The Family Justice Resource Center, in partnership with United Family Advocates, Torn Family, Protecting Innocent Families, and the Pediatric Justice Association, helped prevent the passage of controversial federal legislation that would make families of young children even more vulnerable to medically-based wrongful allegations of child abuse.
In April 2019, Wisconsin Senator Tammy Baldwin proposed SB1009, known as the Early Detection to Stop Infant Abuse and Prevent Fatalities Act. The bill proposed a new research fund of $10 million—in addition to funding already contained in the authorization of the Child Abuse Prevention and Treatment Act—for the investigation of unexplained skin markings or oral lesions on children. Largely driven by Dr. Lynn Sheets, a child abuse pediatrician at Children’s Wisconsin in Milwaukee, the bill sought to label unexplained marks and oral lesions as so-called “sentinel injuries” worthy of investigation.
This study was to be a retrospective analysis that looked into the medical records of children who were determined to be victims of abuse. If the records showed a history of any bruise, it would retroactively be labeled a “red flag” and considered a missed opportunity to spare the child from future abuse.
The purpose of this study was to attempt to substantiate the practice of automatically investigating all unexplained markings and oral lesions on children under the guise of preventing child abuse. While well-intentioned on the surface, the bill did not provide any funding to help medical providers, prosecutors, or child protection investigators distinguish among marks caused by abuse, accidental injury, and undiagnosed medical conditions. By excluding neutral doctors and family advocates from the development of policies, it would open the door to more prosecutions of innocent parents—especially minority parents, parents of disabled children, and parents of children with rare disorders.
The bill failed to take into consideration that many medical conditions resulting in cutaneous and oral lesions can be easily mistaken for child abuse. Such diagnostic errors stem from unusual disease presentations, the presence of a rare condition, or the medical provider’s failure to consult with board-certified treating specialists. Certain populations are especially vulnerable to medically-based wrongful allegations of abuse, including racial and ethnic minorities, the economically disadvantaged, undocumented immigrants, and LGBTQ parents. For this reason, it is urgent that those tasked with identifying the cause of cutaneous and oral lesions are knowledgeable about the conditions that mimic child abuse and rely on board-certified treating specialists experienced in differentiating between medical conditions, accidental injury, and abuse.
Cutaneous lesions, including bruises in pre-mobile infants, are associated with many non-abusive causes, including: Mongolian spots, infections, vasculitis, vascular malformations, petechia, immune thrombocytopenic purpura, idiopathic thrombocytopenic purpura, Von Willebrand disease, hemophilia, Berard-Soulier syndrome, Glanzmann thrombasthenia, storage pool disease, May-Hegglin anomaly, Wiskott-Aldrich syndrome, hemorrhagic telangiectasia, EpisAXIS, cryoglobulinemia, pulmonary-renal involvement, malignancies, Ehlers Danlos syndrome, osteogenesis imperfecta, dermatomysitis, phytophotodermatitis, hemangiomas, meningococcemia, incontinentia pigmenti, erythema multiforme, digitform parapsoriasis, pyoderma gangrenosum, erythema marginatum, eczema, nutritional deficiencies, striae, skin staining from dyes, incontientia pigmenti, Cushing’s Disease, Marfan’s Syndrome, use of medications (heparin, steroids, NSAIDS, etc), and pressure (from clothing and child restraint fasteners).
Oral lesions, including maxillary labial (lip) frenulum tears in pre-mobile infants also have many non-abusive causes, including cysts, osteomyelitis, herpes simplex virus, candidiasis, mucocele, ranula, Riga-Fede disease, breastfeeding keratosis, intubation attempts, neonatal pemphigus, hemangioma, lymphangioma, Langerhans cell histiocytosis X, congenital epulis, melanotic neuroectodermal tumors, epignathus, oral choristomas, and salivary gland neoplasms.
A full list of the medical mimics of child abuse can be accessed here.
The bill also excluded consideration of accidental injuries. A 2001 study of 11,466 children under 6 months of age, found that 2,554 experienced falls. Of these children, 14% reported a visible injury, 56% of which were bruises*. Common accidents between 0-7 months includes caregiver-related accidents (such as dropping the infant or tripping while holding the infant), sleeping on top of a small toy, rolling off furniture, tipping from a sitting position, injuries from pets, injuries from siblings, carpet burns (from rolling or creeping), and more. Some common equipment can also result in cutaneous lesions, such as car seats, bouncy seats, high chairs, and infant carriers. Even the most attentive parents may not realize these injuries occurred or may not notice them promptly enough to give accurate reports to prosecutorial-focused individuals when questioned.
Had SB 1009 become law, all parents—but especially parents already at high risk for intervention by child protective services—would have been more likely to face invasive investigations and risk losing custody, without review by neutral medical experts.
*Source: Warrington SA, Wright CM, Team AS. Accidents and resulting injuries in pre-mobile infants: data from the ALSPAC study. Archives of Disease in Childhood 2001;85:104-107.