1. Is it Child Abuse? A Curious Case Series of Birth Injuries
Lauren Burge, MD; Marcella Donaruma, MD
Child Abuse Pediatrics, Section of Public Health Pediatrics, Baylor College of Medicine, Texas Children’s Hospital
Introduction
Background:
Birth trauma presenting in the neonatal period after hospital discharge is a known mimic of child physical abuse. Such findings can lead to a diagnostic conundrum with potentially significant medicolegal and psychosocial consequences.
Birth injury accounts for 2% of singleton, cephalad vaginal deliveries and continues to be a relatively rare phenomenon1. Presented are 3 cases of infants who have sustained birth-related injury who were consulted upon by our child abuse pediatrics team at Texas Children’s Hospital for concern for physical abuse. All three cases were classified as birth trauma.
Objective:
This case series serves to demonstrate the presentation of a relatively rare phenomenon that can have profound implications for children and families if misdiagnosed as child abuse.
Case 1
Image1: X-ray image of spiral femur fracture
Patient: 7D baby girl, born at 38 weeks via C-section d/t breech presentation. HPI: PCP noted swelling to the child’s L thigh at newborn visit. No history of post-partum trauma
Findings: Left spiral femur fracture (Image 1. L femur X-ray)
Additional evaluation: : Head CT, skeletal survey, fundoscopic exam, and social work evaluation. No other injuries found.
Impression: Unexplained injury in neonate  concern for physical abuse
Outcome: CPS referral made. Discharged home in kinship placement.
Follow-up: In Child Protective Health Clinic, the parents brought birth photos demonstrating an angular deformity of the child’s left leg. (Image 2) Final diagnosis was birth trauma.
Literature Review:
Femoral fractures from birth trauma have an incidence of only per 1,000 live births2,3. The typical injury pattern was a spiral fracture of the proximal femur, that had been previously in extension. Such positioning provides an appropriate mechanism of injury for spiral fracture in this patient.
Obstetric history
Characteristics associated with femur fracture
Pregnancy
Twin gestation
Breech
Delivery
Prematurity
Caesarean section
Image 2: Birth photos demonstrating visible deformity of L leg
Table 1: Risks factors for femur fracture due to birth trauma
Case 2
Patient:10 D male, born C-section with forceps extraction, BW 10lbs 13 oz
HPI: Witnessed transient apneic event at home
Findings: L temporal linear skull fracture, underlying subdural hemorrhage
Additional Evaluation: Skeletal survey, fundoscopic exam, social work evaluation. Birth history verified. No other injuries found.
Additional History: Parents report left sided facial bruising while in the nursery. Mother provided birth photo (Image 3) of her son with facial bruising.
Impression: Birth trauma secondary to traumatic forceps delivery
Literature Review:
Subdural Hematoma: Assisted deliveries have been linked to an increased risk of subdural hematoma. Babies delivered by forceps after attempted vacuum delivery were more likely to have a subdural hematoma than by any other method of delivery4. After birth, MRI monitoring demonstrated resolution of all birth-related subdural hematomas at 4 weeks of life. Babies born without instrumentation also can sustain subdural hematomas; however the location of the hemorrhage tends to be infratentorial4,6 (Table 2)
Skull Fractures: The incidence of skull fractures is reported at 2.9% of all deliveries.7 Most are simple linear fractures and occur with suction extraction or forceps deliveries.7
Injury
Location of Hemorrhage
Abusive
Supratentorial
Birth Trauma
Infratentorial
Image 3: Birth photos of facial bruising to left side
Table 2: Location of intracranial hemorrhage based on injury type
Case 3
Patient:16 D male, reported difficult vaginal delivery, BW 9 lbs 4 oz HPI: 2 days cough and rhinorrhea  ER for CXR Findings: 2 healing posterior rib fractures to L 6th and 7th ribs Additional Evaluation: Skeletal survey, head CT, fundoscopic exam, social work evaluation. Birth history verified. No other injuries found Impression: Birth Trauma
Literature Review: Posterior rib fractures are highly specific for abuse.8 Two common factors found in birth-related posterior rib fractures were large infant size and a difficult birth. Note the development of a callus around the rib fractures (Image 4). This would suggest the infant’s injuries occurred around the time of birth. There are also differences in the specific location of posterior rib fractures when differentiating abusive trauma from birth trauma (Table 3)9
Type of Injury
Location of Post. Rib Fx
Mechanism of Injury
Abusive Injury
Costovertebral junction
Levering of post . rib over transverse process of vertebral bodies
Birth Injury
Midline
Circumferential and rotational forces applied to thoracic wall
Image 4: Posterior rib fractures. Note callus formation and midline placement
Table 3: Location and mechanism of post. Rib fx in abuse vs birth injury
Results
References
There are several known risk factors for birth injury such as infant macrosomia, assisted delivery, and abnormal fetal presentation. The cases presented above possess many of these risk factors as well as plausible mechanisms of injury. These injuries can be highly specific for abusive trauma, yet after completing a thorough evaluation by the child protective team, observing the home environment, and reviewing the literature, it was determined that these children likely sustained injuries secondary to the birthing process.
Alexander JM, Leveno KJ, Hauth J, et al. Fetal injury associated with cesarean delivery. Obste Gynecol 2006; 108:885
Morris S, Cassidy N, Stephens M, McCormack D, McManus F. Birth-associated femoral fractures;incidence and outcome.J Pediatr Orthop.2002; 22(1):27-30
Basha A, Amarin Z, Abu-Hasan F. Birth-associated long bone fractures. Int J Gynecol Obste. 2013;123:
Whitby EH, Griffiths PD, Rutter S, et al. Frequency and natural history of subdural haemorrhages in babies and relation to obstetric factors. Lancet 2004; 363:846-51
Looney CB, Smith JK, Merck LH, et al. Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on MR Images and Relationship to Obstetric and Neonatal Risk Factors. Radiology 2007; 242:
Hughes AC, Harley EH, Milmoe G, et al. Birth Trauma in the Head and Neck. Arch Otolaryngol Head Neck Surg 1999; 125:
Kleinman P, Diagnostic Imaging in Infant Abuse. AJR 1990; 155:
Van Rijn RR, Bilo RA, Robben SG. Birth-related midposterior rib fractures in neonates: a report of three cases (and a possible fourth case) and a review of the literature. Pediatr Radiol 2009; 39:30-34
Conclusions
Pediatricians should be aware of these rare presentations of abuse-specific injuries in the setting of birth trauma
Due to the rarity of these injuries, pediatricians should consult a child abuse pediatrician or complete a thorough psychosocial and medical evaluation before ruling out physical abuse
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