This year Torn Family board member and former University of Michigan Professor of Pathology Dr. Douglas Smith was able to assist in a case involving a child with “bruising” on the abdomen. His findings provided multiple non-abusive explanations for the bruising, ultimately helping the parents get their child back from CPS custody. The following is a paper written by him detailing the case.

When a “Bruise” Is the Beginning of a Family’s Nightmare

The Nightmare Begins
The Parker family’s nightmare began with a diaper change. Their son Dylan was 6 weeks old. Jimmy, Dylan’s dad, noticed an area on the left side of Dylan’s belly covered in a series of small red marks. His wife, Allie had changed Dylan’s diaper earlier that morning, so he asked if she had seen the markings earlier. She hadn’t. They didn’t understand what caused the marks, so they were concerned.

In addition, Dylan had not had a bowel movement in two days, so they had made an appointment with his pediatrician. Dylan ended up having a large bowel movement before the appointment, but they kept the appoint anyway, to address the marks on his belly. 

The Parkers showed the markings to the nurse practitioner. What the Parkers didn’t know was that pediatricians and other medical personnel are routinely taught that non-crawling babies do not get bruises on their own, and therefore bruises can only result from abuse. Because of this, the pediatrician’s office suspected someone was abusing Dylan and filed a report with the Department of Human Services. The Parkers were told that they must go to the emergency room of the University at Michigan Mott Children’s Hospital immediately.

In the mean time, their pediatrician called Dr. Bethany Mohr, the head of the Child Protection Team at Mott’s, and told Mohr to expect the Parkers’ arrival. The pediatrician had received her residency training at Mott’s from Mohr herself.

Mott Children’s Hospital
At the emergency room a child abuse protocol went into “autopilot.” Dylan had X-Rays of every bone in his body, as well as a CT scan of his head. He had a series of blood tests and an ultrasound scan of his belly to look for internal bleeding. Then came the big surprise: Dylan had four healing rib fractures.

Dylan was admitted to the hospital and Child Protective Services took steps to take custody of Dylan and his older sister. The next day they met with Mohr, who separated James and Allie into different rooms in order to question them about Dylan’s injuries and take a medical history. This is not typical for a sick child but is an investigative technique similar to the methods used by police. Mohr then examined Dylan and took photographs. 

Dylan required no medical treatment and was discharged into the custody of Allie’s parents along with his older sister. Allie and James were ordered to have no contact with either child until their first court hearing. 

“Bruises”
Dr. Mohr said she saw several “bruises” on Dylan in addition to the marks on this stomach. However, no other doctors identified these additional marks as “bruises.” Instead, the photos taken show a rash that had been previously diagnosed as eczema by Dylan’s pediatrician.

Furthermore, the “bruises” on Dylan’s stomach turned out to not be bruises at all. Allie’s description of the markings when they were fresh match the description of another type of bleeding into the skin: a petechial rash. Petechial rashes are superficial bleeding from capillaries just under the surface of the skin. A common example of a petechial rash is what is called a “hickey.” In the case of a hickey, the rash is caused by sucking on the skin. Petechial rashes can also be caused by pressure on the skin. It differs from a bruise in that it takes less force to cause one. A bruise is the result of deeper tissue injury. A bruise will be tender while a petechial rash will not be, since it is just superficial capillary bleeding.

Nevertheless, Mohr concluded the following:

“Based upon Dylan’s developmental level, the location of the bruising, the patterned nature of his left abdominal bruising, and no history reported which provides a mechanism for his bruising, Dylan’s bruising is diagnostic of physical abuse.”

“Due to Dylan’s age and developmental level, as well as the location of his rib fractures, his rib fractures are diagnostic of physical abuse. Posterior rib fractures in infants are highly specific for physical abuse due to squeezing.”

Genetic Explanations For the Bruises:
Missing from Mohr’s report was any mention of Dylan’s mother’s medical history, which turned out to be very important. Allie Parker has a genetic condition called Ehlers-Danlos syndrome. This syndrome is characterized by very loose joints and capillary fragility, which leads to easy bruising and petechial rashes. Mohr’s report does not address the possibility that Dylan could have inherited this condition, providing a non-abusive explanation for the marks.

Allie described how she gets a bruise from the blood pressure cuff whenever she gets her blood pressure taken. Allie was examined by a clinical geneticist and he performed a test for joint hypermobility called a Beighton score. Allie had a score of 8 or 9 (see photographs). Any score of 5 or above indicates joint hypermobility. Allie can also dislocate her hips at will and she is developing some hip pain, which is common in Ehlers-Danlos patients as they get older. 

• 

• 

• 

Ehlers-Danlos syndrome is inherited as a dominant trait, meaning that if only one parent has the condition, one can predict that half of their children would inherit the disorder. Dylan has a 50% chance of having inherited Ehlers-Danlos syndrome. 

Origin of the Bruise
Dr. Mohr was later asked in court if she had ever investigated whether the pattern of the “bruise” matched anything in the Parker’s home. She responded that was not her job. 

It turns out the “bruise” does match something in the Parker’s home. In fact, there are two swings and a car seat that have similar harness with horizontal and vertical straps joined by a plastic buckle (see photographs). Dylan had spent time in the swing on the day the bruise appeared. Since the markings were on the left side of Dylan’s belly it seems that he must have gotten twisted a little to his right side in the swing, causing the straps and buckle to tighten against his skin.

• 

• 

Causes of Dylan’s Rib Fractures
In addition to the Ehlers-Danlos syndrome, Allie has a skin condition known as polymorphic light eruption. This condition can cause her to develop rashes from exposure to sunlight. This was important because it led to her and Dylan being severely vitamin D deficient. Vitamin D is essential for bone health, and lack of it can lead to fragile bone diseases such as rickets, thus providing a non-abusive explanation for Dylan’s broken ribs. 

Sure enough, when Dylan was tested for vitamin D at 6 weeks of age, his level was 12 ng/ml. He had been receiving vitamin D drops since birth so his level was undoubtedly much higher than when he was born. When his mother was tested several months after Dylan was born, her level was 8 ng/ml. The baby’s vitamin D level is always less than that of the mother’s at birth.

There is considerable controversy in the medical literature about what level of vitamin D is normal and what level will cause a bone disease such as rickets. It is generally accepted that levels above 30 ng/ml are optimal for bone health. The majority of the medical literature sets the level for “deficiency” as anything less than 20 ng/ml – but some have recommended thresholds for deficiency as low as 10 or 12 ng/ml. 

Mohr testified that the vitamin D level was “insufficient” but not “deficient” and that without signs of rickets on the x-rays Dylan’s vitamin D levels would not explain the fractures. However, autopsy studies show that about 30% of children with Vitamin D levels between 10 and 20 ng/ml have conditions consistent with rickets. These conditions can only be viewed under a microscope, and are not visible with an x-ray. 

 In addition to the low vitamin D level, Dylan had a very elevated level of alkaline phosphatase, a symptom of rickets. Other blood tests that are often abnormal in rickets were normal but it needs to be kept in mind that these blood tests were performed a month or more after the fractures occurred. Dylan was receiving vitamin D drops since birth and these blood tests can return to normal long before the bone strength returns to normal. 

Ehlers-Danlos syndrome alone probably does not cause fractures but some experts have reported that in combination with vitamin D deficiency, it can cause fragility fractures in infants. Since the frequency of Ehlers-Danlos syndrome is only 1 in 5,000 births, one would expect that if the association was random it would be very rare. In reviewing a few dozen fracture cases, this author has already seen two cases where the mother clearly had both Ehlers Danlos syndrome and vitamin D deficiency, and the baby had multiple fractures. Other defense experts have reported similar cases. No studies have been reported that contradict that association. Thus, although not proven, it seems likely that Ehlers-Danlos syndrome makes bone fragility worse in cases of vitamin D deficiency.

Determining the Age of the Fractures
The doctors would later testify that the fractures were “at least” 10 to 14 days old. This is misleading however, because the fractures could have dated back as far as 4-6 weeks, which was when Dylan was born. This makes it very plausible that the rib fractures could have occurred as a result of Dylan’s C-section delivery. Though rare, fractures can occur when the doctor pulls the baby out of the womb during a C-section, even in babies with normal bone strength.

Analysis of two full body bone surveys on Dylan, one at 6 weeks and one at 12, reveals that the older estimate of 4-6 weeks is actually more likely. Dylan’s first bone survey at 6 seeks showed rib fractures, which displayed their peak amount of healing tissue (callus). The second at 12 weeks, showed near complete healing of the fractures. Peak callus occurs at about 5 to 7 weeks. Complete healing doesn’t occur before 9 to 11 weeks. Although dating fractures is not a precise science, the best estimate is that Dylan’s rib fractures occurred sometime between his birth and two weeks of age.

Conclusion
Child Protective Services petitioned the court to terminate the parental rights of both parents. The trial was spread out over three months. The parents ran out of money to hire defense experts, so they petitioned the court to pay for an expert on vitamin D deficiency. The chief judge agreed in an ex-parte motion, but the prosecutor motioned that the approval be rescinded. In a hearing on the motion, the chief judge admonished the prosecutor severely for attempting to deprive the parents of due process. The Parkers were allowed to hire an expert, and they were found not responsible for the injuries. Regarding the Parkers lawyer, Lisa Kirsch Satawa, the judge stated “You need to thank Ms. Satawa because she did a job I rarely see in this courtroom.” Thanks to all of this, the case was dismissed. The judge even tearfully apologized that the parents had to go through this difficult and expensive process.