermobile Ehlers-Danlos Syndrome, severe chronic placental pathology (e.g., massive perivillous fibrin depositions and severe chronic histiocytic intervillositis), and vitamin-D deficiency. As method, we attempted to assess the incidence of these various causes of infant rib fractures, in the Netherlands and the USA. The results are that the estimated Dutch and USA physical abuse-related infant rib fracture incidences are at least about 250 and 45 times lower than the sum of all the non-abuse-related estimates. Because these latter rib fractures are occult and asymptomatic, it is likely that (many) more could be out there. In conclusion, occult asymptomatic rib fractures develop perinatally, virtually always as birth trauma, in infants with sufficiently weak bones due to vitamin D deficiency, transmitted by their vitamin D deficient pregnant mothers. This group also includes cortical rib cracks due to deformation forces, with an estimated 186/100,000 incidence. And, despite obvious uncertainties in all estimated incidences, we provided strong evidence that our hypothesis has relevance, implying that the abundant occult asymptomatic rib fractures, when found in infants, should not be used to assess potential physical child abuse.
Collapse
Affiliation(s)
- Martin J. C. van Gemert
- Department of Biomedical Engineering & Physics, Amsterdam University Medical Centers, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Marianne Vlaming
- Private Practice, Criminal Psychology and Law, 6986 CL Angerlo, The Netherlands;
| | | | - Peter G. J. Nikkels
- Department of Pathology, Wilhelmina Children’s Hospital, University Medical Center, 3584 CX Utrecht, The Netherlands;
| | | |
Collapse
|
2
|
Vlaming M, Sauer PJJ, Janssen EPF, van Koppen PJ, Bruijninckx CMA, Akkerman-Zaalberg van Zelst MWM, Neumann HAM, van Gemert MJC. Child Abuse, Misdiagnosed by an Expertise Center: Part I-Medico-Social Aspects. Children (Basel) 2023; 10:963. [PMID: 37371195 DOI: 10.3390/children10060963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/08/2023] [Accepted: 05/25/2023] [Indexed: 06/29/2023]
Abstract
Child abuse is a dangerous situation for an infant. Professionals need to weigh the risk of failing to act when children are seriously harmed against the serious harm done by carrying out safeguarding interventions. In severe cases, foster care might be advisable. The negative effects for the child's psychosocial development requires that such placement must be based on very solid evidence. Our aim is to identify why Dutch parents whose child may have a medical condition that could mimic symptoms of child abuse have a significant chance of being erroneously convicted and losing custody of their child. As a method, we describe and analyze the following case. An Armenian-Dutch newborn (uncomplicated term vaginal delivery), starting at two weeks after birth, developed small bruises on varying body locations. At two months, a Well-Baby Clinic physician referred the girl to a university hospital, mentioning that there were no reasons to suspect child abuse and that her Armenian grandmother easily bruised as well. However, before consultation by a pediatrician of the hospital-located Expertise Center for Child Abuse, the parents were suspected of child abuse. Based on the expertise center's protocols, skeletal X-rays were made, which showed three healed, asymptomatic rib fractures, while invalid statistics suggested, incorrectly, a 10-100 times more likely non-accidental than accidental cause of the symptoms (discussed in Part II of this series). The expertise enter physician ignored any argument that could show parental innocence, including the positive parent-child relationship reported by the Well-Baby Clinic and the general practitioner. The girl and her older brother were placed in a family foster home and then in a secret home. The case radically resolved when a large bruise also developed there, and an independent tissue disease specialist diagnosed a hereditary connective tissue disorder in the mother, implying that the girl's bruises and rib fractures could well be disease-related. In conclusion, if child abuse is suspected, and foster care placement considered, the patient and the parents should be thoroughly investigated by an independent experienced pediatrician together with an experienced pediatric clinical psychologist or psychotherapist to produce an independent opinion. Children deserve this extra safeguard before being separated from their parents.
Collapse
Affiliation(s)
- Marianne Vlaming
- Private Practice, Criminal Psychology and Law, 6986 CL Angerlo, The Netherlands
| | - Pieter J J Sauer
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center, 9713 GZ Groningen, The Netherlands
| | - Emile P F Janssen
- Private Practice, Rehabilitation Medicine & Consultancy, 6137 CL Sittard, The Netherlands
| | - Peter J van Koppen
- Department of Criminal Law and Criminology, Faculty of Law, VU University Amsterdam, 1081 HV Amsterdam, The Netherlands
| | | | | | | | - Martin J C van Gemert
- Department of Biomedical Engineering & Physics, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| |
Collapse
|
3
|
van Gemert MJC, Zwinderman AH, Koppen PJV, Neumann HAM, Vlaming M. Child Abuse, Misdiagnosed by an Expertise Center-Part II-Misuse of Bayes' Theorem. Children (Basel) 2023; 10:children10050843. [PMID: 37238391 DOI: 10.3390/children10050843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/26/2023] [Accepted: 05/04/2023] [Indexed: 05/28/2023]
Abstract
A newborn girl had, from two weeks on, small bruises on varying body locations, but not on her chest. Her Armenian grandmother easily bruised, too. Her mother was diagnosed with hypermobility-type Ehlers-Danlos-Syndrome (hEDS), an autosomal dominant connective tissue disorder, with a 50% inheritance probability. Referral to a University Medical Center located "Dutch Expertise Center for Child Abuse" resulted (prior to consultation) in physical abuse suspicion. Protocol-based skeletal X-rays showed three healed, asymptomatic rib fractures. A protocol-based Bayesian likelihood ratio guesstimation gave 10-100, erroneously used to suggest a 10-100 times likelier non-accidental-than-accidental cause. Foster care placement followed, even in a secret home, where she also bruised, suggesting hEDS inheritance. Correct non-accidental/accidental Bayes' probability of symptoms is (likelihood ratio) × (physical abuse incidence). From the literature, we derived an infant abuse incidence between about ≈0.0009 and ≈0.0026 and a likelihood ratio of <5 for bruises. For rib fractures, we used a zero likelihood ratio, arguing their cause was birth trauma from the extra delivery pressure on the chest, combined with fragile bones as the daughter of an hEDS-mother. We thus derived a negligible abuse/accidental probability between <5 × 0.0009 <0.005 and <5 × 0.0026 <0.013. The small abuse incidence implies that correctly using Bayes' theorem will also miss true infant physical abuse cases. Curiously, because likelihood ratios assess how more often symptoms develop if abuse did occur versus non-abuse, Bayes' theorem then implies a 100% infant abuse incidence (unwittingly) used by LECK. In conclusion, probabilities should never replace differential diagnostic procedures, the accepted medical method of care. Well-known from literature, supported by the present case, is that (child abuse pediatrics) physicians, child protection workers, and judges were unlikely to understand Bayesian statistics. Its use without statistics consultation should therefore not have occurred. Thus, Bayesian statistics, and certainly (misused) likelihood ratios, should never be applied in cases of physical child abuse suspicion. Finally, parental innocence follows from clarifying what could have caused the girl's bruises (inherited hEDS), and rib fractures (birth trauma from fragile bones).
Collapse
Affiliation(s)
- Martin J C van Gemert
- Department of Biomedical Engineering & Physics, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Aeilko H Zwinderman
- Department of Clinical Epidemiology & Bio-Statistics, Amsterdam University Medical Centers, Location AMC, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Peter J van Koppen
- Department of Criminal Law and Criminology, Faculty of Law, VU University, 1081 HV Amsterdam, The Netherlands
| | | | - Marianne Vlaming
- Private Practice, Criminal Psychology and Law, 6986 CL Angerlo, The Netherlands
| |
Collapse
|
4
|
Mengual L, Frantzi M, Mokou M, Ingelmo-Torres M, Vlaming M, Merseburger A, Roesch M, Culig Z, Alcaraz A, Vlahou A, Mischak H, Van Der Heijden A. Multicentric validation of nomograms based on urine peptide biomarkers for bladder cancer diagnostics and monitoring in two prospective cohorts of patients. EUR UROL SUPPL 2022. [DOI: 10.1016/s2666-1683(22)01956-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
|
5
|
Van Gemert MJC, Vlaming M, Köseoğlu B, Bruijninckx CMA, Van Leeuwen TG, Neumann MHA, Sauer PJJ. Limitations of Dutch Growth Research Foundation Commercial Software Weight Velocity for Age Standard Deviation Score. Am J Case Rep 2020; 21:e925551. [PMID: 33051433 PMCID: PMC7571282 DOI: 10.12659/ajcr.925551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patient: Male, 1-year-old Final Diagnosis: Healthy Symptoms: None Medication:— Clinical Procedure: Foster care Specialty: Pediatrics and Neonatology
Collapse
Affiliation(s)
- Martin J C Van Gemert
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Marianne Vlaming
- Private Practice, Criminal Psychology and Law, Doetinchem, Netherlands
| | - Bülent Köseoğlu
- Department of Maintenance and Production, Waternet, Amsterdam, Netherlands
| | | | - Ton G Van Leeuwen
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | | | - Pieter J J Sauer
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center, Groningen, Netherlands
| |
Collapse
|
6
|
van Gemert MJC, Vlaming M, Osinga E, Bruijninckx CMA, Neumann HAM, Sauer PJJ. Pediatric Condition Falsification Misdiagnosed by Misjudged Weight Growth from the Curve of Measured Weights. Am J Case Rep 2018; 19:752-756. [PMID: 29946058 PMCID: PMC6053948 DOI: 10.12659/ajcr.908770] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Patient: Male, 0–2 Final Diagnosis: Cow milk allergy Symptoms: Obstipation • airway infections Medication: — Clinical Procedure: Elementary feeding Specialty: Pediatrics
Collapse
Affiliation(s)
- Martin J C van Gemert
- Department of Biomedical Engineering and Physics, Academic Medical Center, University of Amsterdam, Amsterdam, Netherlands
| | - Marianne Vlaming
- Private Practice, Criminal Psychology and Law, Doetinchem, Netherlands
| | - Eric Osinga
- Private Practice, Osinga Advocatuur (Law Office), Utrecht, Netherlands
| | | | | | - Pieter J J Sauer
- Department of Pediatrics, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, Netherlands
| |
Collapse
|
7
|
van der Hoorn J, van de Molengraaf R, Nachabe R, Pikkemaat J, Vlaming M, Sio C, Lamerichs R, Degroot J, Steinbach O. 877 IN VIVO MRS ANALYSIS OF NON-ALCOHOLIC FATTY LIVER DISEASE IN A TRANSLATIONAL MODEL FOR THE METABOLIC SYNDROME. ATHEROSCLEROSIS SUPP 2011. [DOI: 10.1016/s1567-5688(11)70878-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
8
|
Vlaming M. [Specialists and nurses]. TVZ 1997; 107:477. [PMID: 9444263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
|